freed from the intermuscular septum, it is safely protected and is

retracted medially with the brachioradialis muscle distally.

Closure: The muscle is allowed to return to its anatomic position. If the triceps
has been reflected, the recommended reattachment is described in the elbow
exposure chapter (see Fig. 3-11). Otherwise, only a subcutaneous and skin
closure is required.

P.99
FIGURE 4-4

P.100

FIGURE 4-4 (Continued)

P.101
FIGURE 4-4 (Continued)

P.102
 FIGURE 4-4 (Continued)

P.103

Distal Extension
If more distal exposure is necessary, the triceps may be reflected from the tip of the
olecranon using the Bryan-Morrey technique. This allows complete exposure of the
entire posterior humerus, elbow joint, and proximal ulna.

Posterior Triceps Splitting Approach

This along with exposure of the ulna is the easiest and safest exposure of the upper
extremity.

Indications
Mid and distal shaft fractures, when extended distally, can be used for exposure for
total elbow arthroplasty and fracture of the midshaft of the humerus.

Position
The patient is supine and the arm brought across the chest. The table is tilted 10
degrees away from the involved extremity.

Landmarks
Tip of olecranon, ulnar nerve, and medial and lateral epicondyle.

Technique

Skin incision: a longitudinal skin incision is made from the tip of the olecranon
distally to the posterior aspect of the deltoid proximally. The length is dictated
by the pathology (Fig. 4-5A).

Flaps are elevated medially and laterally and the tendon of the triceps distally
and the muscle fibers proximally are identified (Fig. 4-5B).
 A longitudinal incision is made in the tendinous portion of the triceps exposing
the posterior aspect of the humerus (Fig. 4-5C).

P.104
The triceps muscle is split proximally and distally. The tendon is incised to the
level of its attachment on the olecranon. Subperiosteal dissection medially and
laterally exposes the posterior aspect of the humerus (Fig. 4-5D).

FIGURE 4-5
 FIGURE 4-5 (Continued)

RECOMMENDED READING
Banks S, Laufman H. An Atlas of Surgical Exposures of the Extremities.
Philadelphia: W.B. Saunders Co., 1953.

Campbell WC. Incision for exposure of the elbow joint. Am J Surg 1932;15:65-67.

Grant JCB. An Atlas of Anatomy, 6th ed. Baltimore: Williams & Wilkins Co., 1972.

Gray H. The Anatomy of the Human Body, 29th ed. Philadelphia: Lea & Febiger,
1975.

Henry AK. Extensile Exposure, 2nd ed. New York: Churchill-Livingstone, Inc., 1963.

Hollinshead WH. Anatomy for Surgeons: The Back and Limbs, 3rd ed. Philadelphia:
Harper & Row, 1982.

Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics: The Anatomical

Approach, 1st ed. Philadelphia: JB Lippincott Co., 1984.

Reckling FW, Reckling JB, Mohr MC. Orthopedic Anatomy and Surgical Approaches.
St. Louis: Mosby Year-book, 1990.

Tubiana R, McCullough CJ, Masquelet AC. An Atlas of Surgical Exposures of the

Upper Extremity. London: Martin Dunitz Publisher, 1990.
Editors: Morrey, Bernard F.; Morrey, Matthew C.
Title: Master Techniques in Orthopaedic Surgery: Relevant Surgical
Exposures, 1st Edition
Copyright ©2008 Lippincott Williams & Wilkins

> Table of Contents > Section I - Upper Extremity > 5 - Shoulder

5
Shoulder
John William Sperling

ANTERIOR SUPERIOR APPROACH FOR ROTATOR CUFF

REPAIR
Indications
Acromioplasty

Rotator cuff repair

Position
The patient is carefully positioned in the beach chair position. The waist should be in
approximately 45 degrees of flexion and the knees in 30 degrees of flexion. The table
may be slightly rolled away from the surgical shoulder.

Landmarks
One should palpate the posterior scapular spine, the lateral border of the acromion,
the anterior border of the acromion, and the anterior portion of the clavicle and
coracoid. These should be marked out with a marking pen (Fig. 5-1). If one is
performing arthroscopy prior to an open procedure, one may wish to mark out the
standard anterior incision and attempt to place the anterior portal in line with this
future incision.

FIGURE 5-1 The landmarks on the shoulder are carefully identified and outlined. A
4 to 5 cm incision is marked out on the shoulder parallel to the lateral border of
the acromion.

P.106

TECHNIQUE
Incision: there is significant variability in the skin incision used for an anterior
superior approach to the shoulder including oblique incisions, horizontal
incisions, as well as vertical incisions. It is based on the individual preference
of the surgeon which incision to use.

An incision is made over the superior aspect of the shoulder parallel with the
lateral border of the acromion in line with Langer's lines. The length of the skin
incision is typically about 4 to 5 cm in length. The skin is incised as well as the
fat. Skin flaps are carefully created and mobilized.

The deltoid muscle is clearly identified. There is significant variability among

surgeons in regard to the manner with which they prefer to take down the
deltoid (Fig. 5-2). In this example, the deltoid is taken down off the anterior
aspect of the acromion with full thickness sleeves (Fig. 5-3). It is critical to
carefully include both the deep and superficial fascia of the deltoid when this
is performed. The surgeon then has the option of splitting the deltoid in line
with the fibers starting from the acromioclavicular (AC) joint anteriorly for
approximately 3 to 4 cm, or the surgeon has the option of extending the
deltoid detachment posteriorly over the lateral border of the acromion. The
extent of the deltoid detachment over the lateral border of the acromion can
be modified based on the size of the rotator cuff tear. One must be careful to
avoid splitting the deltoid more than several centimeters from the acromial
border to protect the axillary nerve. The area where the proximal deltoid split
is made can be marked with a retention stitch (Fig. 5-4). An additional stitch
is placed distally in the deltoid split to prevent propagation (Fig. 5-5).

P.107
An acromioplasty may then be performed based on surgeon preference (Fig. 5-
6). Retention stitches are then placed in the rotator cuff tear (Fig. 5-7). The
rotator cuff repair can then be performed (Fig. 5-8).

For closure, a meticulous repair of the deltoid is required. At the end of the
procedure, the deltoid is repaired back in a tendon-to-tendon as well as a
tendon-to-bone manner (Figs. 5-9, 5-10 and 5-11). Drill holes are placed
through the acromion with tendon-to-bone stitches. Additionally, the split
within the deltoid itself is repaired with side-to-side stitches. Complications in
this approach may be related to deltoid dehiscence postoperatively.

Pearls/Pitfalls: A meticulous and strong repair of the deltoid is

essential to avoid postoperative dehiscence. It is critical to carefully
identify both the deep and superficial deltoid fascia layers during the
exposure and repair.
FIGURE 5-2 A,B: The area of deltoid to be taken off of the acromion is outlined.
FIGURE 5-3 Full thickness flaps of the deltoid are taken down.

P.108
FIGURE 5-4 A marking stitch is placed in the corner of the deltoid to assist in later
repair and ensure proper alignment of the deltoid at the time of repair.

FIGURE 5-5 A stitch is placed in the deltoid split distally to prevent propagation.

P.109
FIGURE 5-6 An acromioplasty may be performed.
FIGURE 5-7 The rotator cuff tear is identified and retention stitches are placed.
FIGURE 5-8 Rotator cuff repair is performed.

P.110
FIGURE 5-9 Drill holes can be placed in the acromion for deltoid repair.

FIGURE 5-10 The corner of the deltoid is sutured back to its anatomic location.

P.111
 FIGURE 5-11 Final deltoid repair.

HORIZONTAL INCISION FOR CLAVICLE FRACTURES AND

NONUNIONS
Indication
Clavicle fracture or nonunion.

Positioning
The patient is placed on the operating room table in the beach chair position. The
entire upper extremity is sterilely prepped and draped in the usual manner. The
endotracheal tube is positioned to the opposite corner of the mouth. A rolled up towel
may also be placed at the medial border of the scapula to make the clavicle more
readily accessible.

Technique
Incision: the incision runs parallel to Langer's line along the inferior border of
the clavicle overlying the fracture nonunion (Fig. 5-12). The incision is placed
inferiorly so that the scar will not lie directly on top of the instrumentation.
The skin is incised as well as the fat. It should be done with great care and
caution to carefully identify any supraclavicular nerves (Fig. 5-13). These
should be carefully preserved. The fascia of the overlying trapezius and the
deltoid is carefully identified and incised. Sutures are placed on the fascial
ends for later reattachment.

Additionally during the course of the procedure, one must be very diligent that
the neurovascular structures are present on the undersurface of the clavicle.

P.112
The fracture is then identified and reduced (Fig. 5-14). Internal fixation may
be performed based on surgeon preference (Fig. 5-15). Closure of the wound is
performed (Fig. 5-16).
 Pearls/Pitfalls: Attention should be made to the identification and
preservation of the supraclavicular nerves to avoid potential creation of
a neuroma.

FIGURE 5-12 The skin incision is carefully outlined.

FIGURE 5-13 Great care is taken to preserve the supraclavicular nerves.
FIGURE 5-14 The fracture ends are reduced and held in place.
FIGURE 5-15 Open reduction, internal fixation can be performed.
 FIGURE 5-16 Closure of the wound.

P.113

DELTOPECTORAL APPROACH FOR FRACTURES AND

ARTHROPLASTY
Indications
Total shoulder or hemiarthroplasty

Open reduction, internal fixation of proximal humerus fractures

Positioning
The patient is carefully padded and positioned in the beach chair position. The waist is
flexed approximately 45 degrees and the knees are placed in 30 degrees of flexion.
The table may be slightly rolled away from the surgical shoulder. In addition, a rolled
up towel under the medial border of the scapula may help with exposure of the
shoulder region. It is critically important to have the medial border of the scapula on
the operative side free to allow adequate exposure of the upper extremity.

Landmarks
The landmarks of the shoulder are carefully palpated and marked with a marking pen
including the posterior spine of the scapula, lateral border of the acromion, anterior
border of the acromion, anterior portion of the clavicle, and the coracoid.

Technique
Incision: the incision begins at the anterior portion of the clavicle and passes
approximately 1 cm lateral to the coracoid and intersects at the arm at the
intersection of the medial 40% and the lateral 60% (Fig. 5-17). The incision is
approximately 15 cm in length. There may be a gentle lateral curve to the
incision proximally.

The skin is incised as well as the fat. Skin flaps are created medially and
laterally.

It is easiest for one to find the deltopectoral interval proximally. A small

triangle of fat is usually present between the deltoid and the pectoralis major
proximally (Fig. 5-18). Once the interval is found, one follows the
deltopectoral interval distally, usually leaving the cephalic vein medially within
its bed (Fig. 5-19). It may be advantageous to place the arm on a Mayo stand
and abduct the arm approximately 30 degrees to help dissect out the
deltopectoral interval. There are multiple crossing branches that are typically
present that do need to be cauterized. A retractor is placed under the deltoid
and the deltopectoral interval is developed distally.

P.114
After this, the clavipectoral fascia which lies on the anterior aspect of the
subscapularis and conjoined group is carefully incised. One can then place a
finger to spread the interval between the conjoint and subscapularis, and a
retractor may be placed in this area.

One then carefully feels for the axillary nerve. It is felt by using an index finger
sweeping under the inferior border of the subscapularis. One may then confirm
its presence by performing a “tug test― feeling for the nerve under the
undersurface of the deltoid more laterally.

The subacromial subdeltoid space is then carefully incised and cleared to allow
mobilization of the deltoid and a place for the deltoid retractor. This is started
first superiorly under the undersurface of the acromion sweeping the bursa
away, then laterally, and then finally anteriorly. A retractor is then placed in
the deltoid (Fig. 5-20). One may on occasion need to release the upper 1 cm
of the pectoralis major muscle to improve exposure. Next, the overlying bursa
of the rotator cuff is carefully débrided and one then clearly identifies the
underlying rotator cuff.

Note: The coracoacromial ligament may be excised for better exposure

(see Fig. 5-20B). However, if the cuff is deficient, ligament should be
left intact.

In cases of shoulder arthroplasty, one then determines how the subscapularis

should be taken down. There is significant variability among surgeons in
regards to management of the subscapularis in routine shoulder arthroplasty
work. There are several options available including incising through the
subscapularis tendon for later tendon repair (Fig 5-21). The second option is
taking down the subscapularis off of bone. Lastly, there is the option of
performing a lesser tuberosity osteotomy.

The arm is externally rotated and the head is dislocated (Fig. 5-22).
FIGURE 5-17 The landmarks are outlined and the incision is planned.
FIGURE 5-18 The medial border of the deltoid is identified. A triangle of fat is
usually present in this location.
FIGURE 5-19 The superior aspect of the pectoralis major is detached. The
cephalic vein is left within its bed medially.

P.115

FIGURE 5-20 A retractor is placed medially beneath the pectoralis and laterally
under the deltoid. The landmarks are outlined and the incision is planned.
FIGURE 5-21

P.116
 FIGURE 5-22 In this case, the rotator interval and subscapularis were incised and
the humeral head was dislocated for a total shoulder arthroplasty.

P.116

Pearls and Pitfalls

Careful deltoid mobilization is critical to exposure for both internal fixation of

fractures as well as shoulder arthroplasty.

One should clearly identify and protect the axillary nerve during the course of
all shoulder procedures performed through the deltopectoral interval. The
“tug test― is a simple and reproducible manner to clearly confirm the
location of the nerve.

POSTERIOR EXPOSURE FOR RECURRENT POSTERIOR

SHOULDER INSTABILITY
Indication
The indication for posterior approach to the shoulder is usually treatment of posterior
instability that has been refractory to nonoperative treatment.

Positioning
The patient is carefully padded and positioned in the lateral decubitus position with
the operative shoulder placed superiorly. Additionally, there are some surgeons that
prefer to perform a posterior approach to the shoulder with the patient in the beach
chair position. In the beach chair position, however, the patient needs to be sitting at
a near 90 degree angle or leaning slightly forward. In the more traditional lateral
position, great care is taken to adequately pad the patient including padding the lower
extremities to prevent a peroneal nerve palsy.

Landmarks
After the patient is prepped and draped in the usual sterile manner, the anatomical
landmarks of the shoulder are carefully palpated and marked including the spine at
the scapula, the acromion, clavicle, and coracoid.

Technique
Incision: the standard incision for posterior approach of shoulder begins
posterior to the acromioclavicular joint and approximately 1 to 2 cm medial to
the lateral border of the acromion and extending distally in line with the
posterior axillary skin fold (Fig. 5-23). An approximately 6 to 8 cm incision is
made. The skin is incised as well as the fat. Skin flaps are mobilized medially,
laterally, superiorly, and inferiorly. Once the superficial dissection is
performed, one visualizes the underlying deltoid muscle.

The deltoid muscle is split in line with its fibers approximately 2.5 cm medial
to the posterior corner of the acromion. This split should not extend greater
than 4 to 5 cm to avoid injury to the underlying axillary nerve (Fig. 5-24). The
posterior repair itself can be performed without removal of any deltoid from
the scapular spine or the underlying acromion. The deltoid flaps are carefully
created. A self-retaining retractor may be used to retract the deltoid from the
underlying rotator cuff muscles.

Once the deltoid is mobilized, one can then expose the underlying
infraspinatus and teres minor. Frequently, it is difficult to specifically see the
interval between the teres minor and underlying infraspinatus. Therefore,
many surgeons have advocated splitting between the two heads in the
infraspinatus rather than going through the interval between the teres minor
and infraspinatus (Fig. 5-25). The infraspinatus does have a specific fat stripe
between the two heads. This is a convenient plane to use for the dissection.
One, however, needs to take great care that the dissection between the two
heads does not proceed more than 1.5 cm medial to the glenoid to avoid injury
to the suprascapular nerve.

The infraspinatus is carefully freed from the underlying capsule. The capsule is
typically more adhered laterally compared to medially. It is critical to obtain
full mobility of the plane between the infraspinatus and capsule to allow
mobilization of the capsule for later repair. An additional set of self-retaining
retractors may be helpful to place between the two heads of the infraspinatus
to clearly expose the underlying capsule.

In regard to the specific capsular repair, there is significant variability in

regard to the type of capsular repair that is preferred by the surgeon.
Specifically, some surgeons prefer to perform a laterally based capsular repair
versus a medially based capsular repair. The procedure then proceeds with
performing a capsular application with either a laterally or medially based T-
type of split as well as addressing any labral pathology (Fig. 5-26).

P.117
FIGURE 5-23 The patient is positioned in the lateral position and an incision is
made 1 to 2 cm medial to the lateral border of the acromion.

FIGURE 5-24 A,B: A split in the deltoid is made approximately 2 to 3 cm medial to

the posterior corner of the acromion. The split should not extend more than 4 to
5 cm.
 FIGURE 5-25 A,B: A split is made between the two heads of the infraspinatus.

P.118

Pearls and Pitfalls

One can perform the posterior exposure through the interval between the
infraspinatus and teres minor or between the two heads of the infraspinatus.
The fatty stripe between the heads of the infraspinatus is a more readily
identifiable landmark and may be the easier interval to use for the procedure.

FIGURE 5-26 A,B: The infraspinatus is carefully freed from the underlying capsule.
 A lateral or medial based repair is based on labral pathology and surgeon
preference.

P.119

ANTERIOR INFERIOR APPROACH FOR SHOULDER

INSTABILITY
Indication
Treatment of shoulder instability.

Positioning
The patient is carefully padded and positioned in the beach chair position. The
affected upper extremity is sterilely prepped and draped in the usual manner.

Technique
Incision: the standard axillary incision begins just inferior to the coracoid
process and extends into the axilla in line with the skin folds. This is
determined by adducting the arm and seeing the line of the skin fold (Fig. 5-
27). One may wish to make a more inferior incision in the axilla for improved
cosmesis. The more inferior incision, however, does necessitate more
extensive subcutaneous dissection.

The skin is incised, then the fat, and the deltopectoral interval is identified. It
is typically easier to identify the interval more proximally. There is typically a
fatty triangle at the most proximal aspect of the deltopectoral interval. The
deltopectoral interval is identified and then dissection is continued distally.
The cephalic vein is typically retracted laterally (Fig. 5-28). The upper 1 cm of
the pectoralis major insertion may be released to improve visualization. The
deltoid insertion does not need to be detached either from the clavicle or on
the humerus. One must take great care when releasing the upper 1 cm of the
pectoralis not to injure the long head of the biceps.

A Richardson type retractor can be placed laterally under the deltoid. Next,
the clavipectoral fascia which overlies the conjoined tendon and subscapularis
is carefully incised lateral to the conjoined group. The conjoined group is then
freed and mobilized. A retractor can then be placed medially (Fig. 5-29).
Next, the axillary nerve is carefully identified and can be readily identified by
placing a finger along the inferior border of the subscapularis.

One carefully identifies the borders of the subscapularis. The superior border
of the subscapularis is marked by the rotator interval. This is classically a
“soft area― present just superior to the subscapularis. This is typically
widened in patients with multi-directional instability or may be frankly open.
The inferior aspect of the subscapularis is defined by the “three sisters.―
The three sisters are the anterior humeral circumflex artery and the two
accompanying veins.

Note: There is significant variability in regards to techniques for

incising the subscapularis tendon including (Fig. 5-30):

Incising the subscapularis approximately 1 to 2 cm medial to its

insertion off the lesser tuberosity and then elevating this carefully off
the underlying capsule.

The second is popularized by Rockwood. The lower one-third to one-

quarter of the subscapularis may be left intact. Detaching alone the
upper portion of the subscapularis.

Lastly, the subscapularis muscle may be split horizontally to expose the

underlying capsule.

Once the underlying capsule is carefully identified, tagging stitches are placed
in the subscapularis, and the muscle again is carefully swept off of the
underlying capsule. There is significant variability in management of the
capsule in regard to either a laterally or medially based split. This is based
primarily on the presence of a labral tear as well as surgeon preference (Fig.
5-31).
FIGURE 5-27 Langer skin lines are outlined in the axillary skin crease.

P.120
FIGURE 5-28 The cephalic vein is identified and retracted laterally.
FIGURE 5-29 The deltoid is retracted laterally and the conjoint group is retracted
medially.

P.121
FIGURE 5-30 There are several ways to dissect the subscapularis from the
underlying capsule including: (A) the entire subscapularis may be reflected off
the capsule, (B) the lower 25% of the subscapularis may be left intact, and (C)
the subscapularis may be split horizontally.
 FIGURE 5-31 A medial or laterally based T split may be performed. In this
example, a medially based shift will be performed.

Pearls and Pitfalls

Careful mobilization of all tissue planes from the deltopectoral interval to the
release of the subscapularis off of the capsule is critical to obtain adequate
exposure especially when performed through a small incision.

One must carefully identify and protect the axillary nerve throughout the
course of this procedure. The “tug test― is a reproducible way to confirm
the exact location of the axillary nerve.

P.122

RECOMMENDED READING
Cetik O, Uslu M, Acar HI, et al. Is there a safe area for the axillary nerve in the
deltoid muscle? A cadaveric study. J Bone Joint Surg Am 2006;88(11):2395-2399.

Cleeman E, Brunelli M, Gothelf T, et al. Releases of subscapularis contracture: an

anatomic and clinical study. J Shoulder Elbow Surg 2003;12(3):231-236.

Gill DR, Cofield RH, Rowland C. The anteromedial approach for shoulder
arthroplasty: the importance of the anterior deltoid. J Shoulder Elbow Surg
2004;13(5):532-537.

Gray H. The Anatomy of the Human Body, 29th ed. Philadelphia: Lea & Febiger,
1975.

Henry AK. Extensile Exposure, 2nd ed. New York: Churchill-Livingstone, Inc., 1963.
Hollinshead WH. Anatomy for Surgeons: The Back and Limbs, 3rd ed. Philadelphia:
Harper & Row, 1982.

Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics: The Anatomical

Approach, 1st ed. Philadelphia: JB Lippincott Co., 1984.

Reckling FW, Reckling JB, Mohr MC. Orthopedic Anatomy and Surgical Approaches.
St. Louis: Mosby Year-book, 1990.

Thompson JE. Anatomical methods of approach in operations on the long bones of

the extremities. Ann Surg 1918;68:309-329.

Tubiana R, McCullough CJ, Masquelet AC. An Atlas of Surgical Exposures of the

Upper Extremity. London: Martin Dunitz Publisher, 1990.

Uz A, Apaydin N, Bozkurt M, et al. The anatomic branch pattern of the axillary

nerve. J Shoulder Elbow Surg 2007;16(2):240-244 [Epub Nov 9 2006].

Zlotolow DA, Catalano LW 3rd, Barron OA, et al. Surgical exposures of the
humerus. J Am Acad Orthop Surg 2006;14(13):754-765.
Editors: Morrey, Bernard F.; Morrey, Matthew C.
Title: Master Techniques in Orthopaedic Surgery: Relevant Surgical
Exposures, 1st Edition
Copyright ©2008 Lippincott Williams & Wilkins

> Table of Contents > Section II - Lower Extremity > 6 - Pelvis

6
Pelvis
Andrew S. Sems

POSTERIOR APPROACH TO THE SACRUM AND

SACROILIAC JOINT
Indications
Open reduction and internal fixation of sacral fractures.

Open reduction and internal fixation of sacroiliac fracture-dislocations.

Open reduction and internal fixation of sacroiliac dislocations.

Open reduction and internal fixation of sacroiliac dislocations with iliac

fractures (crescent fracture).

Position
The patient is placed in the prone position with chest rolls positioned to allow the
abdomen to hang free (Fig. 6-1). A completely radiolucent table is utilized to allow
imaging in multiple planes including Judet views and inlet and outlet views. The chest
roll should be placed proximal enough so that the pelvis actually hangs free, as this is
helpful in assisting in obtaining reduction of these fractures. By supporting the
patient's thorax rather than directly on the anterior pelvis, the axial skeleton will be
stabilized proximally, allowing the hemipelvis to hang free and reduce anteriorly.
Landmarks
The posterior-superior iliac spine as well as the entire iliac crest should be palpated.
The spinous processes of the sacrum and lumbar vertebrae should be identified.

Technique
Incision: the incision is longitudinal in direction (Fig. 6-2). It can be translated
medially or laterally as appropriate for the particular type of fracture. For
sacral fractures, a more medially based incision is appropriate, whereas for
crescent type fractures or pure sacroiliac dislocations, the incision can be
made based more laterally. For a crescent fracture or sacroiliac dislocation,
the incision
P.124
should be just lateral to the posterior-superior iliac spine. It may be curved
laterally as it can fall in line with the iliac crest as it travels anteriorly and
laterally. However, a vertical incision also can be useful to gain full exposure.
In thinner patients, an incision directly over the posterior-superior iliac spine
should be avoided, as the subcutaneous location of the bony prominence may
cause difficulty with wound healing and breakdown.

Note: Injection of lidocaine and epinephrine mixtures into the surgical

site before making the skin incision can assist in controlling bleeding in
the area. There is often a large amount of subcutaneous adipose in this
region with significant vascularity that can bleed throughout the case
and cause exposure and visualization to be difficult, so careful
attention to gaining hemostasis throughout the subcutaneous dissection
is important.

The gluteus maximus is identified as it inserts onto the posterior-superior iliac

spine and iliac crest. It is incised in the tendinous portion along the posterior-
superior iliac spine, leaving a cuff of tissue on the posterior-superior iliac spine
for later repair (Fig. 6-3).

As the dissection extends posteriorly, the gluteal tendon is incised toward the
midline over the sacrum. This allows complete retraction of the gluteus
maximus and exposure of the posterior-superior iliac spine as well as the
posterior aspect of the ilium. Care should be taken to not disturb the
underlying paraspinal muscles, particularly the multifidus, unless dissection
onto the sacrum is necessary. For most sacroiliac dislocations and crescent
fractures, these paraspinal muscles can be left undisturbed. For sacral
fractures, the injury and initial displacement of the
P.125
fracture has often caused severe injury to the paraspinal muscles and some
local debridement during the approach may be all that is necessary in order to
fully visualize the fracture.

The gluteus maximus is elevated subperiosteally along the posterior aspect of

the ilium distally to the greater sciatic notch, giving access to the entire
crescent fracture and sacroiliac joint (Fig. 6-4).

Finger palpation beneath the greater sciatic notch can be utilized to assess
anterior reduction of a sacroiliac dislocation. Exposure of the greater sciatic
notch will allow placement of a reduction clamp to correct the vertical
displacement of the hemipelvis that occurs in posterior pelvic ring injuries.
Care should be taken during dissection into the greater sciatic notch to protect
the sciatic nerve as well as the superior gluteal vessels and nerve (Fig. 6-5).

Once reduction and fixation of the posterior ring is completed, care should be
taken to repair the gluteus maximus insertion in its tendinous portion using a
heavy permanent suture such as 0-Ethibon. Subcutaneous tissue should be
closed in multiple layers as well, and drain placement is recommended
depending on the amount of hemorrhage encountered.
FIGURE 6-1 The prone position allows gravity to assist in reduction of the fracture
and hemipelvis.
FIGURE 6-2 The posterior incision can be either curved or vertical in nature
depending on the exact location of the fracture.
FIGURE 6-3 The gluteus maximus tendon is identified as it inserts on the
posterior-superior iliac spine and as it inserts towards the midline distal to the
posterior-superior iliac spine. The tendon is incised leaving a cuff of tendon
medially for later repair.

FIGURE 6-4 The gluteus maximus is retracted laterally away from the sacroiliac
joint and can be retracted as far as the greater sciatic notch.
 FIGURE 6-5 The superior gluteal neurovascular bundle prevents further lateral
retraction of the gluteus maximus.

P.126

Pearls and Pitfalls

Avoid making an incision directly over the most prominent portion of the
posterior-superior iliac spine, particularly in thinner patients as this may be
very prominent and may break down as the patient lies on their back
recovering.

Subperiosteal dissection along the lateral aspect of the ilium can identify the
proximal extent of crescent fractures. Blunt retractors or malleable retractors
along the lateral aspect of the ilium can be utilized to visualize these fractures
and gain anatomic reduction. Additionally, sacroiliac screws may provide a
 large amount of stability to a fixation construct for sacroiliac dislocations and
crescent fractures. These screws should be placed away from the iliac fracture
line so they will not fail by breaking through into the fracture site, and this can
be visualized through this approach. However, percutaneous incisions will need
to be made over the lateral aspect of the gluteal region in order to place the
screws, as the necessary trajectory cannot be obtained through the posterior
approach to the sacroiliac joint.

APPROACH TO THE ACETABULUM THROUGH THE

ILIOINGUINAL APPROACH
Indications
Both column fractures of the acetabulum.

Anterior column posterior hemi-transverse fractures of the acetabulum.

Anterior column fractures.

In conjunction with the Kocher-Langenbeck approach for treatment and

fixation of transverse, and T-type acetabular fractures.

Position
The patient is positioned supine on a radiolucent table (Fig. 6-6). Traction is often
utilized before reduction of these cases and a table such as a Judet-Tasserit table or
Pro FX fracture table which is radiolucent and allows the use of traction in multiple
directions is optimal.

Landmarks
One should palpate the entire iliac crest as well as paying attention to the anterior-
superior iliac spine. The pubic tubercles and symphysis should be identified.

Technique
Incision: the incision follows the contour of the iliac crest from posterior to
anterior, and then is directed over the inguinal ligament to a point
approximately 2 cm proximal to the pubic symphysis (Fig. 6-7).

P.127
The abdominal musculature is identified as it inserts on the iliac crest. The
aponeurosis of the abdominal muscles terminates just proximal to an avascular
zone between the hip abductors and abdominal musculature. This zone is
identified and this interval should be split directly down to the iliac crest (Fig.
6-8).

Subperiosteal dissection along the iliac crest with elevation of the abdominal
musculature insertion is performed to gain access to the inner table of the
pelvis, exposing the lateral window. Once the lateral window has been exposed
and the iliopsoas has been elevated off the inner fossa, this area of the wound
should be packed with lap sponges and the exposure should continue distally.

The skin incision is then extended from the anterior-superior iliac spine to an
area approximately 2 cm proximal to the pubic symphysis.

The external abdominal oblique musculature and fascia is identified as the

fibers course in a direction from superolateral to inferomedial towards the
superficial inguinal ring. The spermatic cord should be identified and a Penrose
drain should be placed around it to protect it and allow retraction medially and
laterally (Fig. 6-9).

P.128
The external abdominal oblique is split in line with its fibers just proximal to
its insertion on the inguinal ligament (Fig. 6-10). Dissection should be
continued down towards the inferior aspect of the superficial inguinal ring. If
possible the superficial ring should be kept in place so that a later repair is not
necessary.

At this point the combined tendon of the internal abdominal oblique and
transverse abdominus muscle is identified as it inserts on the inguinal ligament.
This conjoined tendon should be incised in line with its fibers near its insertion
on the inguinal ligament giving ample amount of tendon on both sides of the
incision to repair at the end of the case (Fig. 6-11).
The lateral femoral cutaneous nerve is identified crossing over the psoas
muscle near the anterior-superior iliac spine. This nerve may need to be
sacrificed for complete exposure of the acetabulum; however, initial attempts
should be made to protect and save this nerve.

The psoas muscle and femoral nerve should be identified. These structures
should be kept together and a Penrose drain should be placed around them in
their entirety (Fig. 6-12). Care should be taken to elevate the psoas off of the
internal fossa of the ilium in its entirety so that trauma to the muscle is
minimized.

Once the entire psoas muscle and femoral nerve are protected with a Penrose
drain, they can be retracted laterally. The iliopectineal fascia is identified and
very careful dissection just medial
P.129
to this should be performed to separate it from the external iliac vessels. Once
the iliopectineal fascia is separated from the external iliac vessels, a finger
should be placed between the fascia and the vessels to palpate the pulse and
confirm the vessels are medial to the finger.

Once the external iliac vessels are confirmed to be medial and the fascia is
isolated, scissors are used to split the iliopectineal fascia all the way to the
pelvic brim (Fig. 6-13).

With the combined tendon of the transversalis abdominus and internal

abdominal oblique incised near its insertion, dissection should now proceed
medially. A small portion of the rectus abdominus muscle will need to be
incised transversely as it inserts on the pubic tubercle just medial to the
spermatic cord or round ligament (Fig. 6-14). This will allow for exposure of
the medial side of the external iliac vessels.

Circumferential access to the external iliac vessels can now be gained by

placing a Penrose drain around the bundle and it can now be retracted
medially and laterally (Fig. 6-15).

Once this is performed, all three windows of the ilioinguinal approach have
been exposed and reduction and fixation of the acetabular fracture can be
performed.
Following fixation, care should be taken to tightly repair the structures in the
inguinal region to prevent postoperative hernia development. After thorough
irritation of the wound, the portion of the transected rectus abdominus is
reapproximated using interrupted 0-Ethibon sutures. Next, the internal
abdominal oblique and transversalis abdominus conjoined tendon is repaired
back to the inguinal ligament using multiple 0-Ethibon sutures.

Note: Multiple single sutures are preferred in case one should break or
rupture, the remainder of the repair will stay intact.

A layered closure is preferred and the external abdominal oblique is then

closed using 0-Ethibon sutures. If care has been taken during the dissection to
preserve the superficial inguinal ring, the fascia can typically be closed just
below this and the ring will be intact.

A drain can be placed in the lateral aspect of the wound, resting in the
internal iliac fossa. The abdominal aponeurosis can then be reapproximated
using multiple 0-Ethibon sutures. The subcutaneous tissue is closed in layers
and the skin is closed with either a nonabsorbable monofilament suture or a
staple.
FIGURE 6-6 Patient is positioned supine on a radiolucent fracture table allowing
bilateral skin traction with a perineal post in place.
FIGURE 6-7 Incision is made over the iliac crest, anterior-superior iliac spine, and
pubic symphysis.
FIGURE 6-8 The abdominal muscles are incised at their aponeurosis and elevated
from the iliac crest.
FIGURE 6-9 The external abdominal oblique and spermatic cord are identified and
circumferential control of the spermatic cord is gained.
FIGURE 6-10 The external abdominal oblique fascia is identified and split in line
with its fibers proximal to the inguinal ligament.
FIGURE 6-11 The combined tendon of the internal abdominal oblique and
tranversalis abdominus is identified and incised near its insertion on the inguinal
ligament.
 FIGURE 6-12 Circumferential control of the psoas muscle and femoral nerve are
obtained with a Penrose drain placed around the structures.

Pearls and Pitfalls

Exposure can be very difficult in obese patients and consideration should be

given to adjusting the incision slightly proximal in order to gain the appropriate
trajectory for screw and hardware placement. By moving the incision just
proximal a few centimeters this amount of soft tissue will not need to be
retracted as much during the case and appropriate trajectory of the screw can
be obtained.

P.130
The femoral nerve should be clearly identified as it sits on the psoas muscle
prior to placing a Penrose drain around this neuromuscular group. The femoral
nerve may occasionally have multiple branches and care should be taken not to
divide them or retract ones without having control of all of them.

Retraction of the external iliac vessel should be performed carefully. Malleable

retractors can be placed in the middle window to retract the vessels medially;
however, care should be taken so that the sharp edges of the malleable
retractors do not impinge on the external vessels. In patients who are older or
who have known atherosclerotic disease, care should be taken to avoid
excessive or aggressive retraction of these vessels as plaques may dislodge or
intimal damage may occur.
FIGURE 6-13 The iliopectineal fascia is identified and split down to the pelvic rim.
FIGURE 6-14 The rectus abdominus is transected just medial to the spermatic
cord.

P.131
 FIGURE 6-15 Circumferential control of external iliac neurovascular bundle is
obtained.

APPROACH TO THE PUBIC SYMPHYSIS AND STOPPA

APPROACH
Indication
Open reduction and internal fixation of pubic symphyseal diastasis.

Open reduction and internal fixation of pubic rami fractures and

parasymphyseal pubic fractures.

Open reduction and internal fixation of the quadrilateral surface of the

acetabulum and low anterior column fractures.

Anterior plate fixation of pelvic discontinuity for total hip reconstruction.

Position
The patient is positioned supine on the radiolucent table. Skeletal traction is generally
not necessary for this approach and the perineal posts may actually get in the way of
exposure and manipulative procedures.

Landmarks
Identify the pubic tubercles and superior edge of the pubic bodies and superior rami.

Technique
1. Incision: identify the midline of the abdomen over the pubic symphysis, and make a
transverse Pfannenstiel type incision which is in-line with the skin creases in the
suprasymphyseal region (Fig. 6-16). The incision is made 1 to 2 cm proximal to the
pubic symphysis. This incision may move further proximal in patients who are more
obese to allow appropriate trajectory of screw plates into the pubic bodies.

2. The dissection is carried through the skin and subcutaneous tissues gaining
hemostasis along the way. The rectus abdominus muscles are identified. They need to
be split in the midline and then elevated off the pubic tubercles leaving a distally
based insertion. The pyramidalis muscle may be identified inferiorly in the wound, and
oblique fibers of the rectus fascia will tend to point to the midline and can be found
crossing in the raphe of the rectus abdominus.

3. Once the midline of the rectus abdominus is identified, a small vertical incision is
made just over the pubic symphysis. This incision should go through the rectus fascia
and be approximately 5 mm in length, just long enough to allow placement of the right
angle clamp through this incision aimed proximally.

P.132

FIGURE 6-16 The incision is based just proximal to the superior aspect of the
pubic body and superior pubic rami.
4. With anterior retraction and elevation of this clamp, the rectus is lifted off of the
underlying bladder and prevesicular fat. The fascia can then be incised directly onto
the right angle clamp as it is translated proximally as the fascia and muscle are split
(Fig. 6-17).

5. Once the rectus abdominus is split in its midline, access to the space of Retzius is
obtained. The rectus should be elevated directly off the tubercles by retracting the
rectus anteriorly. The distal insertion of the rectus should be maintained and
transection of the rectus abdominus should be avoided for this approach.

6. Once dissection is carried over the pubic tubercles, pointed Holman retractors can
be placed over the tubercles to retract the rectus laterally and gain access to the
symphysis and anterior aspect of the pubic bodies.

7. Reduction and fixation of pubic symphysis diastasis or parasymphyseal fractures can

then be performed.
 FIGURE 6-17 The rectus abdominus is split in line with its fibers and elevated off
the pubic tubercles.

P.133

Alternate Exposure
8. A Stoppa approach can be performed through this incision by dissection along the
pubic ramus to the quadrilateral surface of the acetabulum. Often a headlamp is
utilized because of the relatively deep nature of this wound.

9. Dissection is carried along the desired pubic ramus towards the quadrilateral
surface. Great care should be taken to observe the corona mortis as it anastomoses
between the external iliac vessels and the obturator vessels, crossing the superior
pubic ramus 4 to 6 cm lateral to the pubic symphysis (Fig. 6-18).

10. This anastomosis will need to be identified, carefully dissected out, and then
ligated prior to full exposure of the quadrilateral surface and pelvic brim. As long as
dissection is maintained along the pelvic brim and quadrilateral surface, the soft
tissues can be retracted superiorly and inferiorly and access to the spaces can be
obtained. Malleable retractors can be utilized to retract the peritoneal cavity
medially.

11. Through this approach, access can be gained along the quadrilateral surface all the
way to the sacroiliac joint (Fig. 6-19).

12. Following reduction and fixation of the anterior pelvic ring, the rectus abdominus
is closed with 0-Ethibon sutures. The subcutaneous tissue is then closed in multiple
layers and the skin is closed with either nylon or staples. Care should be taken during
closure of the rectus to avoid injury to the bladder and prevesicular fat.

Pearls and Pitfalls

The incision may be translated proximally in obese patients in order to gain

appropriate trajectory for hardware placement. Often the abdominal fat will
need to be retracted proximally and compressed in order to be able to place
screws down the pubic bodies and into the inferior pubic rami.

Transection of the rectus should be avoided if at all possible. Dissection can be

carried over the pubic tubercles to elevate the rectus abdominus leaving a
distally based insertion.

Retractors can be placed over the pubic tubercles but should not be placed so
far laterally as they enter into the obturator foramen due to potential injury to
the neurovascular structures in the region.
FIGURE 6-18 The exposure is extended along the superior pubic ramus to the
quadrilateral surface. The corona mortis is identified and ligated as it crosses the
pelvic brim.

P.134
 FIGURE 6-19 Access to the entire quadrilateral surface and pelvic brim. The
obturator nerve passes across the inferior aspect of the operative field.

APPROACH TO THE POSTERIOR PELVIS (KOCHER-

LANGENBECK APPROACH)
Indications
Open reduction and internal fixation of acetabular fractures.
 Posterior Wall

Posterior Column

Transverse Posterior Wall

Posterior Column-Posterior Wall

T-type

Transverse

Open irrigation and debridement of the hip joint.

Position
The Kocher-Langenbeck approach can be performed either in a lateral or prone
position. The patient should be kept with the operative knee flexed 90 degrees at all
times to remove tension from the sciatic nerve and to allow for intraoperative
retraction. By placing the patient in a prone position on a specialized fracture table,
knee flexion can be maintained by a special apparatus holding the traction boot on the
operative leg vertically (Fig. 6-20). A distal femoral traction pin can be attached to
the traction device to allow precise control of the amount of hip joint distraction.
Intraoperative sequential compression devices can also be placed when the patient is
in the prone position to help with the deep vein thrombosis (DVT) prophylaxis.

Landmarks
The posterior-superior iliac spine as well as the greater trochanter and lateral aspect
of the femur are identified.

Technique
Incision: the incision is in a line from the posterior superior iliac spine toward
the center of the greater trochanter and then extended distally on the lateral
aspect of the femur (Fig. 6-21). The incision can be gently curved at the
corner or it can be kept at a sharp angle.

The posterior incision over the gluteal region is made first and dissection is
carried through the skin and subcutaneous tissue gaining hemostasis through
the dissection. The fascia over the gluteus maximus and gluteal muscle fibers
are identified.

Note: In more obese patients, following this portion of the incision,

further palpation can be performed to determine the exact location of
the greater trochanter. If necessary, the incision can then be extended
more anteriorly to reach the center of the greater trochanter.

Once the incision has been made to the center of the greater trochanter, it is
extended distally along the line of the femur.

P.135
The iliotibial band and lateral thigh fascia are split in line with their fibers on
the lateral aspect of the femur. The fascial incision begins distally at a level
equal to the inferior gluteal fold of the skin, as this is the location of the
gluteus maximus tendinous sling. This tendon may need to be incised as it
inserts on the femur to allow sufficient posterior retraction of the flap.

Once this incision reaches the center of the greater trochanter the fascia over
gluteus maximus is then split in line with the underlying muscle fibers. The
muscle fibers of the gluteus maximus are then split by blunt finger dissection
(Fig. 6-22).

Once the gluteus maximus and iliotibial band have been split, and the posterior
flap is created, it can be held in place with large no. 5 Ethibond sutures tacked
to the posterior skin. The short external rotators are then identified. The
piriformis muscle is tagged approximately 1 cm from its insertion onto the
femur and retracted posteriorly.

The combined tendon of the gemellae and obturator internus are then
identified and tagged, again 1 cm from their insertion on the femur (Fig. 6-
23).

Note: Care should be taken not to incise these muscles closer than 1 cm
from the insertion on the femur in order to protect the blood supply to
the femoral head.
Dissection should not be carried into the quadratus femoris as the risk of
damage to the femoral head blood supply is encountered. Once the short
external rotators are tagged and retracted, subperiosteal dissection along the
retroacetabular surface is performed.

P.136
The piriformis muscle is elevated back to the greater sciatic notch and the
obturator internus and gemellae muscles are elevated back to their insertions
near the lesser sciatic notch (Fig. 6-24).

Posterior retraction of the obturator internus will provide a sling around the
sciatic nerve and protect it during retraction.

Once the lesser sciatic notch is then exposed, a retractor may be safely placed
into this notch as long as tension is kept on the obturator internus to protect
the sciatic nerve at all times.

Dissection can be performed beneath the gluteus minimus and the remainder
of hip abductor muscle anteriorly.

A Homan retractor can be placed beneath the hip abductors to gain access to
the superior aspect of the acetabulum and more anteriorly for placement of
hardware in this region.

Following reduction and fixation of the acetabular fracture, the short external
rotators are reapproximated to the greater trochanter. If the patient is in a
prone position and the fracture table allows for it, the leg may be externally
rotated to allow for a tension-free repair of the short external rotators.

Ethibond sutures are utilized through either a drill hole in the trochanter or by
suturing them into the tendinous portion of the hip abductors as they insert on
the greater trochanter. The posterior flap is then closed using 0-Ethibon
sutures both laterally and posteriorly over the gluteus maximus. The
subcutaneous tissue is closed in multiple layers and the skin is then closed with
either sutures or staples.
FIGURE 6-20 Prone position of the patient on the fracture table with the distal
femoral traction pin, knee flexed in 90 degrees, and sequential compression
device on the calf to assist in DVT prophylaxis.
FIGURE 6-21 The incision is based on line from the posterior-superior iliac spine to
the center of the greater trochanter and then extending distally in line with the
femur.
 FIGURE 6-22 The posterior muscular flap is made by incising the iliotibial band
fascia in line with its fibers and the gluteus maximus in line with its fibers. The
gluteus maximus tendon insertion on the femur may need to be incised for further
posterior retraction of the flap.

Pearls and Pitfalls

If performed in the prone position, initial internal rotation of the leg during
exposure will place the short external rotators in a stretched position and
allow easier identification and exposure of the tendinous portions of these
muscles.

Incision of a portion of the gluteus maximus tendinous sling that inserts on the
femur may be required if in extremely muscular patients or obese patients in
which further posterior retraction of the muscle flap is necessary.

Placing the patient in a prone position with distal femoral traction pin and
peroneal post-traction may facilitate exposure of the hip. Traction can be
applied using the table's traction mechanism and the hip joint can be
distracted to allow debridement any intra-articular fragments and to assess the
femoral head for articular cartilage injuries.

P.137
FIGURE 6-23 The piriformis and obturator internus muscles are identified and
tagged and incised 1 cm away from their insertion into the femur.

FIGURE 6-24 Dissection underneath the piriformis and obturator internus to the
greater and lesser sciatic notches, respectively, with continual traction on the
obturator internus to protect the sciatic nerve.

P.138
APPROACH TO THE ACETABULUM THROUGH THE
EXTENDED ILIOFEMORAL APPROACH
Indications
The extended iliofemoral approach is rarely utilized in the routine treatment of
acetabular fractures. The majority of complex fractures can be managed through
combined ilioinguinal and Kocher-Langenbeck approaches before an iliofemoral
approach would be necessary. However, certain transtectal transverse or T-type
acetabular fractures with impaction of the acetabular dome or associated posterior
wall fractures are still best treated through the extended iliofemoral approach. This
approach may also be useful for treatment of older or malunited fractures.

Position
The extended iliofemoral approach requires the patient to be placed in the lateral
position in order to gain access to the entire outer aspect of the ilium.

Landmarks
The iliac crest from the posterior-superior iliac spine to the anterior-superior iliac
spine should be identified, as well as the location of the lateral edge of the patella.

Technique
Incision: a curvilinear incision from the posterior-superior iliac spine to the
anterior-superior iliac spine is the continued in a line towards the lateral
border of the patella. The incision will need to be carried to the proximal mid-
thigh in order to provide adequate exposure (Fig. 6-25).

P.139
The tendinous interval between the abdominal and gluteal musculature is
identified along the iliac crest and the origins of the gluteal muscles are
released and elevated subperiostally to the greater sciatic notch (Fig. 6-26).
Continue this elevation anteriorly along the crest to release the tensor fascia
lata from its origin on the ilium.

Next, identify the fascia of the anterior thigh and incise it longitudinally on the
lateral border of the sartorius (Fig. 6-27). Develop the interval between the
sartorius and tensor fascia lata with blunt dissection.

Ascending branches of the lateral femoral circumflex artery may be

encountered in this interval and can safely be ligated to allow further exposure
(Fig. 6-28).

With the tensor fascia lata retracted laterally and the Sartorius retracted
medially, dissection is continued between the rectus femoris medially and
gluteus medius laterally. The reflected head of rectus femoris tendon can be
released from its origin on the supraacetabular ilium.

The gluteus minimus is elevated from the ilium and hip capsule, and its tendon
is incised near the insertion on the greater trochanter, leaving a tendinous cuff
for later repair. Next, the gluteus medius tendon is incised near its insertion on
the greater trochanter, taking care to leave a tendinous cuff on the greater
trochanter for later repair (Fig. 6-29).

Dissection is now carried posteriorly on the greater trochanter to release the

insertion of the piriformis, gemellae, and obturator internus.

These tendons should be released at least 1 cm from their insertions on the

femur in order to protect the remaining blood supply to the femoral head. The
external rotators can now be elevated off the posterior capsule and
retroacetabular surface of the ilium to the greater and lesser sciatic notches
(Fig. 6-30).

Continuous retraction of the obturator internus posteriorly will provide a

protective sling in front of the sciatic nerve and retractors may be placed in
the greater or lesser sciatic notches.

If further exposure of the anterior column is necessary, the origin of the

Sartorius and inguinal ligament may be released from the anterior superior iliac
spine. The aponeurotic insertion of the abdominal muscles can be released
posteriorly along the iliac crest in a similar fashion to the exposure of the
lateral window of the ilioinguinal approach.

Superiosteal dissection along the inner table of the ilium will elevate the
iliopsoas to the pelvic brim.
 Note: An alternative to complete release of all structures from the
anterior-superior iliac spine and iliac crest is to osteotomize the iliac
crest while maintaining the inguinal ligament, Sartorius, and abdominal
musculature insertions and origins on the ilium. Predrilling the
osteotomy will allow easier reduction and fixation during closure.

Following fracture reduction and fixation, close attention must be paid to

repair of the multiple tendons that have been released from their origins and
insertions. Closure begins at the posterior inferior aspect of the greater
trochanter. The obturator internus and gemellae common tendon is repaired
with a permanent suture, size 0 or larger. The piriformis is repaired next in the
same fashion. Working anteriorly on the greater trochanter, the gluteus medius
tendon and gluteus minimus tendons are repaired next, respectively. Again,
large permanent suture is preferred for this repair, using size 1 suture or
larger. Repair of the reflected head of the rectus femoris follows the gluteal
tendon repairs.

The hip abductors are repaired back to the abdominal aponeurosis and
lumbodorsal fascia using multiple interrupted sutures with the hip held in an
abducted position. The fascia over the Sartorius is repaired to complete the
deep closure. Layered closure of the subcutaneous tissues and skin follows to
complete the procedure.

Due to the necessary elevation of the hip abductors from both the ilium and
greater trochanter, postoperative protection of the hip is required.

After surgery patients should be maintained in a hip abduction pillow in the

initial postoperative period and should be restricted from active abduction for
6 weeks or more.

Note: This exposure has been associated with a high incidence of

heterotopic ossification, so consideration of prophylaxis with radiation
or indomethacin should be given.
FIGURE 6-25 Patient is placed in the lateral position with the entire iliac crest
and thigh prepped into the surgical field. The incision follows the contour of the
iliac crest from the posterior superior iliac spine to the anterior superior iliac
spine and then down the anterior thigh in a line toward the lateral border of the
patella.
FIGURE 6-26 The gluteal muscles are released at their origin near the aponeurosis
of the abdominal musculature and subperiosteal dissection is carried out towards
the greater sciatic notch.
FIGURE 6-27 The fascia over the thigh is split in line with the femur and the
interval between the sartorius (medially) and tensor fascia lata (laterally) is
developed. (i) Avascular white line. (ii) Tensor fascia-lata muscle. (iii) Gluteus
medius muscle. (iv) Gluteus minimus muscle. (v) Rectus femoris muscle. (vi)
Sartorius muscle. (vii) No-name fascia covering vastus lateralis. (viii) Ascending
branch of the lateral, femoral, circumflex artery.

P.140
FIGURE 6-28 The ascending branches of the lateral circumflex femoral artery are
identified in the interval between the Sartorius and tensor fascia lata and ligated.
(i) Tensor fascia-lata muscle. (ii) Gluteus medius muscle. (iii) Gluteus minimus
muscle. (iv) Greater trochanter. (v) Piriformis muscle. (vi) Hip joint capsule. (vii)
Two heads of the rectus muscle. (vii) Ligated ascending branch of the lateral,
femoral, circumflex artery.