Extended Iliofemoral Approach to the Acetabulum

What it exposes. The extended iliofemoral is the most extensile approach to the acetabulum, providing 360-degree access through a single lateral incision. It exposes the anterior column (iliac wing to pelvic brim, via the lateral and inner-table windows), the posterior column (from the greater sciatic notch to the ischium, via posterior reflection of the abductors and short external rotators), and the pelvic brim and quadrilateral surface between them — the entire acetabulum in one field. Why a single incision. Described by Emile Letournel (1960s–1970s), the approach was conceived to avoid two separate incisions and the need to reposition the patient. It works the anterior column much like the ilioinguinal approach and the posterior column much like the Kocher-Langenbeck, combining both through one extensile lateral exposure. Its defining advantage remains single-position, single-incision 360-degree access. Indications (now selective). The approach is reserved for patterns that cannot be adequately reduced through a single anterior or posterior window: - Both-column (associated) fractures — complete articular dissociation from the ilium, the spur sign, significant displacement of both columns in young patients where anatomical reduction is critical (the primary indication)

• Complex T-type fractures — a transverse component plus an anterior stem, with significant displacement requiring anterior and posterior fixation
• Anterior column + posterior hemitransverse — a high anterior column component with posterior column extension
• Revision surgery after failed prior fixation where access to both columns is needed Why use has declined. Very high complication rates (HO 40–60% without prophylaxis, nerve injury 15–20%, trochanteric nonunion 5–10%), a steep learning curve, and the availability of lower-morbidity alternatives mean most modern pelvic surgeons now use it sparingly.

The alternatives. - Staged two-incision — Kocher-Langenbeck for the posterior column (patient lateral), then 3–7 days later an ilioinguinal or Stoppa for the anterior column (patient supine). Lower HO risk, no trochanteric osteotomy, uses two familiar approaches. Increasingly preferred.

• Simultaneous two-team — both approaches at once under a single anaesthetic; technically demanding and needs two experienced pelvic surgeons.
• Modified approaches — an anterior intrapelvic (modified ilioinguinal + Stoppa concepts) window, with selective percutaneous fixation of one column.

Position & landmarks. - Lateral decubitus, affected side up, secured on a beanbag or pegboard, with the entire limb prepped and draped free for manipulation

• C-arm positioned to allow inlet, outlet and Judet views from below; the surgeon stands facing the patient's back (as for the Kocher-Langenbeck), with the assistant opposite for retraction
• Landmarks: the iliac crest (PSIS to ASIS, the anterior limb) and the greater trochanter with the femoral shaft (the posterior limb)

Work down through the layers in the lateral position: develop the anterior abductor interval and strip the gluteal muscles off the iliac wing, perform the trochanteric osteotomy to reflect the abductors, then open the posterior column behind them — completing a single-incision 360-degree exposure of the acetabulum.

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The working planes. The approach is fundamentally an extensile lateral exposure. Anteriorly it develops the interval at the front of the abductor mass — between tensor fasciae latae (superior gluteal nerve) and sartorius (femoral nerve) — then strips subperiosteally off the outer iliac wing. Posteriorly, after the trochanteric osteotomy reflects the abductors, the working interval runs through and beneath gluteus maximus (inferior gluteal nerve), a muscle-splitting plane rather than a true internervous one. The whole abductor mass stays pedicled on the superior gluteal neurovascular bundle at the greater sciatic notch, which is therefore the structure most at risk during proximal abductor elevation and must be protected throughout. Trochanteric fixation options. Rigid fixation of the osteotomy is essential for healing and function — nonunion or migration occurs in 5–10% even with optimal technique.

Structures at risk, by layer

Complications — the highest burden of any acetabular approach

Recovery protocol. Rehabilitation is longer than for other acetabular approaches because both the fracture fixation and the trochanteric osteotomy must be protected.

• ORIF of both-column (associated) acetabular fractures — the primary indication, an alternative to a staged two-incision approach
• ORIF of complex T-type fractures requiring extensive anterior and posterior exposure
• ORIF of anterior column + posterior hemitransverse fractures
• Revision acetabular surgery after failed prior fixation requiring simultaneous both-column access
• Delayed or open reduction of complex patterns where extensive exposure aids reduction
• Excision of mature heterotopic ossification through the same extensile plane

Guidelines, Registries and Global Practice Centralisation of complex acetabular trauma. Across major trauma systems (AO Foundation, OTA in the US, BOA/BOAST pelvic and acetabular fracture standards in the UK, and equivalent national networks), displaced acetabular fractures requiring an extensile exposure are recommended for management in high-volume Level 1 centres with subspecialty pelvic/acetabular expertise. Outcome is volume-dependent: anatomical reduction rates and complication profiles improve with surgeon and unit experience. This is the single most consistent message across guidelines worldwide. Approach selection consensus. Contemporary international practice (reflected in AO and OTA teaching) favours a single working window where one can be used, with anterior intrapelvic / modified Stoppa approaches increasingly replacing the ilioinguinal, and reserves extensile or combined exposures for patterns that cannot otherwise be reduced. The extended iliofemoral is now used selectively rather than routinely. HO prophylaxis — side-by-side evidence. There is no single global standard, and practice genuinely differs by unit: - Indomethacin (typically 75 mg daily, or 25 mg three times daily, for about 6 weeks) — first-line in most centres; cheap and effective (Moore et al RCT)

• Single-dose radiation (700 to 800 cGy within about 72 hours) — equivalent efficacy in the randomised data but roughly 200 times more expensive and logistically demanding
• Combined indomethacin plus radiation — lowest reported HO incidence (Piatek et al) and favoured by some surgeons specifically for the extended iliofemoral given its very high baseline risk Registry and outcome context. Acetabular fracture surgery is not implant-registry tracked the way arthroplasty is (NJR, AJRR, AOANJRR, Swedish/Norwegian registries), but secondary total hip arthroplasty after an acetabular fracture IS captured in those arthroplasty registries and is a recognised, higher-complexity revision burden — reinforcing the value of achieving anatomical reduction at the index operation. Blood management. Major pelvic/acetabular surgery carries significant blood-loss risk. Intraoperative cell salvage and locally available massive-transfusion / patient-blood-management protocols are standard of care internationally; tranexamic acid is widely used to reduce transfusion requirement. Rehabilitation. Extended recovery with protected (toe-touch) weight bearing for about 6 to 8 weeks to protect both the fracture fixation and the trochanteric osteotomy, then graduated loading, coordinated through specialist physiotherapy regardless of healthcare system.