import { ComparisonTable, ContentSection, EvidenceCard, ExamCheatSheet, ExamPearl, ExamWarning, InfoCard, InfoCardGrid, MedicalImage, MnemonicCard, OnePagerSummary, SafetyAlert, Tab, Tabs, Timeline, TimelineItem, VivaScenario, VivaScenarioSection } from '@/components/mdx' {/* SECTION 1: ONE-PAGER SUMMARY */} {/* SECTION 2: EXAM WARNING */} **Greater trochanter osteotomy is mandatory** for this approach. It must be adequately large (include vastus ridge), rigidly fixed at closure (wires plus screws or cable plate), and protected post-operatively to heal. Nonunion or migration occurs in 5-10% despite best technique. **Highest HO risk of any approach** - 40-60% incidence without prophylaxis. Extensive soft tissue stripping and muscle trauma cause ectopic bone formation. Prophylaxis with indomethacin AND radiation may be needed. Can severely limit hip motion. Just as in Kocher-Langenbeck, the **sciatic nerve is at significant risk**. Identify early, protect throughout, repair external rotators. Extended dissection increases nerve injury risk compared to isolated K-L approach. The main advantage is **360-degree acetabular access** through one incision, avoiding need for patient repositioning. However, this comes at cost of extensive soft tissue trauma, high complication rates, and prolonged surgery. Most surgeons now prefer two separate approaches. {/* SECTION 2.5: QUICK DECISION GUIDE */} {/* SECTION 3: MNEMONICS */} {/* SECTION 4: OVERVIEW */} The **extended iliofemoral approach** was described by Emile Letournel as the most extensile approach to the acetabulum, providing 360-degree access through a single incision. It combines elements of both the ilioinguinal and Kocher-Langenbeck approaches. **Historical development:** - **Letournel (1960s-1970s)**: Described for complex both-column fractures - **Original indication**: Avoid two separate incisions and patient repositioning - **Peak use (1980s-1990s)**: Widely adopted for both-column fractures - **Modern trend**: Declining use in favor of staged two-incision approaches **Why use has declined:** - **Very high complication rates**: HO 40-60%, nerve injury 15-20%, trochanteric nonunion 5-10% - **Steep learning curve**: Requires expertise in both anterior and posterior pelvic surgery - **Better alternatives**: Staged two-incision approaches have lower morbidity - **Improved perioperative care**: Two separate surgeries no longer as problematic The extended iliofemoral approach still has selective indications: (1) **Both-column fractures in young patients** where anatomic reduction is critical and surgeon has extensive experience with the approach, (2) **Complex T-type fractures** requiring extensive anterior and posterior exposure, (3) **Revision surgery** after failed prior fixation where access to both columns needed. Most surgeons now reserve it for specific cases rather than routine use. **Current indications:** - Both-column fractures (alternative to two-incision) - Complex T-type fractures - Anterior column + posterior hemitransverse - Revision surgery requiring both column access - Typically reserved for surgeons with extensive pelvic surgery experience {/* SECTION 5: ANATOMY */} The extended iliofemoral approach **combines the ilioinguinal and Kocher-Langenbeck approaches** through a single lateral incision with trochanteric osteotomy. **Key anatomical access:** - **Anterior column**: Accessed via lateral window (iliac wing) and anterior reflection - **Posterior column**: Accessed via posterior reflection after trochanteric osteotomy - **Pelvic brim**: Visible through middle exposure - **Quadrilateral surface**: Accessible but limited compared to Stoppa **Critical structures:** **Trochanteric osteotomy anatomy:** - Must include **vastus ridge** laterally for adequate fixation surface - Preserves abductor mechanism attachment - Allows abductors to be reflected proximally, exposing posterior column - Typical thickness 1.5-2.0cm {/* SECTION 5.5: INTERNERVOUS PLANE */} Unlike the standard ilioinguinal or Kocher-Langenbeck approaches, the extended iliofemoral approach does **NOT have a true internervous plane**. The exposure requires a **trochanteric osteotomy** to elevate the abductor muscles (Gluteus Medius and Minimus, innervated by Superior Gluteal Nerve) and extensive soft tissue dissection. **Key Nervous Consideration:** The approach combines elements of both anterior (ilioinguinal) and posterior (Kocher-Langenbeck) dissections. The internervous plane of the anterior component (between Femoral and Obturator nerve territories) is exploited, but the posterior component works through muscle rather than between nerve territories. {/* SECTION 6: INDICATIONS */} **Both-column fractures:** - Complete articular dissociation from ilium - Spur sign present - Significant displacement of both columns requiring reduction - Young patients where anatomic reduction is critical **Complex T-type fractures:** - Transverse component plus anterior stem - Significant displacement requiring anterior and posterior fixation **Anterior column + posterior hemitransverse:** - High anterior column component - Posterior column extension The extended iliofemoral provides complete access but at cost of high complications. **Ideal candidates:** - Young patients (better healing, tolerate complications better) - High-functioning individuals where anatomic reduction critical - Complex fracture patterns requiring extensive exposure - Patients who can comply with prolonged rehabilitation **Poor candidates:** - Elderly or low-demand patients (consider acute arthroplasty) - Significant medical comorbidities (may not tolerate prolonged surgery) - Severe osteoporosis (fixation may fail) - Patients with high HO risk factors (previous HO, head injury, burns) Careful patient selection is essential given the high complication burden. **Staged two-incision approach:** - Kocher-Langenbeck + ilioinguinal or Stoppa - Lower HO risk, no trochanteric osteotomy needed - Two separate surgeries 3-7 days apart - **Increasingly preferred** by most surgeons **Simultaneous two-team approach:** - Both approaches done simultaneously - Requires two experienced pelvic surgeons - Single anesthesia but technically demanding **Modified approaches:** - Anterior intrapelvic (modified ilioinguinal + Stoppa concepts) - Selective use of percutaneous techniques for one column Most modern pelvic surgeons use extended iliofemoral sparingly, preferring two-incision approaches for most both-column fractures. {/* SECTION 7: SURGICAL TECHNIQUE */} **Patient Position:** - **Lateral decubitus** with affected side up - Secure with beanbag or pegboard - Entire limb prepped and draped free for manipulation **Setup Checklist:** 1. **C-arm**: Position to allow inlet, outlet, and Judet views from below. 2. **Surgeon**: Stands facing the patient's back (like K-L approach). 3. **Assistant**: Opposite side for retraction. 4. **Arm**: Free or on arm board, away from surgical field. {/* SECTION 7: SURGICAL TECHNIQUE */} **Skin incision:** - Extensive T-shaped or curved incision - Anterior limb along iliac crest from PSIS to ASIS - Posterior limb from greater trochanter distally along femur - Total length 25-35cm **Trochanteric osteotomy:** Include vastus ridge laterally for fixation surface Thickness 1.5-2.0cm Preserve soft tissue attachments to fragment Use oscillating saw Oblique cut from proximal-lateral to distal-medial Protect abductor soft tissues attached to fragment Elevate trochanter with attached abductors proximally This exposes posterior hip capsule and column Tag osteotomy fragment for later repair The trochanteric osteotomy is the key maneuver that allows complete posterior column access. **Anterior exposure:** - Develop internervous plane between tensor fascia lata and gluteus medius - Expose iliac wing and pelvic brim - Similar to lateral window of ilioinguinal **Posterior exposure:** - After trochanteric osteotomy, reflect abductors proximally - Identify and protect sciatic nerve - Release short external rotators (tag for repair) - Open posterior capsule - Expose posterior column from sciatic notch to ischium **Complete acetabular exposure:** - 360-degree access to acetabulum - Can work on anterior column, posterior column, or both - Allows comprehensive fracture reduction The extensive exposure is the approach's main advantage but requires meticulous technique. **Trochanteric osteotomy fixation:** **External rotator repair:** - Critical for sciatic nerve protection - Repair piriformis and conjoint tendon to trochanter - Use heavy non-absorbable suture **Layered closure:** - Fascia lata - Subcutaneous tissue - Skin - Deep drain placement Rigid trochanteric fixation is essential for healing and function. {/* SECTION 8: COMPLICATIONS */} The extended iliofemoral approach has the **highest HO risk of any orthopaedic procedure** at 40-60% without prophylaxis. **Dual prophylaxis should be strongly considered**: indomethacin 75mg daily for 6 weeks PLUS single-dose radiation 7-8 Gy within 72 hours. Some surgeons use both for extended iliofemoral given the catastrophic impact of severe HO on hip function. Even with prophylaxis, 10-20% develop some HO. {/* SECTION 9: POSTOPERATIVE CARE */} Toe-touch weight bearing only (protect osteotomy) Hip abduction exercises only (no active abduction) Passive ROM as tolerated Indomethacin 75mg daily for HO prophylaxis X-rays to assess trochanteric healing Progress to partial weight bearing if healing Begin active abduction exercises Continue ROM Full weight bearing when fracture and osteotomy healed Strengthening program Gait normalization Return to activities as tolerated Monitor for HO development (up to 18 months) Assess for trochanteric complications Hip arthroplasty consideration if severe arthritis develops **Extended recovery timeline:** - Longer than other acetabular approaches - Trochanteric healing adds 8-12 weeks - Full recovery may take 12-18 months - Some patients never regain normal gait {/* SECTION 10: EVIDENCE BASE */} {/* SECTION 11: VIVA SCENARIOS */} {/* SECTION 12: MCQ PRACTICE POINTS */} **Q: Why is trochanteric osteotomy mandatory in the extended iliofemoral approach?** A: The osteotomy allows the **abductor muscles to be reflected proximally with the trochanter**, providing access to the posterior column and posterior acetabulum. Without this, the approach cannot achieve 360-degree acetabular exposure. The osteotomy must include the vastus ridge for adequate fixation. **Q: What is the incidence of heterotopic ossification with extended iliofemoral approach and how is it prevented?** A: Extended iliofemoral has the **highest HO risk of any orthopaedic procedure at 40-60% without prophylaxis**. Prevention requires **dual prophylaxis**: indomethacin 75mg daily for 6 weeks PLUS single-dose radiation 7-8 Gy within 72 hours. Even with prophylaxis, 10-20% develop some HO. **Q: What is the primary indication for extended iliofemoral approach vs staged two-incision approach for both-column fractures?** A: Extended iliofemoral provides **360-degree acetabular access through single incision** avoiding patient repositioning. However, **most surgeons now prefer staged two-incision approaches** due to lower complications (20-30% HO vs 40-60%, no trochanteric osteotomy, lower nerve injury). Extended iliofemoral reserved for complex cases by experienced surgeons. **Q: What are the fixation options for trochanteric osteotomy and why is rigid fixation important?** A: Options include: (1) tension band wiring, (2) wires plus lag screws, (3) cable plate system. **Rigid fixation is critical** because nonunion occurs in 5-10% despite best technique, causing abductor weakness, Trendelenburg gait, and pain. Cable plate systems provide most rigid fixation with lowest failure rate. **Q: Why has the use of extended iliofemoral approach declined in recent decades?** A: The approach has **very high complication rates** (40-60% HO, trochanteric nonunion 5-10%, superior gluteal nerve injury 10-15%) with **no improvement in fracture outcomes** compared to staged two-incision approaches. Modern surgeons prefer lower-morbidity alternatives that achieve similar reduction quality. Extended iliofemoral now reserved for select cases. {/* SECTION 13: EXAM CHEAT SHEET */} **Trauma Centre Referral**: Complex acetabular fractures requiring the extended iliofemoral approach are typically managed at Level 1 trauma centres with subspecialty pelvic trauma expertise. The Australian Trauma Quality Improvement Program (AusTQIP) promotes centralisation of such cases. **HO Prophylaxis Guidelines**: Indomethacin 75mg daily for 6 weeks or single-dose radiation (7-8 Gy) is standard practice. PBS subsidisation of indomethacin makes pharmacological prophylaxis accessible. **Transfusion Considerations**: Australian Red Cross Blood Service guidelines apply. Cell salvage is routinely used for major pelvic surgery. Massive transfusion protocols are available at trauma centres. **Rehabilitation Pathway**: Extended recovery requiring 6-8 weeks protected weight bearing, with rehabilitation coordinated through hospital-based physiotherapy and transition to community services.

Extended Iliofemoral Approach to the Acetabulum

Extended Iliofemoral Approach to the Acetabulum