Modified ilioinguinal approach in combined surgical exposures for displaced acetabular fractures involving two columns
- Peng Wang†1, 2,
- Xiaodong Zhu†3,
- Peng Xu1,
- Yan Zhang1,
- Lubo Wang1,
- Xiangyan Liu4 and
- Weidong Mu1Email author
© The Author(s) 2016
Received: 12 December 2015
Accepted: 13 September 2016
Published: 19 September 2016
The purpose of this study is to assess the advantages of modified ilioinguinal approach in combined surgical exposures for displaced acetabular fractures involving two columns management. 73 patients with displaced acetabular fractures involving two columns underwent open reduction and internal fixation through combined surgical approaches between 2006 and 2014 in our hospital. The modified ilioinguinal approach combined with Kocher–Langenbeck approach group (group A) included 46 patients. The standard ilioinguinal approach combined with Kocher–Langenbeck approach group (group B) included 27 patients. Outcome was assessed in operative time, blood loss, function outcomes and complications. In group A, the average operative time was 123.2 min, and the average blood loss was 586.2 ml. Anatomic reduction was achieved in 39 patients (84.8 %). The functional recovery was good in 37 patients (80.4 %). Complications related to the approach were observed in 10 patients (21.7 %). In group B, the average operative time was 161.5 min, and the average blood loss was 830 ml. Anatomic reduction was achieved in 24 patients (88.9 %). The functional recovery was good in 22 patients (81.5 %). Complications related to the approach were observed in 9 patients (33.3 %). This study demonstrates that both combined approaches permits good postoperative function results for treatment of acetabular fractures involving two columns. However, the modified ilioinguinal approach combined with Kocher–Langenbeck approach provides less operative time, blood loss and complications.
KeywordsMinimally invasive Ilioinguinal approach Kocher–Langenbeck approach Acetabular fracture
Surgical treatment for acetabular fractures is difficult and technically demanding. Most of the acetabular fractures can be treated with a single operative approach (Grubor et al. 2015). However, there are four types complex acetabular fractures involving two columns including transverse fractures, associated transverse and posterior wall fractures, T-shape fractures and both-column fractures, according to the Judet and Letournel classification system (Letournel 1980). Treatment for this complex situation is particularly challenging. The combination of an anterior ilioinguinal and posterior Kocher–Langenbeck approach is usually considered. Routine approaches had serious complications such as increased morbidity due to longer operative time, injuries to the inguinal neurovascular bundle or concomitant lymphatic structures, greater blood loss, infection, abductor weakness, hernias and heterotopic ossification (Matta 1994; Kloen et al. 2002; Helfet and Schmeling 1994; Rommens et al. 1997). To reduce complications related with approach, several modifications approaches are accepted alternatives, especially anterior modifications based on the ilioinguinal approach (Jakob et al. 2006). The purpose of this study is to assess clinical efficiency using the modified ilioinguinal approach combined with Kocher–Langenbeck approach for displaced acetabular fractures involving two columns. We hypothesize that this minimally invasive anterior approach in combined surgical exposures provides: (1) less invasive soft-tissue dissection for less operative time and blood loss, (2) good postoperative functional outcomes, and (3) less postoperative complications.
Postoperative antibiotics were continued for 24 h and drains were removed 24–48 h postoperatively. Patients routinely received deep vein thrombosis prophylaxis for 4 weeks. All patients’ foot-flat weight bearing was not allowed for at least 6–8 weeks depending on the type of the injury.
Parametric data, such as operative time and blood loss, were expressed as means ± standard deviations and compared using Student’s t test. Nominal variables were expressed as % values and were evaluated using Fisher Exact test. Analysis of the data was performed using SPSS 20.0 (SPSS, Inc., Chicago, IL). A p value of <0.05 was considered statistically significant. Reduction of the articular surface was graded based on the immediate post-operative radiographs as anatomic (<1 mm of displacement), fair (1–3 mm of displacement), poor (>3 mm of displacement) (Matta and Tornetta III 1996). The Harris hip scale was used to assess the functional outcomes.
Patient demographics and characteristics
Number of case
Age in years (mean ± SD)
46.2 ± 3.12
44.9 ± 2.36
Acetabular fracture type (Judet and Letournel)
Associated transverse and posterior wall
Surgical data of 73 patients with acetabular fractures involving two columns
Operation time (min)
123.2 ± 6.83
161.5 ± 8.16
Blood loss (ml)
586.2 ± 56.3
830.0 ± 82.0
Radiological end-result (residual displacement)
Anatomic (0–l mm)
39 (84.8 %)
24 (88.9 %)
Fair (l–3 mm)
5 (10.9 %)
2 (7.4 %)
Poor (>3 mm)
2 (4.3 %)
1 (3.7 %)
Functional result (Harris hip score)
37 (80.4 %)
22 (81.5 %)
5 (10.9 %)
3 (11.1 %)
4 (8.7 %)
2 (7.4 %)
10 (21.7 %)
9 (33.3 %)
Superficial wound infection
Lateral cutaneous nerve lesion
Deep venous thrombosis
Necrosis of the femoral head
In group A, 39 patients (84.8 %) had anatomic results, 5 patients (10.9 %) had fair results, and 2 patients (4.3 %) had a poor result. Meanwhile, anatomic results were achieved in 24 cases (88.9 %), fair results in 2 cases (7.4 %), and poor results in 1 case (3.7 %) in group B. The quality of reduction between the two groups was not significantly different (p > 0.05) (Table 2).
In group A, Harris hip scale more than 80 points were obtained in 37 patients (80.4 %), 60–79 points in 5 patients (10.9 %) and less than 60 points in 4 patients (8.7 %). In group B, Harris hip scale more than 80 points were obtained in 22 patients (81.5 %), 60–79 points in 3 patients (11.1 %) and less than 60 points in 2 patients (7.4 %). The mean Harris hip scale scores between the 2 groups showed no significant difference between the groups (p > 0.05) (Table 2).
The mean complication rate was 21.7 % (10 patients) in group A and 33.3 % (9 patients) in group B. In group A, osteonecrosis of the femoral head was observed in 2 cases. There were 4 deep vein thromboses documented with sonography. Heterotopic ossification was recorded in 3 patients. Lateral cutaneous nerve iatrogenic lesion resulted in 1 case and recovered after 6 weeks. In group B, Superficial infection was observed in 1 case. Osteonecrosis of the femoral head was observed in 2 cases. There were 2 deep vein thromboses documented with sonography. Heterotopic ossification was recorded in 4 patients. The mean complication rate between the 2 groups showed no significant difference between the groups (p > 0.05) (Table 2).
Open reduction internal fixation is gold standard and widely used for the treatment of displaced acetabulum fractures. Achieving good reduction of acetabular and satisfactory postoperative function is highly dependent on choosing the appropriate surgical approach. The operative approaches for treatment of displaced acetabular fractures includes: the anterior ilioinguinal approach, the posterior Kocher–Langenbeck approach, the extended iliofemoral approach and combined approaches. According to Judet and Letournel’s classification, there were five elementary fractures and five associated fractures. Based on this classification, Matta (1996) suggested a single surgical approach for six of ten acetabular fractures. Fracture of anterior wall, fracture of anterior column and fractures of the anterior column associated posterior hemi-transverse could be treated with the ilioinguinal approach. Fracture of posterior wall, fracture of posterior column, and fractures of the posterior column and posterior wall could be treated with the Kocher–Langenbeck approach. The surgical approach for the four remaining fracture types, transverse fracture, associated transverse and posterior wall fractures, T-shape fracture and both-column fractures was inconsistent. Those four type fractures involved two columns. Usually, the combination of an anterior and posterior approach should be considered when treat with those complex fractures.
In the 1960s, Letournel established the ilioinguinal approach for the treatment of pelvic ring and acetabular fractures (Letournel 1961). The ilioinguinal approach provides wide access to the anterior column of acetabulum. However, entire detachment of anterior part of the abdominal wall from the ilium or the inguinal ligament, may result in many soft tissue complications associated with this approach, such as postoperative wound infections, iatrogenic injury to the femoral nerve and the iliofemoral blood vessels (Matta 2006; Helfet et al. 1992). To reduce those complications, a modified ilioinguinal approach has been wide used currently (Yang et al. 2015). Using the modified ilioinguinal approach in combined surgical exposures may archive less complications and good functional outcomes in the management of acetabulum fractures involving two columns. However there is no clinical evidence to confirm its efficiency. The purpose of this study is to assess the operative time, blood loss, function outcomes and complications of modified ilioinguinal approach in combined surgical exposures for complex acetabular fractures management.
In this study, we firstly present our experience of using the modified ilioinguinal approach combined with K–L approach for acetabular fractures involving two columns. The main difficulty in this approach is to detach the iliopubic ligament. The middle iliopubic ligament is strong and difficult to dissect. A long sharp scissor can be used to release it from the iliopectineal eminence. After this stage, there is a subperiosteal “tunnel” between the two windows. The femoral vascular and iliopsoas muscles together with the femoral nerve as the whole bundle are retracted anteriorly and medially. The internal iliac fossa and lateral parts of the anterior column of acetabulum are exposured. In acetabular fractures, the primary objective is the perfect reduction of the both column. Reduction is facilitated with various techniques, including the use of clamps such as a modified Weber clamp, direct pressure with a Cobb elevator or ball-tipped spike pusher, traction with Schanz screws inserted into iliac crest or anterior inferior iliac spine percutaneously, the use of lag screws, reduction with a plate, and other reduction maneuvers that typically are used in acetabular surgery. Temporary K-wires fixations as a conventional and useful method allow maintaining the fracture reduction. In our opinion, this modified ilioinguinal approach offers satisfactory reduction and stable internal fixation for the anterior parts of the acetabular fracture patterns. More important, this approach avoids the surgical dissection of the soft tissue structures in the inguinal part and rectus abdominis. Therefore, this modified ilioinguinal approach is used for displaced acetabular fracture with the following advantages: (1) less invasive dissection without exposure of the femoral nerve, the external iliac vessels and lymphatic channels of the inguinal canal, which is associated with nerve injury, thrombosis and lymphedema, (2) less surgical duration, bleeding and postoperative complications such as heterotopic ossification, (3) preserving circulation of hip joint from ischemia, and (4) rectus abdominis intact offers additional benefits for early functional training. However, there is a risk to injury the corona mortis. For this reason, familiarity with the anatomic structure is essential before using this minimal invasive approach.
Due to the modified ilioinguinal approach mainly for the fractures of the anterior portion of acetabulum, the combined Kocher–Langenbeck approach should be considered for acetabulum fractures involving two columns. The indications for using the combined approach include most comminuted transverse fractures, associated transverse and posterior wall fractures, T-shape fractures and both-column fractures (Harris et al. 2008).
Our aim was to determine whether less complications and good functional outcomes of displaced acetabular fractures involving two columns, could be obtained by use of the modified ilioinguinal approach combined with K–L approach. In our study, 73 patients with acetabular fractures involving two columns were treated through combined approach by a single surgeon. Mean operative time was 123.2 min in group A as compared to 161.5 min in group B. Mean blood loss associated with approach was 586.2 ml in group A as compared to 830.0 ml in group B. The decreased operative time and blood loss are advantages of the modified ilioinguinal approach when combined with K–L approach for acetabular fractures involving two columns. An anatomical reduction was achieved in 84.8 % patients in group A which is comparable to the rates of 88.9 % in group B. The excellent functional outcome was achieved in 80.4 % patients in group A and in 81.5 % patients in group B. Those results were in keeping with previous studies (Andersen et al. 2010; Gary et al. 2012). The mean complication rate was 21.7 % in group A compared with 33.3 % in group B. The low incidence of surgical complications of the modified ilioinguinal approach combined with K–L approach was another important finding in our study. The major complication was deep venous thrombosis in both groups. Trauma was the main factor to deep venous thrombosis. Heterotypic ossification is another common complication, which is mainly due to posterior approaches. We emphasize that less invasive dissection and good reduction together with proper stabilization lead to early mobilization, less complications and good rehabilitation.
This study provides evidence that modified ilioinguinal approach combined with Kocher–Langenbeck approach may be a good choice in the management of acetabular fractures involving two columns.
PW, XZ and PX acquisition, analysis and interpretation of data, revising the manuscript. YZ and LW interpretation of results and revising the manuscript. WM and XL conception and design, revising the manuscript, final approval of the version to be published. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
We declare that our research has been approved by ethics committee and that all subjects gave their consent to participate in this study.
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