Is the Extended Iliofemoral Approach Still Indicated for Visualizing the Acetabulum?

By Jonathan Schneider DO, Kyle Dickson MD, Jordan Johnson DO
MountainView Regional Medical Center
Las Cruces, New Mexico

Abstract
Background: The extended iliofemoral (EIF) approach is an extensile surgical approach that can be used to simultaneously visualize both the anterior and posterior columns of the acetabulum through a single approach. The EIF is associated with morbidities (infection, skin necrosis, abductor dysfunction, heterotopic ossification), therefore, this surgical approach is usually reserved for complex fracture patterns or delayed fractures that still warrant anatomic reduction that would be challenging to address through a non-extensive surgical dissection. We seek to review this surgical approach and address when it is clinically appropriate to utilize in addition to noting some of the complications associated with this dissection.

Methods: We retrospectively reviewed 29 patients age 20 to 65, mean age 41 by the senior surgeon from 2006 to 2011 at a single institution. All 29 patients reviewed had acetabular fractures treated with the extensive iliofemoral surgical approach with 79 percent of surgeries being primary surgeries performed by the senior author and 21 percent being acetabular revision.

Results: The T-type posterior wall (31 percent) was the most common fracture variant, followed by transverse-posterior wall (17 percent), T-type (17 percent), both column-posterior wall (14 percent) and both column fractures (14 percent). The average time from fracture to surgery was 19.1 days. Three patients (10 percent) underwent THA within two years of their initial surgery. 17 percent of patients returned to surgery for a debridement due to infection or wound complications. 10 percent of patients had soft tissue defects requiring flaps by plastic surgery. One patient had surgical excision of heterotopic ossification.

Conclusion: Patients with these complex acetabular fractures can be effectively treated with the EIF approach. There are however, increased risks of infection and wound issues. Ultimately, anatomic reduction of the articular surface is the mainstay of surgical treatment for acetabular fractures, and we believe the best predictor of patient outcome depends on articular reduction.

Keywords: Acetabulum, Orthopedic, Procedures

Introduction
The extended iliofemoral (EIF) approach is an extensile approach developed by Letournel¹ to expose both anterior and posterior columns simultaneously through a single approach. The approach has fallen out of favor due to the concerns of surgical morbidity and elevated complication rate.² Nonetheless, specific fracture patterns are unable to be reduced anatomically through a single non-extensile approach.¹ Moreover, some fractures that could be treated through a single non-extensile exposure can be extremely difficult to reduce after delays to surgery. There is a relative paucity of research over the last twenty years pertaining to this surgical in approach.

In light of this, we asked, when is the EIF approach appropriate? What are the complications associated with the approach? Is the EIF still clinically relevant?

Methods
A retrospective review of the senior author’s surgical cases from 2006 to 2011 identified 29 patients treated with the EIF approach for an acetabular fracture. This review was IRB exempt at the senior author’s institution.  The selection criteria included any acetabular fractures treated operatively by the senior surgeon utilizing the EIF approach at a single institution from 2006 to 2011. There were no exclusion criteria. The EIF was chosen when simultaneous visualization of anterior and posterior acetabular anatomical structures was required and would otherwise be challenging to be approached by a single anterior (ilioinguinal) or posterior (Kocher-Langenbeck) approach. Generally this was deemed appropriate in T-type fractures with posterior wall involvement, transverse-posterior wall with significant displacement of both columns, both column fractures with posterior wall involvement, and acetabular fractures involving both columns over two weeks old.³

Figure 1A & 1B show pre-operative and post-operative radiographs, respectively, of one of the senior author patients who underwent the extended iliofemoral surgical approach for their injury. This is a case example of a 65-year-old male who was involved in motor vehicle accident with anterior wall-posterior hemi-transverse fracture with posterior wall with impaction. Surgery was delayed 19 days for medical stabilization. At 4 year follow up patient was pain free with modified Harris hip score of 94.5. ¹⁷

Surgical Technique
Patients are placed in the lateral decubitus position. We prefer to use the ProFx table as this permits traction through a femoral traction pin with the knee flexed to allow relaxation of the sciatic nerve. It also allows a laterally directed vector to counteract the effects of gravity as the femoral head tends toward protrusio. An incision begins at the posterior-superior iliac spine toward the anterior-superior iliac spine.^1,4 The anterior limb follows the Smith Peterson interval. The gluteal musculature is dissected off the outer table beginning at the junction of the gluteal and abdominal muscles. This continues until the greater sciatic notch is reached with care to avoid the superior gluteal vessels and nerves. This area is packed while the Smith Peterson approach is employed.

The fascia overlying the tensor muscle is first incised. The muscle is retracted laterally and the floor of the fascia is incised. The ascending branches of the lateral femoral circumflex are isolated and ligated. The origin of the tensor muscle is also dissected off the ilium. We perform a trochanteric osteotomy and generally pre-drill for 4.5 cannulated screws. The sciatic nerve position is confirmed and the piriformis and obturator internus tendons are tagged with #5 Ethibond and incised one centimeter from their insertion. Dissection proceeds posteriorly toward the greater and lesser notches. Depending on the fracture pattern, the direct head of the rectus or the sartorius may be dissected. Care must be taken to avoid devascularization of the anterior column in both column fractures.

A capsulotomy may be employed to visualize the joint surface or repair a suspected labral tear. Direct visualization of the upper aspect of the anterior column is achieved, with palpation of quadrilateral surface. Posteriorly, direct visualization of the outer table, posterior wall and posterior column down to the ischial tuberosity is achieved. We place a large drain deep to the tensor fascia and one along the outer table. The rectus and sartorius can be repaired with suture anchors while the tensor can be repaired with bone tunnels and Ethibond suture. Careful repair of the gluteal musculature is performed with interrupted #1 Vicryl sutures that are tied all at once while abducting the hip 30 degrees to decrease abductor dysfunction post-operatively.

All patients received the same postoperative protocol including pharmacologic DVT prophylaxis (unless medically contraindicated), physical therapy on post-operative day one with protected toe-touch weight bearing, and a single dose of radiation therapy (XRT) to decrease the risk of heterotopic ossification.³ Some patients did not receive XRT due to surgery timing before the weekend or medical instability (XRT required transfer to outside hospital).

 Results
19 patients were male (66 percent) and 10 patients were female (34 percent). The median age of patients at the time of surgery was 41. The senior surgeon primarily treated 23 patients (79 percent) with ORIF of an acetabular fracture through the EIF approach. The senior surgeon revised 6 patients (21 percent) using the EIF approach that was initially treated by another surgeon who were unable to adequately reduce the fracture or had a loss of fixation in the early postoperative period. The average time to surgery was 19.1 days (median 16.0 days), with the majority of patients delayed due to medical factors. One patient was treated initially conservatively with loss of joint congruence and operated on six weeks after her injury for a T-type fracture. One patient was delayed due to an injury outside the country and operated on 18 days after his injury for a both column fracture. 37.9 percent of patients were smokers. 86 percent of patients received XRT at an average of 1.9 days.

The majority of patients (55 percent) sustained their fracture from a motor vehicle accident. Nine patients (31 percent) were involved in a motorcycle accident. Two patients fell from a height, one patient had a crush injury, and one patient was involved in a plane crash. All fractures involved both the anterior and posterior aspects of the acetabulum with 9 patients (31 percent) having a T-type, posterior wall variant. Harris Hip score were obtained in 5 of the 29 patients in our case series. The Harris Hip scores were 19.8, 38.5, 68.1, 96.7, and 94.5.

Complications
Three patients (10 percent) underwent total hip arthroplasty (THA) for arthrosis all within 2 years of their initial surgery. One of the patients who underwent a THA also had heterotopic ossification (HO) excised surgically prior to his THA. One patient had loss of fixation of their greater trochanter and required revision three days after the initial surgery. This patient had a traumatic brain injury and was non-compliant with weight-bearing restrictions.

Five patients (17 percent) had wound dehiscence or infections requiring operative debridement, of which 80 percent were smokers. Three patients (10 percent) had necrosis of soft tissue requiring plastic surgery coverage with a flap. Of the three patients requiring flaps, one patient was a revision of a T-type with an associated posterior wall fracture that was initially treated by another surgeon through a Kocher-Langenbeck approach but was unable to be reduced. In this case the superior gluteal vessels were partially trapped in the fracture site. The second patient had a both column-posterior wall two months out from the injury. This patient initially underwent osteotomies and release through an ilioinguinal approach prior to his definitive fixation through an EIF approach at a later date. The third patient was treated by attempted percutaneous treatment of a both column-posterior wall fracture by another surgeon that resulted in a loss of fixation.

Two patients (6.9 percent) had pulmonary emboli. There were no deaths in the immediate post-operative period.

Discussion
Certain fracture patterns are difficult to manage with a single non-extensile approach. Several cases in this series were attempted to be treated with a single non-extensile approach but were revised due to inadequate reduction. An alternative is to treat some of these fractures with simultaneous ilioinguinal and Kocher-Langenbeck approaches, however this requires re-positioning the patient intra-operatively and limits the amount of fixation that can be placed from one side. The advantage of the EIF approach is the simultaneous visualization of both the anterior and posterior columns. However, the complication rate is higher with 17 percent of patients in our series requiring an operative debridement due to wound dehiscence or infection. Our reported conversion rate to THA is similar to prior published series.² Only one patient underwent surgical excision of HO (3 percent), which compares favorably to prior series published.² This may be a result of our high rate of patients who receive XRT.

Three patients required flap coverage by plastic surgery. In all three cases, patients had incisions prior to the EIF approach. The use of the EIF approach in these cases should proceed with caution, as there is likely a higher risk of wound complications and skin necrosis. Some authors have advocated obtaining angiographic studies prior to performing the EIF to assess the superior gluteal artery.⁵ However, a prospective study showed far fewer injuries than previously predicted for fractures displaced into the sciatic notch.^6, One patient without any flow through the superior gluteal artery still tolerated the EIF approach.⁶ No studies have looked specifically at performing an EIF on patients with a prior incision.

A delay in operative treatment leads to worse outcomes.⁷ This is likely due to the presence of callous formation and inability to reduce the fracture anatomically. Specifically, transverse-posterior wall and T-type fractures have significantly worse outcomes when delayed greater than 3 weeks.⁸ The revisions of mal-reduced acetabular fractures have been studied with worse outcomes than cohorts of primarily treated patients.⁹

Surgeons have been decreasing their use of the EIF over time.⁸ Matta treated 20 to 30 percent of his acetabular fractures with the EIF in the 1980s, but after 2000 has treated less than 10 percent of his patients with the EIF.⁸ He specifically treats both column fractures that involve the sacroiliac joint with this approach. A modified EIF approach is used at some centers.^4,11 A T-shaped incision is centered at the iliac crest with osteotomies of the iliac crest and anterior superior iliac spine to allow reflection of the abductor muscles posteriorly. Similar complication rates have been seen in both groups.¹²

Limitations of this study include long-term radiologic follow up and not collecting Harris Hip scores on each patient. We were only able to obtain Harris Hip scores on five patients. We also failed to present data on abductor dysfunction. All the revisions were treated on patients whose index procedure the senior author did not perform, and perhaps these could have been initially treated by the senior author with a non-extensile approach. An ideal study would randomize patients to the EIF group compared to a group of patients treated with two stage procedures utilizing non-extensile approaches. To decrease surgical time involved in dual approaches, some centers employ two surgical teams concurrently, with one team working on a Kocher-Langenbeck approach and the second team performing an iliofemoral approach.^13,15

Ultimately, anatomic reduction of the articular surface is the mainstay of treatment for acetabular fractures. Patients’ outcomes depend on articular reduction.^1,5,6

References

1. Letournel E, Judet R, Elson R. Fractures of the acetabulum. Second ed. New York: Springer-Verlag, 1993.
2. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg (Am) 1996;78(11):1632-1645.
3. Blokhius TJ, Frölke JP. Is radiation superior to indomethacin to prevent heterotopic ossification in acetabular fractures? a systematic review. Clin Orthop Relat Res 2009;467(2):526-530.
4. Stöckle U, Hoffmann R, Südkamp NP, Reindl R, Hass NP. Treatment of complex acetabular fractures through a modified extended iliofemoral approach. J Orthop Trauma 2002;16(4):220-230.
5. Alonso JE, Davila R, Bradley E. Extended iliofemoral versus triradiate approaches in management of associated acetabular fractures. Clin Orthop Relat Res 1994;305:81-87.
6. Reilly MC, Olson SA, Tornetta P 3^rd, Matta JM. Superior gluteal artery in the extended iliofemoral approach. J Orthop Trauma 2000;14(4):259-263.
7. Matta JM, Anderson LM, Epstein HC, Hendricks P. Fractures of the acetabulum. A retrospective analysis. Clin Orthop Relat Res 1986; 205:230-240.
8. Jimenez ML, Vrahas MS. Surgical approaches to the acetabulum. Orthop Clin North Am 1997;28(3):419-434.
9. Tannast M, Najibi S, Matta JM. Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures. J Bone Joint Surg (Am) 2012;94(17):1559-1567.
10. Mayo KA, Letournel E, Matta JM, Mast JW, Johnson EE, Martimbeau CL. Surgical revision of malreduced acetabular fractures. Clin Orthop Relat Res 1994;305:47-52.
11. Johnson EE, Matta JM, Mast JW, Letournel E. Delayed reconstruction of acetabular fractures 21-120 days following injury. Clin Orthop Relat Res 1994;305:20-30.
12. Reinert CM, Bosse MJ, Poka A, Schacherer T, Brumback RJ, Burgess AR. A modified extensile exposure for the treatment of complex or malunited acetabular fractures. J Bone Joint Surg (Am) 1988;70(3):329-337.
13. Bosse MJ, Poka A, Reinert CM, Brumback RJ, Bathon H, Burgess AR. Preoperative angiographic assessment of the superior gluteal artery in acetabular fractures requiring extensile approaches. J Orthop Trauma 1988;2(4):303-307.
14. Reilly MC, Olson SA, Tornetta P 3^rd, Matta JM. Superior gluteal artery in the extended iliofemoral approach. J Orthop Trauma 2000;14(4):259-263.
15. Harris AM, Althausen P, Kellam JF, Bosse MJ. Simultaneus anterior and posterior approaches for complex acetabular fractures. J Orthop Trauma 2008;22:494-497.
16. Griffin DB, Beaulé PE, Matta JM. Safety and efficacy of the extended iliofemoral approach in the treatment of complex fractures of the acetabulum. J Bone Joint Surg (Br) 2005; 87-B:1391-1396.
17. Dickson, Kyle, MD, Southwest Orthopedic, 6560 Fannin, Suite 1016, Houston, Texas, 77030, Surgical Case Presentation

Table 1: Patient Characteristics

Table 2: Mechanisms & Classifications

Table 3: Complications