Review Article

Surgical Approaches to the

Acetabulum and Modifications in
Technique

Abstract
Norele Jean Cutrera, MD Acetabular injuries are often difficult to treat because the acetabulum
Daphne Pinkas, MD is surrounded by many important structures, making access difficult
and sometimes dangerous. Surgical exposures of the acetabulum are
Jose Bernardo Toro, MD
complex and require significant skill and in-depth knowledge of pelvic
anatomy. Each approach has its limitations, and the potential
morbidity associated with these exposures can be daunting. Recent
modifications to traditional acetabular approaches have been
developed to address these issues. Knowledge of the ilioinguinal,
Kocher-Langenbeck, and extended iliofemoral surgical exposures
and the potential drawbacks associated with each approach are
essential to optimize treatment and minimize morbidity.

S urgical approaches to the acetab-

ulum can be challenging. Although
classic approaches are familiar to most
choose the proper exposure for ana-
tomic reduction and fracture fixation.

orthopaedic surgeons, they are pri-

From the Department of Orthopaedic
Surgery, Jacobi Medical Center,
Bronx, NY (Dr. Cutrera), the Kayal
Orthopaedic Center PC, Franklin
Lakes, NJ (Dr. Pinkas), and the
Department of Orthopedics, Peconic
Bay Medical Center, Krauss
Musculoskeletal Institute, Riverhead,
NY (Dr. Toro).
None of the following authors or any
immediate family member has
received anything of value from or has
stock or stock options held in
a commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Cutrera, Dr.
Pinkas, and Dr. Toro.
J Am Acad Orthop Surg 2015;23:
592-603
http://dx.doi.org/10.5435/
JAAOS-D-14-00307
Copyright 2015 by the American
Academy of Orthopaedic Surgeons.
marily used by traumatologists to
treat acetabular fractures. Choosing
the correct approach requires a thor-
ough understanding of the fracture
pattern because no single approach
allows access to the entire acetabulum.
The ilioinguinal, Kocher-Langenbeck,
and extended iliofemoral exposures
are the three main approaches to
the acetabulum. The ilioinguinal
approach allows direct access to the
anterior column, whereas the Kocher-
Langenbeck approach primarily ex-
poses posterior structures. The
extended iliofemoral approach is
reserved for delayed fixation and for
fractures that are not amenable to
treatment by less extensile exposures.
Modifications have been developed
to broaden traditional approaches to
the acetabulum and mitigate compli-
cations. An understanding of the ad-
vantages and limitations of each
technique can enable surgeons to
Ilioinguinal Approach
The ilioinguinal approach to the
acetabulum was developed to access
the anterior column, quadrilateral
surface, and upper posterior column
through the creation of three ana-
tomic “windows” into the pelvis1
(Figure 1). This approach is used to
manage fractures that involve the
anterior column and/or the anterior
wall, anterior column-posterior
hemitransverse fractures, and many
both-column and transverse frac-
tures.2-4
The patient is positioned supine on
a radiolucent operating table or
fracture table. The leg is draped free
to control position and aid visuali-
zation. Traction is applied to the
injured limb to anatomically position
the femoral head, allowing the sur-
geon to build the acetabulum around
it. However, traction places tension
on the surrounding musculature and

592 Journal of the American Academy of Orthopaedic Surgeons

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 Norele Jean Cutrera, MD, et al

Figure 1

A through C, Illustrations demonstrating the ilioinguinal approach. A, The incision and associated bony access.
B, Acetabular exposure with access via the medial and middle windows. C, Exposure via a lateral window provides access
to the inner table of the ilium. Inset, Illustration of the anterior and posterior aspects of the hip demonstrating areas of direct
access (blue) and secondary access by touch (yellow).

can limit exposure. On a standard
table, the surgeon can place a radio-
lucent triangle or bump under the
knee to relieve tension on the muscles
and the neurovascular bundle,
thereby improving visualization.
An incision is made along the iliac
crest, extending approximately 5 cm
superior to the anterior superior iliac
spine (ASIS) and medially toward the
pubic symphysis (Figure 1). The at-
tachments of the abdominal and
iliacus muscles are released from the
crest, allowing access to the inner
table of the ilium. Blunt dissection
along the iliac fossa directly exposes
the sacroiliac joint and pelvic brim.
The ilioinguinal exposure requires
incision of the inguinal canal. The
aponeurosis of the external abdomi-
nal oblique muscle is incised from the
ASIS toward the midline, where its
fibers blend with the external sheath
of the rectus abdominis muscle. The
rectus is similarly dissected in line
with the skin incision, unroofing
the inguinal canal to expose the
spermatic cord, or round ligament,
and the accompanying inguinal
nerve. Retraction of these structures
exposes the inguinal ligament, which
is flanked laterally by the lateral
femoral cutaneous nerve (LFCN) and
medially by the external iliac vessels
and lymphatics. Dividing this liga-
ment along its length allows for
development of the retropubic space
between the bladder and the poste-
rior aspect of the pubic symphysis,
which permits access to the pubic
ramus.
The ilioinguinal approach requires
the creation of three important win-
dows that allow access to the entire
anterior column and the quadrilateral
surface.1 The lateral, middle, and
medial windows are framed by two
curtains: the lacuna vasorum and the
lacuna musculorum. The lacuna
vasorum consists of the femoral ves-
sels and lymphatics within a common
sheath. The iliopsoas muscle and
femoral nerve sit lateral to these ves-
sels, forming the lacuna musculorum.
The iliopectineal fascia lies between
these curtains and must be divided
down to the level of the pectineal
eminence, which separates the true
pelvis from the false pelvis. This step
allows access to the three windows.
The lateral window, which is lateral
to the iliopsoas muscle, exposes the
inner table of the ilium, anterior
sacroiliac joint, and pelvic brim. The
middle window, which is located
between the iliopsoas muscle and
femoral vessels, allows access to the
quadrilateral plate and pelvic brim
from the anterior sacroiliac joint to
the pectineal eminence. The medial
window, which is medial to the fem-
oral vessels, exposes the superior
pubic ramus and pubic symphysis.
Fracture reduction and fixation can
be accomplished by navigating within
these three windows.
Risks
Nerve injury, vascular injury, hypo-
perfusion, and thrombosis are among

October 2015, Vol 23, No 10 593

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Surgical Approaches to the Acetabulum and Modifications in Technique
the potential dangers encountered
during the ilioinguinal approach. The
LFCN is encountered during super-
ficial dissection, and the incidence of
injury to this nerve is as high as 18%,
making it the most frequently injured
nerve during the ilioinguinal
approach.1 The LFCN lies from 3 to
46 mm medial to the ASIS.5 It courses
under the inguinal ligament anterior
to the iliacus muscle, where it divides
into anterior and posterior branches
on the surface of the sartorius muscle.
In 26.7% of cases, the LFCN
branches proximal to the inguinal
ligament.6 Historical studies on mer-
algia paresthetica have described
anecdotal variations of the LFCN
course, including lateral to the ASIS
or through the inguinal ligament;
however, these variations have been
disputed by recent studies.5-7
Corona mortis is a vascular anas-
tomosis located between the obtura-
tor and external iliac arteries or the
inferior epigastric artery—vessels
that are encountered posterior to the
superior pubic ramus. This anasto-
mosis has been found at an average
of 68 mm from the pubic symphysis
(range, 40 to 96 mm).8 The corona
mortis can be venous (60%), arterial
(36%), or both (4%). The estimated
incidence of this anatomic variant is
10% to 40%.1 Although this vas-
cular connection was present in 83%
of 80 cadaver specimens, Darmanis
et al8 encountered it in only 5 of 492
anterior acetabular approaches. The
authors concluded that the corona
mortis may not be as common
a threat as once believed. Nonethe-
less, the corona mortis is an impor-
tant potential source of bleeding that
may be encountered during anterior
acetabular exposures.
Case reports have described
thrombosis or injury to the external
iliac or femoral vessels during the
ilioinguinal approach.9 Iliac or fem-
oral artery thrombosis can occur if
prolonged retraction of vessels is
needed for exposure in the middle
594
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window.9 Signs of hypoperfusion
caused by artery compromise can be
subtle, such as diminished pulses on
the side of injury. Any suspicion of
thrombosis or vessel injury should
trigger vascular evaluation because
prolonged hypoperfusion can result
in compartment syndrome, limb loss,
or even death.3
Modifications
Numerous modifications to the
ilioinguinal approach have been
described. Minimally invasive surgi-
cal (MIS) approaches have gained
popularity due to shorter surgical
times and decreased neurovascular
risk. Ruchholz et al10 described
a MIS approach in which the middle
and medial windows were accessed
through two 3- to 4-cm incisions.
This technique requires the use of
specialized retractors. At the pubic
symphysis, the rectus abdominus
muscle is split to access the medial
window. An incision created over the
linea terminalis allows access to the
iliopectineal fascia and the middle
window. This modified approach was
used in a study of 26 older patients
(mean age, 67 years) with anterior
column and anterior column–
posterior hemitransverse fractures.10
Compared with traditional ilioingui-
nal approaches, less surgical time was
required with the modified approach
(mean, 109 minutes versus 175 mi-
nutes), but the amount of bleeding
was similar (1,000 mL versus 1,500
mL).3,10 Although the authors re-
ported no wound complications, 23%
of patients had a 2- to 3-mm articular
incongruity on initial postoperative
radiographs, and two had loss of
reduction at short-term follow-up.
Wolf et al11 described a MIS
approach performed with a “median”
lower abdomen incision, which is
a midline vertical incision located
superior to the pubic symphysis
combined with a lateral incision at the
iliac crest, similar to a traditional
Journal of the American Academy of Orthopaedic Surgeons
lateral window exposure. This less
extensive approach seeks to decrease
morbidity and broaden the use of the
ilioinguinal approach. The use of
a median window improves access to
the quadrilateral surface and can be
considered for management of frac-
tures with medial femoral head dis-
placement and minimal displacement
of the posterior column.
Other studies have examined the
use of the ilioinguinal approach in
combination with other exposures.
Kloen et al12 combined the classic
ilioinguinal approach with a modi-
fied Smith-Petersen approach. The
incision begins over the iliac crest
and continues toward the ASIS. At
the level of the ASIS, however, the
approach continues distally as the
Smith-Petersen approach, improving
access to the anterior hip and ace-
tabulum. A third arm of the incision
is made medially toward the pubic
symphysis, completing access to all
three windows (Figure 2, A). Os-
teotomy of the ASIS minimizes
traction on the LFCN during
retraction of the sartorius muscle
and inguinal ligament. A second os-
teotomy performed along the iliac
crest may allow detachment of the
abductor muscles from the iliac
wing, exposing the outer table of the
ilium13 (Figure 2, B). In the setting of
low anterior column fractures and
comminuted fractures of the anterior
wall, the Smith-Petersen modifica-
tion is ideal for providing access to
structures that are often obscured by
the iliopsoas muscle in the standard
dissection. This technique may also
improve exposure of the quadrilat-
eral surface. The modified approach
also enables subluxation or disloca-
tion of the hip for intra-articular
visualization, whereas the tradi-
tional ilioinguinal approach relies on
anatomic reduction of extra-
articular structures for joint con-
gruity. Finally, this modification may
be associated with a decreased inci-
dence of injury to the LFCN, with
 Norele Jean Cutrera, MD, et al

Figure 2

Illustrations of the incision for a combined ilioinguinal and Smith-Petersen approach (A) and the modified ilioinguinal and
Smith-Petersen exposure with osteotomies of the anterior superior iliac spine and iliac crest (B). Inset, Illustration of the
anterior and posterior aspects of the hip demonstrating areas of direct access (blue) and secondary access by touch
(yellow).

only 2 of 15 patients sustaining an
incomplete LFCN palsy in one
series.12
The ilioinguinal approach offers
limited visualization of posterior
column structures. Although many
both-column fractures are amenable
to treatment with this traditional
approach, fractures with extension
into the sacroiliac joint or sciatic
notch make choosing the correct
exposure difficult. Some surgeons
elect to manage these fractures through
the invasive extended iliofemoral
approach. Weber and Mast14 describe
an alternative extended ilioinguinal
approach, combining the classic
ilioinguinal approach with a posterior
approach to the sacroiliac joint
(Figure 3). The patient is placed in
a semilateral position, with the table
tilted to maintain access to the
posterior sacrum. The ilioinguinal
exposure is continued posteriorly to
the posterior superior iliac spine
(PSIS) and inferiorly along the sacro-
iliac joint. Exposing the posterior
column requires release of the gluteus
maximus from the lateral sacrum and Figure 3
PSIS. Weber and Mast14 reported
excellent reductions in six patients
treated using this approach, with only
one case of asymptomatic heterotopic
ossification (HO). Although posterior
approaches to the sacroiliac joint are
associated with wound complications,
only two patients in this series had
wound issues at the ilioinguinal por-
tion of the incision. Potential draw-
backs of this approach include
lengthy surgical times (mean, 10
hours) and significant blood loss
(mean, 2.45 L).
The ilioinguinal approach provides
incomplete access to the quadrilateral
surface. Direct visualization is limited Illustration demonstrating the
to the ischial spine, and placement of extended ilioinguinal incision, which
hardware along the quadrilateral sur- provides additional access to the
sacroiliac joint.
face is difficult. Karunakar et al15
described the use of a modified ilioin-
guinal approach in which the modified the medial window, exposing the
Stoppa approach was used to cir- entire quadrilateral plate. Unlike the
cumvent this issue. A midline Pfan- traditional ilioinguinal approach, most
nenstiel incision is incorporated into surgical work is done through this
the medial aspect of the ilioinguinal expanded medial window. This mod-
approach to more extensively develop ified approach is ideal for fractures

October 2015, Vol 23, No 10 595

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Surgical Approaches to the Acetabulum and Modifications in Technique

Figure 4

Illustrations of the incision and bony access (A) for the Kocher-Langenbeck approach and the exposure (B) via this
approach. The short external rotators are resected 1.5 cm from their insertion onto the greater trochanter to preserve the
femoral blood supply. Inset, Illustration of the hips demonstrating areas of direct access (blue) and secondary access by
touch (yellow).

with concomitant anterior pelvic ring
injuries and fractures involving medial
displacement of the quadrilateral plate.
Kocher-Langenbeck
Approach
Bernhard von Langenbeck first
described the posterior acetabular
approach in 1874; it was primarily
used to treat infections and war-related
hip injuries.16 Theodor Kocher
modified Langenbeck’s approach by
extending the incision caudally to
divide the gluteus maximus muscle
and reflect the gluteus medius
and minimus muscles. The Kocher-
Langenbeck approach has been used
since 1892, and it allows access to the
entire posterior column, retro-
acetabular surface, ischial spine, and
the greater and lesser sciatic notches.16
It is ideal for fractures involving the
posterior column and posterior wall.
Many transverse and T-type fractures
can also be managed with this
approach, depending on fracture
obliquity and which column has
greater displacement. Infratectorial
and juxtatectorial transverse fractures
generally involve major displacement
of the posterior column, and the
Kocher-Langenbeck approach is ideal
for management of these fractures. In
the setting of major displacement of
the anterior column, the ilioinguinal
approach is preferred.
Patients can be placed in the lateral
decubitus or prone position, de-
pending on the fracture pattern. Lat-
eral positioning allows gravity to pull
the soft tissue and musculature of the
buttock away from the surgical field.
A trochanteric osteotomy and surgi-
cal hip dislocation, as described by
Siebenrock et al,17 can be performed
with the patient in the lateral posi-
tion but not in the prone position.
Lateral positioning is preferred in the
setting of concomitant pubic rami
fractures or bladder injuries. Prone
positioning allows for easier palpa-
tion of the quadrilateral surface and
facilitates clamp placement through
the greater sciatic notch. This position
is generally preferred when treating
transverse and T-type fractures
because they are predisposed to
medial displacement and internal
rotation of the caudal segment. In
these instances, lateral positioning
can cause difficulty in counter-
acting gravity and the weight of the
injured limb, resulting in fragment
medialization by the femoral head.
Prone positioning eliminates gravity
as a potential deforming force and
allows for easier hip extension and
knee flexion, relieving tension on the
sciatic nerve. In a retrospective study
of patients with transverse fractures
treated using the Kocher-Langenbeck
approach with the patient positioned
prone or lateral, Collinge et al18
found no significant difference in
bleeding, surgical time, or perioper-
ative complications. The authors did
find a trend toward increased malre-
ductions in the lateral versus prone
groups (P = 0.08), although this trend
was not statistically significant. Ulti-
mately, patient positioning is deter-
mined by surgeon preference.

596 Journal of the American Academy of Orthopaedic Surgeons

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 Norele Jean Cutrera, MD, et al

The Kocher-Langenbeck incision is Figure 5

centered over the posterior half of the
greater trochanter. The incision con-
tinues proximally toward the PSIS
and distally along the femoral shaft
for approximately 10 cm (Figure 4,
A). Distally, the fascia lata is incised
in line with the skin incision. Proxi-
mally, the gluteus maximus muscle is
bluntly dissected in line with its fi-
bers. The short external rotators
(SERs) are detached 1.5 cm from
their trochanteric insertion to protect
the blood supply to the femoral head
(Figure 4, B). The gluteus medius
and minimus tendons can be divided
at the greater trochanter if visuali-
zation of the acetabular dome is
required. Elevation of the piriformis
muscle and conjoint tendons to their
retroacetabular origins allows access
to the greater and lesser sciatic A and B, Illustrations demonstrating the trochanteric flip osteotomy. The bone is
notches, respectively. The inner wall of retracted anteriorly along with the attached abductor and vastus lateralis
the ilium can be accessed through the muscles.
lesser sciatic notch. Dissection through
the greater sciatic notch allows pal-
pation of the quadrilateral surface. obturator externus tendon, where it ted an alternative approach to the
Retractors can be carefully placed into gives off a greater trochanteric branch. external rotators during the Kocher-
the sciatic notches to expose the pos- It then continues anterior to the con- Langenbeck approach, conserving the
terior column.1 A T-shaped capsu- joint tendon, perforating the hip cap- obturator externus tendon at its
lotomy can be performed, although sule between the piriformis and insertion on the femur. Instead of
the capsule often is already disrupted. superior gemellus tendons. Once in- transecting the piriformis and conjoint
tracapsular, the artery continues tendons at their insertions, a 1.5-cm
proximally along the posterosuperior cuff is preserved to protect the MFCA.
Risks femoral neck, giving off terminal Care is also taken to preserve the
The Kocher-Langenbeck approach re- branches that perforate the bone 2 to quadratus femoris tendon because the
quires an understanding of two key 4 mm lateral to the bone-cartilage obturator externus and dbMFCA lie
neurovascular structures: the medial junction. In a cadaver study, Gautier immediately anterior to it.
femoral circumflex artery (MFCA) et al19 established the relationship Iatrogenic injury to the sciatic nerve
and the sciatic nerve. The MFCA between the dbMFCA and the land- is another potential complication
originates from the profunda femoris marks encountered during posterior associated with the Kocher-
artery or, less frequently, from the acetabular exposure. On average, the Langenbeck approach. The sciatic
common femoral artery and winds artery is 18.2 mm from the top of the nerve is intimately associated with the
posteriorly around the femur between lesser trochanter, 8.8 mm from the piriformis tendon, but its course can
the iliopsoas and pectineus muscles. It obturator externus insertion, and 12.4 vary, as described by Beaton and
can be found posteriorly between the mm from the obturator internus Anson20 in a study of 120 cadavers.
inferior gemellus and quadratus fem- insertion. The authors sequentially The sciatic nerve most commonly
oris muscles. The deep branch of the tenotomized muscle insertions on the emerges from the pelvis anterior to the
MFCA (dbMFCA) is the primary proximal femur, performed a circum- piriformis tendon (84.5%), but may
source for the blood supply to the ferential capsulotomy, and dislocated also divide into its common peroneal
femoral head.19 At the proximal bor- the femoral head. The dbMFCA was and tibial branches before exiting the
der of the quadratus femoris, the preserved if the obturator externus pelvis (14.7%). The piriformis can
dbMFCA lies directly posterior to the tendon remained intact. This promp- also have two distinct muscle bellies

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Surgical Approaches to the Acetabulum and Modifications in Technique
Figure 6
Illustration demonstrating the
modified Gibson incision and
associated bony access. Inset,
Illustration of the hip demonstrating
areas of direct access (blue) and
secondary access by touch (yellow).
(11.7%), a so-called bipennate varia-
tion that makes the nerve appear
transtendinous. The piriformis ap-
pears to split around the nerve. Rarely,
the sciatic nerve transects the tendon
(0.8%). Knowledge of these anatomic
variants helps ensure adequate pro-
tection of the sciatic nerve during the
Kocher-Langenbeck approach. Proper
leg positioning may also prevent iat-
rogenic injury. The surgical limb
should be held in hip extension and
knee flexion to relieve tension on the
nerve throughout the procedure.
Modifications
Modifications to the Kocher-
Langenbeck approach seek to
598
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
improve visualization and preserve
the normal anatomy of the posterior
hip. The greater trochanteric flip os-
teotomy is perhaps the best-known
modification; it was popularized by
Siebenrock et al17 and improves
access to the superior hip joint and
supracetabular region. Theoretically,
it may also limit HO because less
forceful abductor retraction is
required to achieve exposure. A
plane osteotomy (approximately
1.5-cm thick) is performed between
the posterior gluteus medius muscle
insertion and the vastus lateralis
(Figure 5, A). The trochanteric
fragment is retracted anteriorly
along with the attached gluteus
medius and minimus muscles and the
vastus lateralis muscle (Figure 5, B).
By retaining the muscle attachments
to the fragment, the postoperative
cranial migration that can occur in
traditional greater trochanteric os-
teotomies can be prevented. The
osteotomy also facilitates posterior
dislocation of the femoral head if
joint inspection is required. The
greater trochanter is later repaired
with screw fixation. In a study of 10
acetabular fractures treated using the
Kocher-Langenbeck approach with
a trochanteric flip osteotomy, no
cases of osteotomy nonunion, mal-
union, or HO were reported.17
The modified Gibson (mG)
approach is an alternative to tro-
chanteric osteotomy; it also improves
access to the supracetabular region.21
Instead of splitting the gluteus max-
imus muscle, as in the Kocher-
Langenbeck approach, the proximal
mG incision is directed anteriorly into
the interval between the gluteus
maximus muscle and the tensor fascia
lata (TFL). The entire gluteus max-
imus muscle is retracted posteriorly
and deep dissection continues as in
the Kocher-Langenbeck approach.
Anterosuperior acetabular access is
improved because the gluteus medius
muscle, which is unencumbered by
the overlying gluteus maximus mus-
Journal of the American Academy of Orthopaedic Surgeons
cle fibers, can be retracted anteriorly
(Figure 6). In addition to the
improved cosmesis provided by
the vertical nature of the incision,
the risk of injury to the neuro-
vascular supply of the anterior
portion of the gluteus maximus
muscle is decreased.
Several authors have described SER-
sparing modifications to the Kocher-
Langenbeck approach.22-24 Theoreti-
cally, these modifications decrease the
risk of iatrogenic injury to the MFCA,
thus preventing femoral head necrosis.
Limited dissection may also decrease
HO formation. SER-sparing mod-
ifications use viewing portals proximal
and distal to the rotators. The superior
portal lies between the gluteus medius
and piriformis tendons, whereas the
inferior portal lies between the SERs
and the ischial tuberosity. Magu et al22
used this technique to manage acute,
isolated, noncomminuted posterior
wall fractures. Josten and Trabold23
applied the same MIS approach more
broadly to treat posterior column
fractures. Acceptable reductions were
achieved, but no differences in active
rotation or abductor strength were
found with SER-sparing techniques.
Sarlak et al24 described a more
extensive approach that exploits the
interval used in the mG approach to
access the superior acetabular region,
working deeply through SER-sparing
portals. The authors reported
decreased blood loss and surgical
times. Larger studies are needed to
determine which patients may ben-
efit from these modified approaches.
SER-sparing techniques are not
currently indicated for comminuted
posterior wall fractures or when
visualization of the articular surface
is required.
Extended Iliofemoral
Approach
The extended iliofemoral (EIF)
approach was developed by Letournel
 Norele Jean Cutrera, MD, et al

Figure 7

A, Illustration demonstrating the incision for the extended iliofemoral approach and associated bony access. B, Illustration
demonstrating the exposure, which provides access to the entire iliac crest, iliac fossa, superior pubic ramus, and sacroiliac
joint. Inset, Illustration of the anterior and posterior aspects of the hip demonstrating areas of direct access (blue) and
secondary access by touch (yellow).

and Judet25 in 1974 to access both the
anterior and posterior columns; it is
reserved for complex fractures that
involve displacement of both columns
and those treated subacutely (.3
weeks). The lateral decubitus position
allows access to the entire ilium. The
lateral aspect of the EIF approach is
similar to that of the ilioinguinal
approach. The incision runs parallel
to the iliac crest but begins more
posteriorly at the PSIS. The incision
continues anteriorly to the ASIS,
where the EIF approach curves dis-
tally along the lateral border of the
sartorius (Figure 7, A). The gluteal
muscles and TFL are dissected sub-
periosteally from the outer ilium
(Figure 7, B). Abdominal musculature
and the iliacus may be dissected off
the ilium to gain access to the inner
table. The sartorius muscle and
ilioinguinal ligament can be released
approximately 2 cm from their ori-
gins on the ASIS, or an ASIS osteot-
omy can be performed. Detachment
of these structures allows exposure of
the entire iliac crest, iliac fossa,
superior pubic ramus, and sacroiliac
joint.
Anteriorly, the interval is developed
superficially between the sartorius
muscle and the TFL and deeply
between the gluteus medius and rec-
tus femoris muscles, as in the Smith-
Petersen approach. Release of the
reflected head of the rectus femoris
from its supra-acetabular origin aids
visualization of the hip joint. The
lateral femoral circumflex artery
(LFCA) is found between the rectus
femoris and vastus lateralis muscles
and is routinely ligated. The
gluteus minimus and medius tendons
are released from the greater tro-
chanter, tagged for later repair, and
superiorly reflected. Similar to the
Kocher-Langenbeck approach, the
SERs are released from the greater
trochanter to aid visualization of the
hip joint. Capsulotomy may also be
performed.
Risks
Anatomic structures at risk of injury
during the EIF approach are similar
to those at risk in both the ilioinguinal
and Kocher-Langenbeck approaches.
Of unique concern is the superior

October 2015, Vol 23, No 10 599

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Surgical Approaches to the Acetabulum and Modifications in Technique

Figure 8

A, Illustration demonstrating the incision for the Maryland modification of the extended iliofemoral approach. B, Illustration
demonstrating osteotomies of the greater trochanter, iliac crest, and anterior superior iliac spine. Inset, Illustration of the
anterior and posterior aspects of the hip demonstrating areas of direct access (blue) and secondary access by touch
(yellow).

gluteal artery (SGA), the main vas-
cular pedicle to the large abductor
flap created in the EIF approach.26
The LFCA provides the collateral
blood supply to this flap, but is
routinely ligated to gain exposure.
The SGA can be severed at the time
of injury, particularly with signifi-
cant fracture displacement into the
sciatic notch. Preoperative angiog-
raphy can be performed if injury to
the SGA is suspected.27 If injury to
the artery is confirmed or an SGA
embolization is required, a combined
ilioinguinal and Kocher-Langenbeck
approach may be the preferred
option to avoid ligation of the LFCA.
Injury to the SGA may be a theo-
retical concern. Reilly et al28 exam-
ined the incidence of SGA laceration
associated with the EIF approach. In
39 patients with fractures that were
displaced into the sciatic notch and
treated using the EIF approach, the
authors reported no SGA lacerations
and only one SGA thrombosis, with
no incidents of flap necrosis. More
research is needed to clarify which
patients may benefit from pre-
operative angiography before an EIF
approach.
Modifications
Modifications to the EIF approach
attempt to limit its extensile nature.
The Maryland modification uses
a stepwise method to tailor the extent
of dissection.29 Unlike the J-shaped
incision of the EIF approach, this
modification uses a T-shaped inci-
sion (Figure 8, A). The proximal
incision extends from the PSIS to the
ASIS. Distally, however, the incision
runs parallel to the lateral femoral
shaft. An anterior flap is created to
the ASIS, with care taken to preserve
the LFCN, and deep dissection con-
tinues through the Smith-Petersen
interval between the gluteus medius
and rectus femoris muscles. Dissec-
tion in the posterior flap exposes the
hip with release of the SERs.
The main modification to the
Maryland approach lies in the use of
osteotomies (Figure 8, B). An os-
teotomy of the greater trochanter is
performed instead of gluteal muscle
detachment. The ilium is exposed
with an iliac crest osteotomy, and the

600 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

attached abductor flap is retracted
posteriorly. An ASIS osteotomy also
aids anterior exposure. All osteoto-
mies undergo screw fixation to allow
early postoperative rehabilitation.
This modification may decrease the
hip abductor weakness associated
with the standard EIF approach.
Dual Approaches
For management of complex acetab-
ular fractures, combined anterior and
posterior approaches have become
increasingly popular as an alternative
to the EIF and other extensile ap-
proaches. Prior to the development of
the EIF approach, Letournel et al30
used dual approaches for fractures
when complete reduction was unat-
tainable through a single exposure.
Combined approaches are often
performed in a staged fashion during
one or more procedures. Staging can
prove disadvantageous if rigid fixa-
tion is employed during the initial
procedure because any displacement
encountered during the second sur-
gery will be difficult to correct.
Harris et al31 advocated the use of
dual exposures performed simulta-
neously by two surgical teams to
diminish surgical time and blood loss
while maintaining the intraoperative
flexibility to reduce and repair frac-
tures from both anterior and poste-
rior aspects. The indications for
a combined approach are similar to
those for the EIF approach, including
T-type fractures, posterior column-
posterior wall fractures with signifi-
cant displacement, comminuted
transtectal transverse fractures, and
many both-column fractures.
Complications
The risk of complications (eg, infec-
tion, thromboembolism, HO, nerve
injury) exists with all acetabular ap-
proaches. Therefore, surgeons must
October 2015, Vol 23, No 10
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
counsel patients regarding the preva-
lence of such complications.
The overall infection rate after open
acetabular fixation ranges from 3% to
5%.32 A retrospective review found
that body mass index, intensive care
unit stay, and Morel-Lavallée lesions
were independent risk factors for
surgical site infections.32 Another
retrospective review found that pre-
operative embolization, obesity (body
mass index .30 kg/m2), and pre-
operative leukocytosis were associ-
ated with surgical site infection.33
Patients with one or more of these
factors should be warned of the
increased risk of infection.
Patients with acetabular fractures
also have an increased risk of
thromboembolic complications.34
The incidence of deep vein throm-
bosis ranges from 9% to 58%, and
the incidence of symptomatic pul-
monary embolism is approximately
2%.35 Mechanical compression,
low-molecular-weight heparin and
prophylactic inferior vena cava fil-
ters have been used to decrease the
risk of thromboembolic complica-
tions. However, there are currently
no clear guidelines on standardized
prophylaxis in this population. A
recent systematic review on the pre-
vention of thromboembolic events in
patients with pelvic and acetabular
fractures was unable to yield specific
recommendations.34 Well-designed
clinical trials are needed to develop
clear protocols.
HO is a well-known complication
associated with acetabular fracture
fixation. In a study of 9 acetabular
fractures, Letournel36 reported an
overall HO rate of 24%, with clini-
cally significant HO occurring in
35%, 10%, and 2% of patients
undergoing surgery with the EIF,
Kocher-Langenbeck, and ilioingui-
nal approaches, respectively. The use
of HO prophylaxis is not uncommon
in patients undergoing surgery with
the EIF approach and in those with
risk factors for HO (eg, head
Norele Jean Cutrera, MD, et al
injuries, burns). Indications for the
use of HO prophylaxis in patients
undergoing surgery with the Kocher-
Langenbeck approach are more
controversial. Two randomized
controlled trials showed no benefit
associated with the prophylactic use
of indomethacin to prevent HO in
patients undergoing surgery with the
Kocher-Langenbeck approach.37,38
In addition, the use of indomethacin
has been linked to nonunion of pos-
terior wall and long bone fractures as
well as adverse gastroenterologic ef-
fects.39 In a randomized controlled
trial that included 68 patients, those
in group 1 received a placebo and
those in groups 2, 3, and 4 received
indomethacin prophylaxis for 3 days,
1 week, and 6 weeks, respectively.40
Sagi et al40 found that 62% of pa-
tients who received a 6-week course
of indomethacin for HO prophylaxis
went on to develop nonunions, pre-
dominantly of the posterior wall. The
authors reported that a 1-week
course of indomethacin may be suf-
ficient to reduce HO formation
without increasing the rate of fracture
nonunion. Routine prophylaxis with
the ilioinguinal approach is not cur-
rently recommended.38
Iatrogenic nerve palsy after ace-
tabular surgery occurs in 1% to 18%
of cases.41 The most common iatro-
genic injury involves the peroneal
division of the sciatic nerve. Sciatic
nerve palsy is most commonly
encountered in patients undergoing
surgery with a Kocher-Langenbeck
approach, particularly in patients
with posterior wall fractures sec-
ondary to a hip dislocation. The
sciatic nerve can also be injured
during an ilioinguinal approach. In
one study, the ilioinguinal approach
was associated with more sciatic
nerve palsies than the Kocher-
Langenbeck or EIF approaches.41
This may be the result of heightened
vigilance regarding limb positioning
and retractor placement during pos-
terior approaches. The ilioinguinal
601
Surgical Approaches to the Acetabulum and Modifications in Technique
approach uses hip flexion to relax the
iliopsoas muscle. This position, cou-
pled with retractors placed near the
sciatic notch, places the sciatic nerve
at risk of injury.
The use of intraoperative neuro-
monitoring to mitigate nerve injury is
controversial. Decreased nerve injury
has been reported with the use of in-
traoperative somatosensory evoked
potentials and electromyography.42
However, Haidukewych et al41
found no improvement in the inci-
dence of nerve injury with intra-
operative monitoring and estimated
that the cost was .$60,000 per case.
Summary
The selection of a surgical approach
to the acetabulum is predicated on
several factors. The approach should
be determined after the fracture has
been classified and assessed for dis-
placement. Knowledge of the tradi-
tional and modified acetabular
approaches is essential to tailor
treatment to specific patient needs, to
avoid complications, and to minimize
surgical morbidity. Although frac-
ture characteristics play a pre-
dominant role in choice of approach,
other factors should be considered,
including the presence of concomi-
tant fractures or neurologic injury
and whether the patient is obese.
Future studies may determine which
treatments are optimal for certain
fracture types and patient groups.
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602
Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
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