Introduction Allows exposure to entire internal iliac fossa and pelvic brim from the SI joint to the pubic symphysis quadrilateral surface of innominate bone and superior/inferior pubic rami (thus allows exposure of anterior column) portion of external aspect of ilium Indications anterior wall fx anterior column fx anterior column plus posterior hemitranverse fx majority of associated both-column fractures even in presence of posterior wall fracture posterior-wall fragment attached to ilium can be reduced through lateral ilium exposure not recommended for fractures associated with comminuted post wall fractures or SI joint fractures some T-type can used for minimally posteriorly displaced T-type fractures some transverse type for transverse fx if displacement is anterior Positioning Anesthesia patient must be paralyzed throughout case Position supine with greater troch on side of fracture at edge of table place bump under ipsilateral buttock flex affected leg to relax iliopsoas and neurovascular structures Imaging ensure clear fluoroscopic images can be obtained prior to draping Catheter insert catheter to empty bladder (will obscure vision) Incision Incision incision begins at midline 3-4cm proximal to symphysis pubis proceeds laterally to ASIS, then along anterior 2/3's of iliac crest extend incision beyond most convex portion of ilium Superficial Dissection dissect through subcutaneous fat start laterally, incise periosteum along iliac crest release abdominal and iliacus muscle insertions from ilium superiosteally elevate iliacus from internal iliac fossa to SI joint and pelvic brim pack internal iliac fossa for hemostasis through lower portion of incision expose aponeurosis of external oblique and rectus abdominus divide exposed aponeurosis in line with skin incision one cm proximal to external inguinal ring will often have to sacrifice lateral cutaneous nerve of the thigh thus unroofs inguinal canal, and exposes inguinal ligament identify and protect ilioinguinal nerve isolate spermatic cord/round ligament and place penrose around structures to retract sharply incise inguinal ligament, leaving 1-2mm cuff of ligament still attached to divided origin of internal oblique, transversus abdominus, and transversalis fascia may need to divide conjoint tendon at its insertion on pubis as well as anterior rectus sheath Deep Dissection bluntly dissect a plane between the symphysis pubis and the bladder (space of Retzius), pack with sponges expose anterior aspect of femoral vessels and surrounding lymphatics in midportion of incision (lacuna vasorum) lacuna musculorum is lateral and contains iliopsoas, femoral nerve, and lateral femoral cutaneous nerve identify iliopectineal fascia, which seperates the lacuna vasorum and lacuna musculorum dissect vessels and lymphatics from medial aspect of fascia, free iliopsoas and femoral nerve from lateral aspcet of fascia sharply divide iliopectineal fascia down to pectineal eminence, then detach from pelvic brim; allows access to true pelvis, quadrilateral plate, and posterior column place second penrose drain around iliopsoas, femoral nerve, and lateral femoral cutaneous nerve place thrid penrose drain around femoral vessels and lymphatics identify and ligate corona mortise before retracting vessels subperiosteal dissection is used to expose pelvic brim, rami, and quadrilateral surface work through 3 windows to reduce and fix fracture: Medial window medial to external iliac artery & vein access to pubic rami; indirect access to internal iliac fossa and anterior SI joint Middle window between external iliac vessels and the iliopsosas access to pelvic brim, quadrilateral plate, and a portion of the superior pubic ramus Lateral window lateral to iliopsoas (iliopectineal fascia) access to quadrilateral plate, SI joint, and iliac wing Closure drains suction drains are placed in the space of Retzius and along quadrilateral surface repair tendon of rectus abdominus transversalis fascia and the conjoined tendon of the internal oblique and transversus abdominus are attached to inguinal ligament roof of inguinal canal is repaired by closure of aponeurosis of external oblique iliopectineal fascia is not repaired Dangers & Complications Femoral nerve Femoral & External Iliac Arteries damage can cause thrombosis protect by leaving in femoral sheath Lymphatics present in fatty areolar tissue around vessels disruption can impair postoperative lymphatic drainage and cause edema Lateral cutaneous nerve of thigh often have to sacrifice leaving numbness on the outer side of the thigh Inferior epigastic artery must sacrifice if has anomoulous origin off obturator artery to allow retraction of iliac vessels Spermatic cord (contains vas deferens and testicular artery) must protect damage can cause testicular ischemia, infertility Heterotopic Ossification much more common in the extended iliofemoral and Kocher-Lagenbeck approaches Obturator nerve causes medial thigh numbness when injured