Approaches to Pelvis and Acetabulum

Anterior Approach to the Iliac Crest for Bone Graft

Posterior Approach to the Iliac Crest for Bone Graft

Anterior Approach to the Pubic Symphysis

Anterior Approach to the Sacroiliac Joint

Posterior Approach to the Sacroiliac Joint

Applied Surgical Anatomy of the Bony Pelvis Ilioinguinal Approach to the Acetabulum

Applied Surgical Anatomy of the Ilioinguinal Approach to the Acetabulum

Posterior Approach to the Acetabulum

 

Pelvis

The pelvis is a complex bony structure with interconnecting ligaments. It consists of the two innominate bones, which articulate anteriorly with each other at the pubic symphysis and posteriorly with the body of the sacrum at the sacroiliac joint. The bones are covered on each side by muscles, and the intra-abdominal contents make surgical exposure potentially complex. The presence of a large subcutaneous surface (the iliac crest), however, allows safe access to the ilium.

Five approaches to the pelvis are described in this chapter, all of which provide access to the bone via its subcutaneous portion. The anterior and posterior approaches to the iliac crest are used almost exclusively for bone grafting. The anterior approach to the pubic symphysis and the anterior and posterior approaches to the sacroiliac joints are performed rarely; their use is associated almost exclusively with the open reduction and internal fixation of pelvic ring fractures.

Acetabulum

Approaches to the acetabulum are the most complex and demanding approaches a surgeon can be asked to perform. They are nearly always used for the reconstruction of the acetabulum following fractures. Because each approach only gives access to a limited part of the acetabulum, it is critically important that the correct approach is used for each fracture pattern (Fig. 7-1). This requires accurate assessment of the anatomy of the fracture, using radiographic techniques, including computerized tomography.1–3 The use of a bone model is invaluable especially when a surgeon is inexperienced.

The ilioinguinal approach to the acetabulum allows access to the anterior column and medial aspect of the acetabulum. It also allows visualization of the inner aspect of the pelvis from the sacroiliac joint to the symphysis pubis. It does not allow direct access to the posterior column or posterior lip (see Fig. 7-21).

Figure 7-1 To appreciate the anatomy of the anterior and posterior columns of the acetabulum, hold a hemipelvis up against a light source. These two massive columns can then be appreciated in contrast to the thin central area of the wing of the ilium.

The posterior approach to the acetabulum allows access to the posterior column, posterior lip, and dome segment of the acetabulum. It allows very limited access to the anterior column of the acetabulum and no access to the medial aspect of the acetabulum (see Fig. 7-39).

The applied surgical anatomy of the ilioinguinal approach is to be found immediately after the description of the surgical approach. The applied surgical anatomy of the posterior approach is found in Chapter 8 (see page 451).

Because each approach only provides limited access to the acetabulum complex fractures may require the use of more than one approach.

Most acetabular fractures occur as a result of extremely violent trauma.

The tissues therefore are contused and muscle planes are often difficult to develop. The fractures themselves are difficult to reduce, and control and specialized instruments are necessary to ensure anatomical reduction and stable fixation. There is rarely, if ever, an indication to perform these approaches in an emergency situation. Acetabular fractures are rare. Understanding of the anatomy of the fracture is difficult and surgical approaches are technically demanding. The results of acetabular reconstruction depend largely on the accuracy of the reduction of the fracture. For these reasons, acetabular surgery, if at all possible, should be performed by experienced surgeons working in centers large enough to attract a sufficient volume of patients.