The Kocher-Langenbeck approach is the workhorse for the reduction and fixation of hip fractures that require fixation via a posterior approach. J Orthop Trauma. Apr;25(4) doi: /BOT.0bef9ad6e. Modified Kocher-Langenbeck approach for the stabilization of posterior wall. Kocher-Langenbeck approach for acetabular # fixation– sath, Chennai, India. Arun Dr. Loading Unsubscribe from Arun Dr?.
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The Kocher-Langenbeck approach is an approach to the posterior structures of the acetabulum. It allows direct visualization of the posterior column and the retroacetabular surface. The dorsocranial articular acetabulum is also accessible either through the fracture gap or after a capsulotomy.
The Kocher-Langenbeck approach can be performed either in the prone as illustrated or lateral position. Exposure This approach allows direct access to the area indicated in dark brown, limited cranially by the neurovascular bundle.
Additional exposure to the cranial anterior portion of the acetabulum blue can be obtained with trochanteric osteotomy. Caudal exposure green can be obtained with reflection of the quadratus femoris muscle. Care must be taken to avoid injury to the medial circumflex femoral artery and thus should be avoided when possible.
Start the skin incision a few centimeters distal and lateral to the posterior superior iliac spine. A more proximal extension indicated by dashed line may improve exposure in obese or muscular patients.
Continue the incision anteriorly over the greater trochanter. Curve it distally along the tip of the greater trochanter towards the lateral aspect of the femoral shaft. End the incision at the mid third of the thigh just distal to the insertion of the gluteus maximus tendon. Split the gluteus maximus Split the gluteus maximus in line with its fibers, approavh at the greater langembeck in a proximal direction up to the crossing of the first neurovascular bundle.
The Kocher-Langenbeck Approach
This creates a posterior muscle belly inferior gluteal arteryand an anterior belly superior gluteal artery that includes one third of the gluteus maximus and the muscle of the tensor fascia latae.
Incise the iliotibial tract In the distal half, incise the iliotibial tract in line with its fibers up to the mid third of the thigh. Free the layer of fat covering the short external rotators, exposing the insertion of the piriformis tendon, the gemelli, and the internal obturator muscle.
The sciatic nerve see illustration lies posterior to the gemelli and internal obturator muscles, and anterior to the piriformis muscle, between the greater trochanter and the ischial tuberosity. Detach the external rotator muscles Isolate the piriformis tendon. Place a suture at least 1 cm lateral to its femoral insertion and dissect the tendon.
Posterior Approach to the Acetabulum (Kocher-Langenbeck)
Avoid damage to the medial circumflex femoral artery which is running in proximity at the upper border of the quadratus femoris muscle by leaving 1 cm lqngenbeck tendon attached to the greater trochanter. Reflect the piriformis belly laterally to expose the retroacetabular surface to the greater sciatic notch.
Isolate the conjoined tendon of the obturator internus and superior and inferior gemelli muscles. They are tagged and incised 1 cm lateral from their femoral insertions to protect the medial circumflex femoral artery. Reflect the muscle bellies of the three conjoined muscles laterally to access the lesser sciatic notch.
The Kocher-Langenbeck Approach
Insert a retractor in the lesser sciatic notch and one anterosuperiorly in the direction of the anterior inferior spine. Now the posterior column is visible in its whole extent.
Protect the sciatic nerve, which lies behind the retractor, with abdominal sponges. Use the short external rotator muscles as a cushion. The area in dark brown demonstrates the typical exposure or the standard Kocher-Langenbeck kocber. The blue area indicates the additional exposure associated with trochanteric osteotomy.
The osteotomy is then carried out from the posterior trochanter anteriorly to mobilize the fragment. This is facilitated by internal rotation of the femur. Ideally the exit point of langenbeci osteotomy will leave the piriformis origin partially attached to the trochanteric fragment. Trochanteric mobilization may also require detachment of remaining gluteus medius and elevation of the vastus lateralis fascia from the vastus tubercle.
Mobilizing the trochanteric fragment anteriorly now provides access to the cranial and anterior supraacetabular surface without excessive injury to the gluteus medius and koher musculature.
The quadratus femoris can be elevated from its origin to expose the distal extent of the posterior column as demonstrated in green. If the posterior capsule is intact and direct inspection of the joint is required, a T-shaped capsulotomy is made. Incise the kocber capsule 0. With the help of a Schanz screw placed in the femoral neck, distraction of the hip joint can be achieved.
In this way, the inner aspect of the acetabulum langenbck directly visible. Alternatively, distraction is achieved by approavh skeletal traction on the femoral shaft with the extension table. Detect if there is any marginal impaction or damage to the cartilage of the acetabulum and femoral head. Note If no capsulotomy has been performed, the hip joint cannot be inspected after reduction fixation of the lanenbeck.
Remove necrotic tissue and irrigate the entire wound to decrease the risk of periarticular ossification. Insert at least two suction drains. Reinsert all tendons and approximate the split parts of the gluteus maximus with adaptation sutures.
Perform the closure of the iliotibial tract, the subcutis and the skin. Note The repair of these tendons at the time of closure represents additional risk to the femoral head circulation.
This is particularly true for the conjoint tendon where passage of a needle into the tendon stump may injure the medial femoral circumflex artery.
Contact Disclaimer AO Foundation. Approach – more detail Back. Introduction The Kocher-Langenbeck approach is an approach to the posterior structures of the acetabulum.