Hip, Pelvis, Upper Leg Surgery

James I. Huddleston MD¹

Michael J. Bellino MD¹

Stuart B. Goodman MD, PhD, FRCSC, FACS¹

Frederick G. Mihm MD²

Pedro P. Tanaka MD²

¹SURGEONS

²ANESTHESIOLOGISTS

OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF PELVIS OR ACETABULUM

SURGICAL CONSIDERATIONS

Description: Pelvic fractures present several challenging treatment problems. Surgical management is complex and often difficult in nature. Specialized training and equipment are required for a successful outcome. Major trauma mechanisms produce pelvic-ring injuries, and patients with pelvic-ring disruptions frequently have associated systemic injuries, which may be life-threatening (e.g., hemorrhagic shock). Pelvic stabilization and surgical control of hemorrhage may be performed acutely in the polytrauma patient who is hemodynamically unstable. This is in conjunction with an exploratory laparotomy performed by a trauma surgeon. The majority of patients with pelvic fractures who are treated operatively are taken to the OR on a delayed basis, after they have been stabilized. Pelvic fractures that do not heal are “nonunions,” whereas those that heal in an unsatisfactory position are “malunions.”

Anterior approaches to the pelvis include Pfannenstiel’s and ilioinguinal incisions, which are utilized for reduction and fixation of dislocations and fracture/dislocations of the symphysis pubis, fractures of the pubic rami, and access to the anterior aspect of the sacroiliac (SI) joint. Posterior approaches to the pelvis involve either vertical or curved incisions along the iliac crest and are used for reduction and fixation of SI joint dislocations, fracture/dislocations of the SI joint, and fractures of the iliac wing and of the sacrum. These procedures are often lengthy
and are staged, requiring changes in patient position. Reductions are facilitated by neuromuscular paralysis. The posterior approach requires a large operative field, which may prevent the use of an epidural catheter. In addition, postop anticoagulation for DVT prophylaxis is used uniformly and may contraindicate the use of epidural catheters. The goal of pelvic reconstruction is to restore the anatomy and stability of the pelvis, which will decrease hemorrhage in the hemodynamically unstable patient, aid in mobilization of the multiply injured patient, and improve long-term function.

Figure 10.4-1. Schematic views of the pelvis with the principal ligamentous supports. A: Symphysis pubis fibrocartilage. B: Posterior SI ligaments. C: Posterior view. D: Anterior view. (Redrawn from Chapman MW: Chapman’s Orthopaedic Surgery, Vol 1, 3rd edition. Lippincott Williams & Wilkins: 2001.)

Figure 10.4-2. Schematic view of the principal pelvis injury patterns, as determined by the vector of the provocative blow. A: Anteroposterior compression or external rotation injury. B: Stable lateral compression or internal rotation injury. C: Unstable lateral compression or internal rotation injury. D: Unstable vertical shear disruption. (Redrawn from Chapman MW: Chapman’s Orthopaedic Surgery, Vol 1, 3rd edition. Lippincott Williams & Wilkins: 2001.)

Usual preop diagnosis: Fractures of pelvis/acetabulum; nonunion/malunion of the pelvis/acetabulum

▪ SUMMARY OF PROCEDURE

Position	Supine (anterior); prone (posterior)
Incision	Pfannenstiel’s, ilioinguinal (anterior); posterior, curving along iliac crest (posterior)
Special instrumentation	Radiolucent table; pelvic instruments and implants; Cell Saver; I.I.
Antibiotics	Cefazolin 1 g iv q 6-8 h × 24 h (vancomycin or clindamycin for 24 h if penicillin allergic)
Surgical time	1-6 h (anterior); 3-6 h (posterior)
Closing considerations	May require neuromuscular relaxation to aid reduction and closure; postop radiograph
EBL	≥ 1000 mL
Postop care	Multiple-trauma patient → ICU; others → PACU
Mortality	10%+, dependent on extent of multiple trauma
Morbidity	Ileus: Common Neurologic injury: Common Genitourinary injuries: Not uncommon Failure of fixation: Rare Infection: Rare Malunion: Rare Nonunion: Rare
Pain score	9

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Procedures about the Pelvis and Hip (p. 1015).

Suggested Readings

1. Guyton JL: Fractures of hip, acetabulum, and pelvis. In: Canale ST, ed. Campbell’s Operative Orthopaedics, 10th edition. Mosby-Year Book, St. Louis: 2003.

2. LaVelle DG: Delayed union and nonunion of fractures. In: Canale ST, ed. Campbell’s Operative Orthopaedics, 10th edition. CV Mosby, St. Louis: 2003, 3125-65.

3. Leighton RK: Nonunions and malunions of the pelvis. In: Chapman MW, ed. Chapman’s Orthopaedic Surgery, Vol I, 3rd edition. Lippincott Williams & Wilkins, Philadelphia: 2001, 921-34.

4. Mears DC, Durbhakula SM: Fractures and dislocations of the pelvic ring. In: Chapman MW, ed. Chapman’s Orthopaedic Surgery, Vol I, 3rd edition. Lippincott Williams & Wilkins, Philadelphia: 2001, 531-85.

5. Prevezas N: Evolution of pelvic and acetabular surgery from ancient to modern times. Injury 2007; 38(4):397-409.

6. Rice PL Jr, Rudolph M:. Pelvic fractures. Emerg Med Clin North Am 2007; 25(3):795-802.

CLOSED REDUCTION AND EXTERNAL FIXATION OF THE PELVIS

SURGICAL CONSIDERATIONS

Description: This procedure entails manipulating the pelvis to obtain an acceptable reduction by closed means under GA, and then applying an anterior external fixation device to maintain the reduction. The pins for the external fixator are inserted into the iliac crest either percutaneously or through small incisions. During this procedure, either radiographs or the I.I. is used to confirm that an acceptable reduction has been obtained. In some centers, this procedure is done in the emergency department as a lifesaving procedure.

Usual preop diagnosis: Displaced fracture of the pelvis; unstable fracture of the pelvis

▪ SUMMARY OF PROCEDURE

Position	Supine
Incision	Percutaneously or through small incisions along the iliac crest
Special instrumentation	External fixation; often performed on a radiolucent table using I.I.
Antibiotics	Cefazolin 1 g iv q 6-8 h × 24 h (vancomycin or clindamycin for 24 h if penicillin allergic); combination antibiotics, if multiple severe, open fractures or other significant injuries are present.
Surgical time	1-1.5 h
EBL	Negligible from surgical procedure; however, anticipate large blood losses (4+ U) from the pelvic fracture alone.
Postop care	Multiple-trauma victim → ICU; others → PACU
Mortality	10% or more, depending on extent of multiple trauma; 50% in open fractures
Morbidity	Ileus: Virtually 100%; Sacroiliac (SI) pain: 15-30%+ Genitourinary problems, including bladder or urethral rupture: 13% Neurological deficit to lumbosacral plexus: 1-10% Malunion/severe deformity: 5% Leg-length discrepancy: 3-5% Impotence: 1-5% Residual instability: 1-3% Vascular complications: 1% Hypotension 2° to retroperitoneal hematoma: Common Respiratory distress: Common Gynecological and colorectal injuries: More common with open fractures/dislocations Delayed union, nonunion: Not uncommon Osteomyelitis: Rare Rupture of diaphragm: Rare
Pain score	7-10

▪ PATIENT POPULATION CHARACTERISTICS

Age range	Any age, but predominance of males < 30 yr
Male:Female	5:1
Incidence	Common
Etiology	Motorcycle and motor vehicle accidents (60-80%); falls (10-15%); crush injuries (5%); other (5%)
Associated conditions	Frequently associated with trauma to other organ systems, including head and neck, chest, abdomen, and extremities. Patient sustaining a pelvic fracture also has a probability of having other injuries, including: musculoskeletal (85%); respiratory (60%); CNS (40%); GI (30%); urologic (12%); CVS (6%). These often will be addressed concurrently with the pelvic fracture.

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Procedures about the Pelvis and Hip (p. 1015).

Suggested Readings

1. Guyton JL, Perez EA: Fractures of acetabulum and pelvis. In: Canale ST, Beaty JH, eds. Campbell’s Operative Orthopediacs, Vol 3, 12th edition. Mosby, St. Louis: 2012, 2777-820.

2. Mears DC, Durbhakula SM: Fractures and dislocations of the pelvic ring. In: Chapman MW, ed. Chapman’s Orthopaedic Surgery, Vol I, 3rd edition. Lippincott Williams & Wilkins, Philadelphia: 2001, 531-85.

3. Prevezas N: Evolution of pelvic and acetabular surgery from ancient to modern times. Injury 2007; 38(4):397-409.

4. Rice PL Jr, Rudolph M: Pelvic fractures. Emerg Med Clin North Am 2007; 25(3):795-802.

OPEN REDUCTION AND INTERNAL FIXATION (ORIF) OF ACETABULUM FRACTURES

SURGICAL CONSIDERATIONS

Description: Although the acetabulum is contained within the bony architecture of the pelvis, surgical management of acetabulum fractures are approached separately from pelvic fractures. The goal of surgical treatment of acetabulum fractures is to preserve the hip joint by accurately reconstructing the supporting bony anatomy. Surgical treatments of these challenging injuries are performed by surgeons who have undergone specialized training in orthopedic pelvic surgery. The mechanism of injury is usually high-energy trauma (e.g., motor vehicle, motorcycle accidents), industrial accidents, or a fall from a height that drives the femur into the acetabulum. Associated injuries to the pelvis are common, as are associated systemic injuries.

Optimal results are achieved when surgery is performed within 7 d. The approach is dictated mainly by the unique characteristics of the fractures. Essentially, three approaches are commonly used: the ilioinguinal (anterior, Fig. 10.4-3), the extended iliofemoral (lateral, Fig. 10.4-4), and the Kocher-Langenbeck (posterior, Fig. 10.4-5). The most difficult portion of the procedure is the reduction; it may be facilitated by neuromuscular relaxation, pelvic reduction instruments, and traction. The I.I. is used frequently throughout the procedure to assess the reduction and position of implants, which necessitates the use of lead aprons. A radiograph also is obtained at the end of the case to verify a satisfactory reduction and position of the implants. Patients are anticoagulated in the postop period to prevent
thromboembolic complications. Weight-bearing restrictions are maintained until enough healing has occurred to permit functional ambulation.

Figure 10.4-3. Ilioinguinal approach, right side: (i) Penrose drain around iliopsoas, femoral nerve, and lateral femoral cutaneous nerve; (ii) Penrose drain around femoral vessels; (iii) bladder and space of Retzius; (iv) pubis; (v) pubic tubercle; (vi) symphysis pubis; (vii) Penrose drain around spermatic cord. (Redrawn from Sledge CB, ed: The Hip. Lippincott-Raven: 1998.)

Figure 10.4-4. Extended iliofemoral approach: (i) Gluteus minimus tendon; (ii) gluteus medius tendon; (iii) gluteus maximus tendon; (iv) superior gluteal neurovascular bundle; (v) sciatic nerve; (vi) piriformis and conjoint tendons; (vii) hip joint capsule; (viii) greater trochanter; (ix) medial femoral circumflex artery overlying quadratus femoris. (Redrawn from Sledge CB, ed: The Hip. Lippincott-Raven: 1998.)

Figure 10.4-5. Kocher-Langenbeck approach. (Redrawn from Sledge CB, ed: The Hip. Lippincott-Raven: 1998.)

Usual preop diagnosis: Fracture of the acetabulum; nonunion/malunion of the acetabulum

▪ SUMMARY OF PROCEDURE

Position	Supine (anterior); lateral decubitus (lateral); prone (posterior)
Incision	Ilioinguinal (anterior, Fig. 10.4-3); extended iliofemoral (lateral, Fig. 10.4-4), Kocher-Langenbeck (posterior, Fig. 10.4-5)
Special instrumentation	Pelvic table; pelvic instruments and implants; I.I.; Cell Saver
Antibiotics	Cefazolin 1 g iv q 6-8 h × 24 h (vancomycin or clindamycin for 24 h if penicillin allergic)
Surgical time	2-5 h
EBL	100-2000 mL
Postop care	Multiple-trauma: ICU; others: PACU
Mortality	2.28%
Morbidity	Ectopic ossification: 24.4% Osteoarthritis after perfect reduction: 10.2%; after imperfect reduction: 35.7% Injury to lateral cutaneous nerve of the thigh: 12% Sciatic nerve damage: 6.3% Infection: 4.2% Avascular bone necrosis: 4.1% DVT: 3% Wound hematoma: 1.5% Secondary displacement of fracture site: 1.5% PE: 1% Pseudoarthrosis: 0.7% Ileus after ilioinguinal approach: Common
Pain score	7-8

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Procedures about the Pelvis and Hip, p. 1015.

Suggested Readings

1. Briffa N, Pearce R, Hill AM, Bircher M: Outcomes of acetabular fracture fixation with ten years’ follow-up. J Bone Joint Surg Br 2011; 93(2):226-36.

2. Gettys FK, Russell GV, Karunakar MA: Open treatment of pelvic and acetabular fractures. Orthop Clin North Am 2011; 42(1):69-83, vi.

3. Guyton JL. Perez EA: Fractures of acetabulum and pelvis. Chapter 56. In: Canale ST, Beaty JH, eds. Campbell’s Operative Orthopediacs, Vol 3, 12th edition. Mosby, St. Louis: 2012, 2777-820.

4. Prevezas N: Evolution of pelvic and acetabular surgery from ancient to modern times. Injury 2007; 38(4):397-408.

5. Rice PL Jr, Rudolph M: Pelvic fractures. Emerg Med Clin North Am 2007; 25(3):795-802.

OSTEOTOMY AND BONE GRAFT AUGMENTATION OF THE PELVIS

SURGICAL CONSIDERATIONS

Description: Acetabular insufficiency (acetabular dysplasia) is characterized by deficient anterior and lateral coverage of the acetabulum on the femoral head. This condition of the hip produces joint incongruity and instability, eventually leading to arthrosis and a dysfunctional hip joint. Treatment is aimed at reorienting the dysplastic acetabulum (Fig. 10.4-6). In children, bone grafting alone may be sufficient; in adults, however, pelvic osteotomy, to reorient or broaden the weight-bearing surface, is necessary. A supplemental bone graft to expand the weight-bearing surface may be added. In certain instances following pelvic osteotomy, incongruity of the hip may persist. In this situation, the pelvic osteotomy is combined with a proximal femoral osteotomy to restore congruence. Pelvic and proximal femoral osteotomies usually are fixed internally with screws and plates to allow early mobilization without displacement. Weight-bearing is permitted after healing of the osteotomy at ˜8 wk.

Usual preop diagnosis: Acetabular dysplasia; developmental dysplasia of the hip

Figure 10.4-6. The Bernese periacetabular osteotomy. (Redrawn from Ganz R, Klaue K, Vinh TS, et al: A new periacetabular osteotomy for the treatment of hip dysplasias: technique and preliminary results. Clin Orthop 1988; 232:26-36.)

▪ SUMMARY OF PROCEDURE

Position	Supine
Incision	Anterior: ilioinguinal or iliofemoral and Smith-Peterson
Special instrumentation	Pelvic instruments and implants; special osteotomes and saws; I.I., Cell Saver
Unique considerations	Intraop radiographs and use of I.I.
Antibiotics	Cefazolin 1 g iv q 6-8 h × 24 h (vancomycin or clindamycin for 24 h if penicillin allergic)
Surgical time	3 h
EBL	500+ mL
Postop care	PACU → room; usually on protected, weight-bearing walker or crutches × 8 wk
Mortality	Minimal
Morbidity	Ileus: 100% Leg-length discrepancy: Uniformly present after pelvic osteotomy Injury to lateral cutaneous nerve: Common (50%) Sciatic nerve: Uncommon (1%) Thromboembolism: 5-10% Wound infection: 1-5% Septic arthritis, osteomyelitis: 1-7% Delayed union, nonunion, malunion: 1-2% Genitourinary problems—urinary retention requiring catheterization: Common Hematoma: Common Hypotension 2° to retroperitoneal hematoma: Rare Vascular complications: Rare
Pain score	8

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Procedures about the Pelvis and Hip (p. 1015).

ARTHRODESIS OF THE SACROILIAC JOINT

SURGICAL CONSIDERATIONS

Description: In this procedure, a painful and/or unstable sacroiliac (SI) joint is fused, usually by excising the joint through an anterior or posterior approach and employing an iliac crest bone graft. Supplemental screw fixation of the joint is used. The incision follows the iliac crest from the anterior superior iliac spine past the convexity of the iliac tubercle; the aponeurosis of the external abdominal musculature is elevated from the iliac crest. The internal iliac
fossa is exposed subperiosteally, posterior to the SI joint; then the joint cartilage is excised and packed with cancellous bone strips. The SI joint is fixed with plates and screws. Alternatively, a posterior approach to the SI joint may be used. A straight vertical incision is made just lateral to the posterior superior iliac spine. The origin of the gluteus maximus is elevated from its origin off the posterior ilium and sacrum and reattached laterally. The SI joint is identified, debrided of cartilage, and packed with strips of cancellous bone. It is then fixed with screws.

Variant procedure or approaches: Anterior or posterior approach

Usual preop diagnosis: Arthritis or arthrosis of the SI joint; pelvic instability

▪ SUMMARY OF PROCEDURE

Position	Supine (anterior) or prone (posterior)
Incision	Lateral portion of ilioinguinal (anterior); posterior approach to SI joint (posterior)
Special instrumentation	Radiolucent table; pelvic instruments and implants; I.I.; Cell Saver
Unique considerations	Intraop radiographs or use of I.I.
Antibiotics	Cefazolin 1 g iv q 6-8 h × 24 h (vancomycin or clindamycin for 24 h if penicillin allergic)
Surgical time	2-3 h
EBL	250-500 mL
Postop care	Usually on protected, weight-bearing walker or crutches × 6-8 wk; anticoagulation for DVT prophylaxis
Mortality	Extremely low
Morbidity	Ileus: Virtually always Osteomyelitis: < 1% Wound infection: < 1% Genitourinary problems; urinary retention requiring catheterization: Common Delayed union, nonunion, malunion, leg-length discrepancy: Not uncommon Neurological deficit; injury to lumbosacral plexus: Rare, unless present preop; L5 nerve root susceptible in anterior approaches Hypotension 2° to retroperitoneal hematoma: Rare Injury to bowel: Rare Vascular complications; injury to iliac arteries: Rare Thromboembolism
Pain score	7

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations for Procedures about the Pelvis and Hip (p. 1015).

Suggested Readings

1. Prevezas N: Evolution of pelvic and acetabular surgery from ancient to modern times. Injury 2007; 38(4):397-409.

2. Rice PL Jr, Rudolph M: Pelvic fractures. Emerg Med Clin North Am 2007; 25(3):795-802.

3. Wise CL, Dall BE: Minimally invasive sacroiliac arthrodesis: outcomes of a new technique. J Spinal Disord Tech 2008; 21(8):579-84.

AMPUTATIONS ABOUT THE HIP AND PELVIS: DISARTICULATION OF THE HIP AND HINDQUARTER AMPUTATION

SURGICAL CONSIDERATIONS

Description: These surgical procedures accomplish an excision of the entire lower extremity. In a hip disarticulation, the amputation is performed through the hip joint. An anterior, racquet-shaped incision is made, and all muscles crossing the hip joint are incised or detached. The femoral artery, vein, and nerve; obturator vessels; sciatic nerve; and deep vessels are isolated and ligated. The gluteal flap is brought anteriorly and sewn to the anterior portion of the incision. In a hindquarter amputation, excision of the lower extremity, hip joint, and a portion of the pelvis is performed. Anterior and posterior incisions are used, the iliac wing is divided posteriorly, and the symphysis pubis is disarticulated anteriorly. Either the common iliac or external iliac vessels are ligated, as are all nerves to the lower extremity. Usually the gluteal flap is drawn anteriorly for closure. These procedures are performed very rarely—for severe trauma, tumor, or infection—and are often lifesaving surgeries. They often are performed in conjunction with a general surgeon, and standard bowel prep is done. The operations are long and tedious, with extensive blood loss, in patients who are usually systemically ill.

Usual preop diagnosis: Malignant tumor of femur, hip or pelvis; traumatic amputation to femur, hip, or pelvis; uncontrollable infection to leg, hip, or pelvis (e.g., clostridia)

▪ SUMMARY OF PROCEDURES

	Hip Disarticulation	Hindquarter Amputation
Position	Supine	Lateral decubitus; stabilized by bean bag and/or kidney rests.
Incision	Anterior racquet type (rare)	Anterior and posterior
Unique considerations	Urinary catheter should be placed.	Urinary catheter; NG tube; scrotum strapped to opposite thigh; anus stitched closed/sealed.
Antibiotics	Cefazolin 1 g iv q 6-8 h × 24 h (vancomycin or clindamycin for 24 h if penicillin allergic)	⇚
Surgical time	3-4 h	4-5 h
EBL	1000-2000 mL (intraop blood salvage system recommended, except for tumors)	2000-3000 mL
Postop care	ICU	⇚
Mortality	Rare in patients undergoing elective amputation for trauma or localized tumor; higher for patients with debilitated trauma, chronic infection, or extensive invasive malignant tumor; highest in clostridial infections: ˜50%+	⇚
Morbidity	Anemia: Common Electrolyte abnormalities: Common Hematoma: Common Neurological injury to lumbosacral plexus or peripheral nerves: Common Paralytic ileus: Common Psychosocial problems: Common UTI: Common Flap necrosis: Not uncommon	⇚ ⇚ ⇚ ⇚ ⇚ ⇚ ⇚ ⇚
	Incomplete excision with recurrence of tumor or infection: Not uncommon Injury to peritoneal or retroperitoneal contents, including bowel and bladder: Not uncommon Vascular injury—iliac, other vessels: Not uncommon	⇚ ⇚ ⇚
Pain Score	10	10

ANESTHETIC CONSIDERATIONS FOR PROCEDURES ABOUT THE PELVIS AND HIP

(Procedures covered: ORIF, pelvis, acetabulum; closed reduction, external fixation, pelvis; osteotomy and bone graft of pelvis; arthrodesis of SI joint; amputations about hip and pelvis: disarticulation of hip and hindquarter amputation)

PREOPERATIVE

Patients presenting for pelvic surgery generally fall into two categories: (1) Major trauma—pelvic fracture requires substantial force and seldom occurs alone. These patients require aggressive fluid resuscitation with large-bore ivs and invasive monitors (arterial line and CVP). If the patient can be made hemodynamically stable with volume resuscitation, a thorough evaluation for coexisting neurological, thoracic, or abdominal trauma should be undertaken before anesthesia. (2) Tumor resection and amputation of thigh, hip, and pelvis. Because of large intraop blood loss and 3rd-spacing of fluids, invasive hemodynamic monitoring is necessary. Although epidural anesthesia is seldom adequate for surgery, postop epidural analgesia is an effective means of controlling the tremendous pain caused by this type of surgery. Other patient populations covered in this section include otherwise healthy patients with congenital or acquired hip dysplasia presenting for augmentation procedures.

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