Introduction: The Kocher-Langenbeck (K-L) approach is the most commonly utilized approach in the treatment of acetabular fractures requiring repair from a posterior approach. Modifications to the approach, including a trochanteric osteotomy and use of the Gibson skin incision and interval, have been developed to address anterior and cranial fracture morphologies. To this point, the benefits of these modifications have been mostly case reports and expert opinion, with no comparative studies validating the benefits touted with these approaches. With this in mind, we sought to compare the exposure of the classic Kocher-Langenbeck approach against the modified Gibson. Additionally, we assessed the benefit of a trochanteric osteotomy in the setting of both of these approaches. Methods: A classic Kocher-Langenbeck (followed by a Gibson approach on the contralateral hip) was performed in the lateral position on eight cadavers. No limb had undergone previous surgery about the hip. In both settings, gluteus minimus was debrided to the superior gluteal neurovascular bundle, to a level 5 cm cranial to the hip joint if the bundle was unidentifiable. Retractors were placed in standard positions about the acetabulum. Once the exposure was complete, a 2.0 mm k-wire was used to outline the bony surfaces which were available for instrumentation using this exposure. Subsequently, a trochanteric osteotomy was performed and a retractor was placed anteriorly, displacing the trochanter and abductors anterior. A 2.0 mm k-wire was again used to outline the limits of the exposure. All soft tissue was then removed from the pelvis and the drill holes were outlined using a marker. A digital picture was taken with a 1 cm ruler in the field and the images were analyzed using ImageJ. Width of the pelvis was measured at the level of the superior capsule from the AIIS to the greater sciatic notch to control for projection and camera position between sides (Figure 1). Extent of anterior exposure (with and without a trochanteric osteotomy) was then measured from the greater sciatic notch and recorded. The proportion of the pelvis visualized from posterior to anterior was calculated. This value was compared between each side of the specimens to assess for a difference in exposure using the Gibson and K-L approach. Results: The Gibson approach yielded a significant increase in the anterior exposure when compared to a Kocher-Langenbeck done on the contralateral side in only three of eight cadavers. The addition of a trochanteric osteotomy yielded on average 1.6 centimeters (range, 0.9-2.6 cm) of increased anterior exposure in the K-L approaches and 1.3 centimeters (range 0.8-1.8 cm) in the Gibson approaches. Conclusion: The Gibson approach did not reliably provide increased anterior exposure when compared with a traditional Kocher-Langenbeck in our cadaver model. A trochanteric osteotomy can be expected to add 1 to 2 cm of increased anterior exposure in either a Gibson or K-L approach.
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