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The approach to the sciatic plexus and lateral part of the sacrum is difficult. A subperitoneal anterolateral approach can be extended by sectioning the iliac bone above the acetabulum and lowering it toward the external part of the iliac wing and buttock. This transiliac anterolateral approach exposes the lumbosacral trunk, first sacral foramina and sciatic plexus to the origin of the sciatic trunk. Exposure can be extended upward by subperitoneal lumbotomy, downward by opening the ischiorectal fossa, or outward by trochanterotomy. This approach was used 18 times by one of the authors (FHD) for resection of 13 malignant tumors and 5 plexus releases. Procedure time was 3-6hours, with 500-4,000ml blood loss. The approach systematically enabled surgical objectives to be met. There was 1 septic complication that healed after debridement.

Resume L’abord du plexus sciatique et de la partie laterale du sacrum est difficile. Une voie anterolaterale sous-peritoneale peut etre agrandie par la section de l’os coxal au-dessus de l’acetabulum et l’abaissement vers le dehors de l’aile iliaque et de la fesse. Cet abord trans-iliaque antero-lateral permet d’exposer le tronc lombo-sacre, les premiers foramens sacres et le plexus sciatique jusqu’a la constitution du tronc sciatique. L’exposition peut etre agrandie en haut par une lombotomie sous-peritoneale, en bas par l’ouverture de l’espace ischio-rectal ou en dehors par une trochanterotomie. Cette voie a ete effectuee 18 fois par un des auteurs (FHD) pour la resection de tumeurs malignes (13 cas) ou la liberation du plexus (5 cas). Les interventions ont dure de 3 a 6 h, avec des pertes sanguines totales de 500 a 4000 ml. Cet abord a permis d’atteindre constamment les objectifs chirurgicaux. Il y a eu une complication septique.

Introduction Among the various options for internal fixation of acetabular fractures, the enlarged iliofemoral approach is less often used, being more invasive, although providing greater exposure enabling control of all components in complex fractures. Even so, the impact of its invasiveness has not been confirmed, and long-term results are not known. We therefore performed a retrospective study, aiming: to assess long-term functional outcome, and; to assess associated morbidity. Hypothesis The enlarged iliofemoral approach allows precise reduction, with favorable long-term outcome. Material and methods Between 1992 and 1997, 15 patients were operated on for complex acetabular fracture by a single surgeon using an enlarged iliofemoral approach. Two patients were excluded due to lack of follow-up data, leaving 13 patients for analysis: 3 simple transverse fractures, 4 transverse + posterior wall fractures, 4 anterior column + posterior hemi-transverse fractures, one T-shaped fracture and one 2-column fracture. There were 4 cases of posterior dislocation of the hip, and 8 of intrapelvic protrusion. Surgical morbidity was assessed in terms of operative time, number of packed red blood cell transfusions, iatrogenic lesions or postoperative complications, rehabilitation time, and hospital stay. Functional assessment at follow-up used the WOMAC index and Harris score; radiologic assessment used the Kellgren–Lawrence score for osteoarthritis and Brooker score for ossification. Results Reduction was in all cases anatomic. There were no intra- or post-operative complications. Median number of packed red blood cell transfusions was 5 [range, 3–10]. Median operative time was 4 hours [3–6]. Median hospital stay was 6 weeks [6–8], to allow systematic traction with early postoperative mobilization. Weight–bearing was resumed at a median 8 weeks [8–12]. At a median 22 years’ follow-up [20–24], median Harris score was 83.5 [63–92] and median WOMAC index 24.5 [1–52]. All patients showed Brooker 1 or 2 ectopic ossification and moderate osteoarthritis. Two underwent subsequent arthroplasty (at 1 and 11 years after the index procedure). Discussion The enlarged iliofemoral approach allowed anatomic reduction of acetabular fracture. It provided very good long-term results, without excessive morbidity. Level of evidence IV, retrospective non-controlled study.