The Ilioinguinal Approach: State of the Art

The ilioinguinal approach is the standard approach for the open reduction and internal fixation of the majority of displaced, anteriorly based acetabular fractures as it offers wide access to the acetabulum, is extensile, and has been associated with enhanced recovery. The anterior ilioinguinal approach as described by Letournel in 19611 is the approach of choice for the exposure, reduction, and fixation of fractures involving the anterior column of the acetabulum and the inner surface of the innominate bone2-5. Access to these structures through the ilioinguinal approach requires the opening of the inguinal canal and the mobilization of the external iliac vessels with the subsequent development of 3 “working windows.” The first or lateral window extends from the sacroiliac joint to the lateral aspect of the iliopsoas muscle, providing access to the sacroiliac joint, the internal iliac fossa, and the proximal pelvic brim. The second or middle window is defined laterally by the medial aspect of the iliopsoas muscle and the femoral nerve and medially by the external iliac artery, offering access to the distal pelvic brim, the quadrilateral surface, the anterior acetabular wall, the iliopsoas gutter, and the iliopectineal eminence. The third or medial window is developed between the external iliac vein and the lateral aspect of the rectus abdominis muscle, allowing access to the space of Retzius, the pubic symphysis, and the superior pubic ramus from the pubic tubercle to the pectineus recess. Extensile maneuvers can offer broader exposure of the anterior wall, the anterior hip capsule, the quadrilateral surface, and the external iliac fossa. The anatomical muscle-sparing ilioinguinal approach offers wide access to the acetabulum, is extensile, and has been associated with enhanced recovery. Disadvantages include the need to mobilize the external iliac neurovascular bundle, the need to open the inguinal canal, and the limited access to the inner aspect of the posterior column and inferior quadrilateral surface. Moreover, the direct visualization of the acetabular articular surface is not possible through the ilioinguinal approach. Consequently, the quality of the articular reduction relies on the quality of cortical osseous reductions of the innominate bone and the confirmation provided by intraoperative fluoroscopy. Described complications include damage to the external iliac neurovascular bundle, bladder injury, anterior thigh numbness, inguinal hernia, thromboembolism, and infection6,7. The risk of heterotopic ossification is low. The ilioinguinal approach does not allow for visualization of the acetabular articular cartilage. The management of anteromedial dome impaction is best addressed with the anterior intrapelvic approach. If an ilioinguinal approach is used, an independent iliac corticotomy is necessary. Additionally, posterior marginal impaction and displaced posterior wall fractures are difficult to manage with the classic ilioinguinal approach and the surgeon should consider other options such as a double (anterior and posterior) approach to the acetabulum8. Various modifications of the ilioinguinal approach have been described in the literature, and the surgeon should be familiar with them in order to address any potential intraoperative difficulties9.