• Acetabulum:-large cup-shaped structure in the coxal bone, at the point where the ilium,

ischium, and pubis meet.

• “acetabulum” comes from the Latin word for “vinegar cup.” It acts as a socket to hold the
ball-like head of the femur
• The hip is a ball-and-socket joint. The acetabulum is the socket for that joint
• The acetabulum is not a single bone; it is formed by the three coxal bones. The ilium and
ischium each make up about 40% of the acetabulum. This portion is fairly thick. Much of
the superior anterior and posterior acetabulum can be surgically removed without
appreciably weakening the joint. The remaining 20% of the acetabulum is part of the pubis.
In this inferior area, the bone is much thinner and can be easily damaged during surgery
 The Pelvis and its landmarks

The Pelvis is made up of three main bones fused together

ilium,
ischium,
pubis,

The Acetabulum - the cup-shaped cavity which

articulates with the femoral head
 Acetabulum-Lateral View

Lunate surface
Ilium
Acetabular Fossa
Acetabular Labrum Acetabular Notch

Pubis
Acetabular Ligament
Ischium

Ligamentum teres
 Kocher-Langenbeck approach to the acetabulum
• An approach to the posterior structures of the acetabulum
• Allows direct visualization of the posterior column and the retroacetabular surface
• Can be performed either in the prone (as illustrated) or lateral position
• Maintenance of knee flexion (at 90°) and hip extension throughout the procedure reduces
tension on the sciatic nerve
• allows direct access to the area indicated in dark brown, limited
cranially by the neurovascular bundle
 Skin Incision
Outline the following bony landmarks with a sterile marking pen:
• Posterior superior iliac spine
• Greater trochanter
• Shaft of femur

• 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).
Superficial surgical dissection
Fascial incision
After dividing the subcutaneous tissues, sharply incise the
subcutaneous tissues along:
1. The gluteus maximus muscle (using scissors)
2. The iliotibial tract (using a scalpel)

Split the gluteus maximus

Split the gluteus maximus in line with its fibers, starting at the greater trochanter
in a proximal direction up to the crossing of the first neurovascular bundle.
This creates a posterior muscle belly (inferior gluteal artery), and 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.
 Deep Dissection

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.
Carefully visualize the sciatic nerve.
Ensure at all times that no direct pressure or stretching is exerted on the nerve.
 Deep Dissection
• Option: detach the gluteus maximus muscle
Detach the gluteus maximus 1 cm from its insertion into the gluteal
tuberosity of the femur.
• Detachment can be done partially or completely.
• This allows less tension and easier mobilization of the gluteus maximus
muscle
Deep Dissection
• 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.
• 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
of tendon attached to the greater trochanter
• Reflect the piriformis belly laterally to expose the retroacetabular surface to the
greater sciatic notch.
Deep Dissection

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.
Exposure of the posterior wall and column

Expose the greater sciatic notch, the ischial spine, and the lesser sciatic
notch.
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
Trochanteric osteotomy for additional cranial and anterior exposure

To enhance cranial and anterior exposure a trochanteric osteotomy can be

performed.
The area in dark brown demonstrates the typical exposure or the standard
Kocher-Langenbeck approach. The blue area indicates the additional
exposure associated with trochanteric osteotomy.
This may be performed in either the prone or the lateral patient position.

It may be useful to predrill the trochanter for subsequent reattachment

prior to the 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 the 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.
 Trochanteric osteotomy for additional cranial and anterior exposure

• Mobilizing the trochanteric fragment anteriorly now provides access to the

cranial and anterior supraacetabular surface without excessive injury to the
gluteus medius and minimus musculature.
Quadratus femoris elevation for additional caudal exposure

The quadratus femoris can be elevated from its origin to expose the distal extent
of the posterior column as demonstrated in green.
Perform a capsulotomy

If the posterior capsule is intact and direct inspection of the

joint is required, a T-shaped capsulotomy is made.
Incise the joint capsule 0.5 cm lateral to the edge of the
posterior wall, avoiding damage to the limbus.
Place the vertical leg of the incision parallel to the femoral
neck.

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 is directly visible
Alternatively, distraction is achieved by enhancing skeletal
traction on the femoral shaft with the extension table.
 Iliac Crest

Ilium

Anterior Superior
Iliac Spine ASIS
Posterior Superior
Iliac Spine PSIS
Anterior Inferior
Iliac Spine AIIS

Posterior Inferior
Iliac Spine PIIS

Acetabulum

Obturator Foramen

Pubis

Ischium
Lateral View Anterior View
The Pelvis and its landmarks

Posterior Anterior
Column Column
Anatomy of Acetabulum