Retract the posterior soft tissues with a right-angle retractor placed on top of a laparotomy sponge to avoid compression or excessive traction on the sciatic nerve. Place an additional retractor beneath the transverse acetabular ligament to provide inferior exposure. The safest position is near the level of the anterosuperior iliac spine. The risk increases with a more inferior placement of the retractor. Erroneous placement of this retractor over the psoas muscle can cause injury to the femoral nerve or adjacent vessels. Place a curved cobra or Hohmann retractor in the interval between the anterior rim of the acetabulum and the psoas tendon ( Fig. ▪Ĭarefully divide the anterior capsule between the jaws of the clamp ( Fig. Retract the femur anteriorly with a bone hook to place the capsule under tension.
![complete anatomy of hip joint complete anatomy of hip joint](https://i.ytimg.com/vi/2s2bZGDcT7M/hqdefault.jpg)
Isolate the anterior capsule by passing a curved clamp within the sheath of the psoas tendon. The sciatic nerve has frequent variation in its relationship to the piriformis muscle as it exits the sciatic notch, with common separation of tibial and peroneal branches at this level. The functioning of both the tibial and common peroneal components of the sciatic nerve must be carefully documented in the emergency department and after subsequent interventions (including reduction of a hip dislocation and changes in traction). The sciatic nerve exiting the greater sciatic notch inferior to the piriformis muscle frequently is injured with posterior fracture-dislocations of the hip and fractures with posterior displacement ( Fig. The neurovascular structures passing through the pelvis are at risk during the original injury and subsequent treatment, and the various surgical approaches are designed around these structures. The quadrilateral surface may be comminuted and incompetent, especially in acetabular fractures in the elderly, and the thin nature of this bone may limit the types of fixation that can be used in this region. The quadrilateral surface is the flat plate of bone forming the lateral border of the true pelvic cavity and lying adjacent to the medial wall of the acetabulum ( Fig. Anatomic restoration of the dome with concentric reduction of the femoral head beneath this dome is the goal of both operative and nonoperative treatment. Further, it must be recognized that when the dome occurs as a separate fragment or impacted articular segment, it is important to optimize reduction, fixation, and thus, patient outcomes. While it is a confluence of the anterior and posterior walls, the ability to provide anatomic restoration must be considered when choosing an approach. The dome, or roof, of the acetabulum is the weight-bearing portion of the articular surface that supports the femoral head when in an upright bipedal position ( Fig. This area can be especially difficult to access and provide stable fixation when represented as a separate fragment. The iliopectineal eminence is the prominence in the anterior column that lies directly over the femoral head and represents the inferior half of the anterior wall. The posterior wall is larger than the anterior wall and more often presents as a separate fragment because of the flexed position of the hip during the occurrence of many acetabular fractures. The articular surface of the acetabulum is divided into the remaining four parts. Classification of these fractures used the column concept, and its understanding is central to the discussion of fracture patterns, operative approaches, and internal fixation. The shorter posterior column ends at its intersection with the anterior column at the top of the sciatic notch. The posterior column is the ischium, the ischial spine, the posterior half of the acetabulum, and the dense bone forming the sciatic notch. The anterior column is composed of the anterior half of the iliac crest, the iliac spines, the anterior half of the acetabulum, and the pubis. The two columns of bone, described by Letournel and Judet as an inverted Y, support and transmit load to the remainder of the pelvis ( Fig. The acetabulum can best be described as a partial ball and socket joint composed of six components: (1) anterior, or iliopubic, column, (2) posterior, or ilioischial, column, (3) anterior wall, (4) posterior wall, (5) acetabular dome/roof, and (6) medial wall or quadrilateral plate.
![complete anatomy of hip joint complete anatomy of hip joint](https://etc.usf.edu/clipart/53500/53526/53526_hip_lg.gif)
The acetabulum is an incomplete hemispherical socket with an inverted horseshoe-shaped articular surface surrounding the medial nonarticular cotyloid fossa. Azar MD, in Campbell's Operative Orthopaedics, 2021 Anatomy