FRACTURE OF ACETABULUM

The acetabulum can be described as an incomplete hemispherical socket with an inverted horseshoe-shaped articular surface surrounding the nonarticular cotyloid fossa. This articular socket is composed of and supported by two columns of bone, described by Letournel and Judet as an inverted Y. The anterior column is composed of the bone of the iliac crest, the iliac spines, the anterior half of the acetabulum, and the pubis. The posterior column is the ischium, the ischial spine, the posterior half of the acetabulum, and the dense bone forming the sciatic notch. The column concept is used in classification of these fractures and is central to the discussion of fracture patterns, operative approaches, and internal fixation. The dome, or roof, of the acetabulum is the weight bearing portion of the articular surface that supports the femoral head Anatomical restoration of the dome with concentric reduction of the femoral head beneath this dome is the goal of both operative and nonoperative treatment. The quadrilateral surface is the flat plate of bone forming the lateral border of the true pelvic cavity and thus lying adjacent to the medial wall of the acetabulum. The iliopectineal eminence is the prominence in the anterior column that lies directly over the femoral head. Both the quadrilateral surface and the iliopectineal eminence are thin and adjacent to the femoral head, limiting the types of fixation that can be used in these regions

Two-column concept of Letournel used in classification of acetabular fractures

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 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 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

The superior gluteal artery and nerve exit the greater sciatic notch at its most superior aspect and can be tethered to the bone at this level by variable fascial attachments. Fractures that enter the superior portion of the greater sciatic notch can be associated with significant hemorrhage, possibly requiring angiography with embolization of the superior gluteal artery. Knowledge of the intrapelvic relationships of the lumbosacral trunk, common and external iliac vessels, and inferior epigastric vessels as well as of the obturator artery and nerve becomes crucial as retractors, reduction forceps, drills, and screws are used. One particularly noteworthy anatomical relationship is the occasional large anastomosis between the external iliac artery or inferior epigastric artery and the obturator artery known as the corona mortis Failure to ligate this vascular connection during the ilioinguinal approach can lead to significant hemorrhage that is difficult to control as the external iliac vessels are mobilized.

RADIOGRAPHIC EVALUATION The acetabulum is evaluated radiographically with an AP pelvic view as well as with the 45-degree oblique views of the pelvis described by Judet and Letournel, commonly called Judet views. In the iliac oblique view, the radiographic beam is roughly perpendicular to the iliac wing. In obturator oblique view, radiographic beam is roughly perpendicular to the obturator foramen. Inclusion of the opposite hip in the radiographic field on the anteroposterior and Judet views is essential for evaluation of symmetrical contours that may

have slight individual variations and to determine the width of the normal articular cartilage in each view. The medial clear space between the femoral head and the radiographic teardrop in the injured and uninjured hips should be compared on the anteroposterior view as an indication of femoral head subluxation. Fractures that traverse the anterior column disrupt the iliopectineal line, whereas fractures that traverse the posterior column disrupt the ilioischial line.

Landmarks of standard anteroposterior radiograph of hip. 1. Iliopectineal line beginning at greater sciatic notch of ilium and extending down to pubic tubercle. 2. Ilioischial line formed by posterior four fifths of quadrilateral surface of ilium. 3. Radiographic teardrop composed laterally of most inferior and anterior portion of acetabulum and medially of anterior flat part of quadrilateral surface of iliac bone. 4. Roof of acetabulum. 5. Edge of anterior lip of acetabulum. 6. Edge of posterior lip of acetabulum.

A, Obturator oblique view of hip. hip.

B, Iliac oblique view of

In the operating room, the three standard views can be obtained with fluoroscopy. The restoration of the radiographic landmarks is a guide to the adequacy of fracture reduction. The anatomical dome is a three-dimensional structure composed of subchondral bone and its overlying cartilage that articulates with the weight bearing portion of the femoral head. Multiple studies have concluded that the single most important factor affecting long-term outcome in both operatively and nonoperatively treated acetabular fractures is maintenance of a concentric reduction of the femoral head beneath an intact or anatomically reconstructed dome. The dome, or roof, can be seen on the anteroposterior and Judet views of the pelvis, but the subchondral bone shown on each of these views is only 2 to 3 mm wide and represents only that small portion of the actual articular weight bearing surface that is tangential to the x-ray beam. Matta et al. developed a system for roughly quantifying the acetabular dome after fracture, which they called the roof arc measurements.

These measurements involve determination of how much of the roof remains intact on each of the three standard radiographic views: anteroposterior, obturator oblique, and iliac oblique. The medial roof arc is measured on the anteroposterior view by drawing a vertical line through the roof of the acetabulum to its geometric center. A second line is then drawn through the point where the fracture line intersects the roof of the acetabulum and again to the geometric center of the acetabulum. The angle thus formed represents the medial roof arc The anterior and posterior roof arcs are similarly determined on the obturator oblique and iliac oblique views, respectively Although these are rough quantitations, they are useful in the assessment of fractures of the posterior or anterior column, transverse fractures, T-type fractures, and associated anterior column and posterior hemitransverse fractures; they have limited usefulness for evaluation of both-column fractures and fractures involving the posterior wall. According to Matta et al., if any of the roof arc measurements in a displaced fracture are less than 45 degrees, operative treatment should be considered. Computed tomography is invaluable in the treatment of acetabular fractures. Axial cuts must be taken with thin (3-mm) intervals and corresponding slice thicknesses. The entire pelvis generally is included to avoid missing a portion of the fracture, and comparison to the opposite hip is performed routinely. In general, the transverse fracture lines and fractures of the anterior and posterior walls are in the sagittal plane, paralleling the quadrilateral surface when they are viewed on axial CT images Anterior and posterior column fractures usually extend through the quadrilateral surface and into the obturator foramen with a more coronal orientation; variant fracture types, however, may not follow these generalities. Olson and Matta showed that CT scans can give the same information about the acetabular dome as the roof arc measurements on the anteroposterior and oblique radiographs.

Axial CT scans showing the superior 10 mm of the acetabular roof to be intact corresponded to radiographic roof arc measurements of 45 degrees. They also found that fracture of the cotyloid fossa did not jeopardize stability of the femoral head under the dome if the fossa extended to within 10 mm of the apex of the roof and the articular surface was intact. Three-dimensional CT reconstructions of a fracture have become sophisticated and can be projected in many different views with subtraction of the femoral head that show unique features of the various fracture patterns..

CLASSIFICATION The classification of acetabular fractures described by Letournel and Judet is the most widely used classification system. They divided acetabular fractures into two basic groups: simple fracture types and the more complex associated fracture types. Simple fracture types are isolated fractures of one wall or column along with transverse fractures; this type includes fractures of the:

1. Posterior Wall, 2. Posterior Column, 3. Anterior Wall, Or Anterior Column 4. Transverse Fractures.

The associated fracture types have more complex fracture geometries and include: 1. T-Type Fractures, 2. Combined Fractures of the Posterior Column and Wall, 3. Combined Transverse and Posterior Wall Fractures, 4. Anterior Column Fractures with a Hemitransverse Posterior Fracture 5. Both-Column Fractures.

Letournel and Judet classification of acetabular fractures. A. Posterior wall fracture. B. Posterior column fracture. C. Anterior wall fracture. D. Anterior column fracture. E. Transverse fracture. F. Posterior column and posterior wall fracture. G. Transverse and posterior wall fracture. H. T-shaped fracture. I. Anterior column and posterior hemitransverse fracture. J. Complete both-column fracture Although several of the associated fracture types involve both columns of the acetabulum, the designation both-column fracture in this classification denotes

that none of the articular fracture fragments of the acetabulum maintain bony continuity with the axial skeleton: a fracture line divides the ilium, so the sacroiliac joint is not connected to any articular segment. The spur sign, shown on the obturator oblique view, is pathognomonic of a bothcolumn fracture. It represents the remaining portion of the ilium still attached to the sacrum and is seen projected lateral to the medially displaced acetabulum

The AO group has developed an alphanumeric classification system for acetabular fractures based on the severity of the fracture:

Type A fractures include fractures of a single wall or column; Type B fractures involve both anterior and posterior columns (transverse, or Ttype, fractures); Type C fractures involve both anterior and posterior columns, but all articular segments, including the roof, are detached from the remaining segment of intact ilium Type C fractures are those designated both-column fractures in the Letournel and Judet classification. Each type has subtypes 1, 2, and 3 (e.g., A1, A2, or A3), depending on the characteristics of the fracture.

TREATMENT Initial Treatment

Acetabular fractures generally are caused by high-energy trauma, and associated injuries are frequent. Treatment of the entire patient should follow accepted Advanced Trauma Life Support (ATLS) protocol, with orthopaedic management of the acetabular fracture appropriately integrated into the treatment plan. In general, operative treatment of an acetabular fracture should not be performed as an emergency except when it is part of open fracture management or is performed for a fracture associated with an irreducible dislocation of the hip. In the latter case, urgent open reduction of the hip dislocation and treatment of the associated fracture are required to prevent the complications of osteonecrosis and ongoing cartilaginous damage to the femoral head. Closed reduction of hip dislocations should be performed with sedation in the emergency department or with general anesthesia and fluoroscopy. The patient then can be placed in skeletal traction to maintain reduction and possibly slight distraction of the hip while the other acute injuries are treated and radiographic studies of the pelvis are obtained. The older term central fracture-dislocation of the hip was previously used to describe any acetabular fracture with medial subluxation of the femoral head. Although this terminology has been replaced with more descriptive fracture classification systems, a true central fracture-dislocation, with the femoral head completely dislocated medially into the pelvis, is an unusual injury that requires urgent treatment The femoral head can be locked between the fracture fragments, making reduction extremely difficult. Closed reduction with general anesthesia and fluoroscopic assistance should be attempted. After reduction, the femoral head is extremely unstable and will easily redisplace into the pelvis if skeletal traction is not maintained

INDICATIONS FOR NONOPERATIVE TREATMENT 1) Nondisplaced and Minimally Displaced Fractures

Fractures that traverse the weight bearing dome but are displaced less than 2 mm can be treated with nonweight bearing for 6 to 12 weeks, depending on the fracture characteristics. Radiographs should be obtained immediately after the patient is first mobilized and periodically thereafter to ensure that no displacement has occurred.

2) Fractures with Significant Displacement but in which the region of the joint involved is judged to be Unimportant Prognostically This determination is made with the roof arc measurements described by Matta and Olson as 45 degrees for each roof arc: medial, anterior, and posterior. Most authors agree that displaced fractures through the weight bearing dome should be treated with operative reduction and internal fixation, regardless of how they may line up in traction. These fractures have a tendency to displace, leading to inferior results. One exception to this rule is an extremely comminuted both-column fracture that attains secondary congruence. In reality, very few fractures are treated definitively by traction to maintain a reduction of the acetabular dome. Posterior wall fractures associated with posterior fracture-dislocations of the hip require separate consideration and are evaluated after closed reduction. Larger posterior wall fragments lead to posterior hip instability and require fixation. Posterior wall fractures involving more than 50% of the posterior wall consistently led to posterior hip instability. Traditionally, any patient for whom nonoperative treatment of a small posterior wall fracture is being considered should have a clinical evaluation of hip stability with flexion to 90 degrees with the patient sedated or under general anesthesia. We should perform stress views under fluoroscopy when patients are considered for nonoperative treatment of smaller posterior wall fractures. As described by Tornetta, view the pelvis in the obturator oblique view, flexing the hip to 90 degrees with enough posteriorly directed pressure to rock the pelvis.

Spot fluoroscopic views obtained during performance of this maneuver are scrutinized to assess subluxation. Stable hips are treated similar to pure dislocations of the hip, with mobilization on crutches with range of motion restrictions and progressive weight bearing during approximately 2 weeks.

3) Secondary Congruence in Displaced Both-Column Fractures A both-column fracture, by definition, has all its fragments free to move independent of the remaining ilium. Frequently, comminuted both-column fracture fragments assume a position of articular secondary congruency around the femoral head, even though the femoral head is displaced medially and there may be gaps between the fracture fragments. The concept of secondary congruence was described by Letournel, and closed treatment of these fractures has yielded reasonable and occasionally exceptional results. The concept applies only to this specific subset of fractures and cannot be applied to other fracture types. 4) Medical contraindications to surgery In patients with multiple trauma, medical contraindications from multisystem injury are common, even in previously healthy patients. On occasion,severity of the medical condition mandates that operative intervention be delayed. On occasion, severe head trauma with a tenuous, evolving spectrum of injury may preclude a surgical procedure.

5) Local Soft-Tissue Problems, such as Infection, Wounds, and Soft-Tissue Lesions from Blunt Trauma An open wound in the anticipated surgical field is a contraindication, as is systemic infection. The Morel-Lavalle lesion is a localized area of subcutaneous fat necrosis over the lateral aspect of the hip caused by the same trauma that causes the acetabular fracture.

The size and extent of this lesion are variable, and operating through it has been associated with a higher rate of postoperative infection. Alternatively, some fractures can be treated through the ilioinguinal approach, thus avoiding the affected area. The presence of a significant Morel-Lavalle lesion can be suspected by hypermobility of the skin and subcutaneous tissue in the affected area from the shear-type separation of the subcutaneous tissue from the underlying fascia lata. The presence of a suprapubic catheter generally is considered a contraindication to acetabular open reduction and internal fixation by the ilioinguinal approach. The best method of avoiding this situation is to discuss with the urologist the possibility of avoiding suprapubic drainage of the bladder with possible primary repair of the bladder rupture and Foley catheter drainage.

6) Elderly Patients with Osteoporotic Bone in Whom Open Reduction May Not Be Feasible Only rare comminuted fractures in elderly, osteopenic patients cannot be treated by standard open reduction and internal fixation. The options for these patients include mobilization without fixation, percutaneous fixation with mobilization, and primary total hip arthroplasty.

INDICATIONS FOR OPERATIVE TREATMENT 1) Fracture Characteristics An acetabular fracture with 2 mm or more of displacement in the dome of the acetabulum as defined by any roof arc measurements of less than 45 degrees is an indication for operative intervention, as is any subluxation of the femoral head from a displaced acetabular fracture noted on any of the three standard radiographic views. Also, operative treatment should be considered for posterior wall fractures with more than 50% involvement of the articular surface Posterior wall fractures involving less than 50% of the wall may be unstable and are assessed clinically by flexing the hip to 90 degrees with the patient sedated or anesthetized as well as by stress testing of equivocal cases under anesthesia with fluoroscopy.

2) Incarcerated Fragments in the Acetabulum after Closed Reduction of a Hip Dislocation Fragments noted on CT scan to be lodged between the articular surfaces of the femoral head and the acetabulum warrant excision.

3) Prevention of Nonunion and Retention of Sufficient Bone Stock for Later Reconstructive Surgery The last indication is debatable and should be applied only in cases of extreme deformity because total hip arthroplasty after failed open reduction and internal fixation of an acetabular fracture may be more difficult than hip arthroplasty after nonoperative management. Timing of Surgery Most authors advocate waiting 2 or 3 days after injury before performing acetabular surgery to allow the patient to be adequately stabilized and to allow pelvic bleeding to subside. Ideally, operative reduction and internal fixation of acetabular fractures should be performed within 5 to 7 days of injury. Anatomical reduction becomes more difficult after that time because hematoma organization, soft-tissue contracture, and subsequent early callus formation hinder the process of fracture reduction, especially if the more limited Kocher-Langenbeck or ilioinguinal exposure is used. After a delay of more than 2 to 3 weeks, an extensile exposure may be necessary to obtain adequate reduction.

Choice of Surgical Approach Some fracture patterns are routinely reduced through an anterior ilioinguinal approach, whereas the posterior Kocher-Langenbeck approach is more appropriate for others. With transverse fractures, the choice of an anterior or posterior approach is determined by which exposure allows access to the side of the fracture with maximal displacement. Osteotomy of the trochanter also can aid exposure of transverse fractures or supraacetabular extension of fractures of the posterior column and wall. This osteotomy does not seem to affect the vascularity of the femoral head and has a high rate of union.

Siebenrock et al. described the trochanteric flip osteotomy, leaving the vastus lateralis attached to the trochanteric fragment, similar to a trochanteric slide osteotomy. More complicated fractures may require one of the extensile approaches, such as the extended iliofemoral approach described by Letournel and Judet, the triradiate approach of Mears and Rubash, or the T-approach described by Reinert et al. If an extensile exposure is used, Bosse et al. recommended confirmation of the patency of the superior gluteal artery with angiography because this may be the only vascular pedicle supplying the abductor muscles.

Treatment of Specific Fracture Patterns

A, Multifragmented posterior wall fracture with intraarticular comminution. B, Posterior column fracture with lag screw reaching anterior column. C, Transverse fracture with lag screw reaching anterior column. D, Associated transverse and posterior wall fracture. E, Associated T-type acetabular fracture. Lag screws are inserted into both anterior and posterior columns. F, Anterior column fracture. Several lag screws are placed between inner and outer tables of innominate bone. G, Associated anterior column and posterior hemitransverse fracture. Screws inserted from pelvic brim must reach distal to fracture line and engage in posterior column

H, Both-column fracture operated on through ilioinguinal approach. Screws inserted from pelvic brim reach posterior column. I, Both-column fracture. Internal fixation is performed through extended iliofemoral approach. Two very long screws are inserted into anterior column and reach superior pubic ramus POSTERIOR WALL FRACTURES The most common fracture treated by the average orthopaedist is the posterior wall fracture. These fractures are treated through a Kocher-Langenbeck approach with the patient positioned either prone or in the lateral decubitus position on a fracture table. To avoid osteonecrosis of the posterior wall, the posterior wall fragments must not be detached from the posterior capsule during exposure. If the fracture extends superiorly into the dome, a trochanteric osteotomy may be performed to allow additional exposure. The hip is distracted to clear any incarcerated fragments before reduction of the wall fragments. A close inspection is made for marginal impaction of articular fragments into the intact posterior column.

Impacted segments are elevated and bone grafted. After reduction of the wall fragments, provisional fixation with Kirschner wires can be used while definitive fixation is performed with lag screws and a contoured reconstruction plate placed from the ischium, over the retroacetabular surface onto the lateral ilium. The use of spring plates has been advocated to improve stability in comminuted fractures. These are made out of one-third tubular plates by cutting or breaking the plate through the last screw hole and bending down the remaining end as tines, which are used to capture bone fragments that cannot be easily fixed with screws. The spring plate is slightly overcontoured so that when the reconstruction plate is applied over the spring plate, the captured fragments are held firmly in position. Osteonecrosis of the femoral head as a result of associated hip dislocation, marginal impaction, multiple fracture fragments, and osteochondral injuries of the femoral head all adversely affect the out-come of these fractures. Intraarticular screw placement must be avoided & Intraoperative fluoroscopy in multiple views should be used to ensure that all screws are extraarticular.

Posterior wall fracture fixed with contoured 3.5-mm pelvic reconstruction plate. Posterior wall acetabular fracture treated with spring plate and associated contoured pelvic reconstruction plate. POSTERIOR COLUMN FRACTURES Posterior column fractures are relatively uncommon and, if significantly displaced, require operative reduction and internal fixation. The Kocher-Langenbeck approach is used routinely.

Rotational deformity in addition to displacement must be corrected by placement of a Schanz screw in the ischium to control rotation while the fracture is reduced with a reduction clamp. Typical fixation is with a lag screw combined with a contoured reconstruction plate along the posterior column.

Posterior column fracture of acetabulum ANTERIOR WALL AND ANTERIOR COLUMN FRACTURES Isolated anterior wall fractures are uncommon and sometimes associated with anterior hip dislocation. Fractures requiring surgery are fixed through an ilioinguinal or iliofemoral approach. Anterior column fractures are approached similarly, with fixation by a contoured plate along the pelvic brim At the level of the iliopectineal eminence, the medial wall of the acetabulum is thin, and screws generally should not be placed in this region. Anterior column fractures that exit higher through the iliac wing require fixation along the iliac crest as well.

Fixation of low anterior column fracture with contoured plate along pelvic brim. TRANSVERSE FRACTURES These fractures, although apparently simple, present a spectrum of difficulty. Transtectal fractures, or fractures that occur above the cotyloid fossa, have the worst prognosis, and accurate reduction is essential. Juxtatectal fractures, those that occur at the junction of the cotyloid fossa with the articular surface, also usually require reduction, whereas infratectal fractures frequently can be treated nonoperatively. Reduction most often is through a posterior approach with the patient positioned prone. A small Jungbluth clamp is used to reduce the fracture while rotation is controlled by a Schanz screw in the ischium. The intraarticular reduction can be assessed directly by distracting the limb in traction and by palpating the reduction of the quadrilateral surface through the greater sciatic notch. Posterior fixation typically is with a buttress plate along the posterior column with anterior fixation, by use of a 3.5-mm lag screw placed into the anterior column from a position above the acetabulum. Care must be taken with placement of the anterior lag screw because of the proximity of the iliac vessels.

 From the ilioinguinal approach, reduction can be performed by a variety of methods. We frequently use plate reduction to close the fracture gap; a large spiked reduction clamp placed on the quadrilateral surface and the lateral surface of the ilium in the region of the anterior inferior spine controls medial displacement and rotation of the caudad fragment. Typical fixation is a contoured plate along the pelvic brim with lag screws directed down the posterior column On occasion, extensile or combined approaches are necessary for more complex transverse fractures POSTERIOR COLUMN FRACTURE WITH ASSOCIATED POSTERIOR WALL FRACTURE A Kocher-Langenbeck approach is used, with or without a trochanteric osteotomy. The column fracture is reduced first, and a short reconstruction plate is placed posteriorly along the posterior edge of the column. A separate plate is used for the wall fragment. When the wall fragment is small, spring plates can be used instead of a separate wall plate.

Posterior column and posterior wall acetabular fracture fixed with two plates. First reconstructs posterior column, and second reconstruction plate (supplemental spring plate) fixes posterior wall fragments TRANSVERSE FRACTURE WITH ASSOCIATED POSTERIOR WALL FRACTURE

This common fracture usually is treated through the Kocher-Langenbeck approach with the patient prone. The intraarticular portion of the transverse fracture can be seen through the defect created by the retraction of the posterior wall fragment. Reduction of the transverse fracture can be difficult through a Kocher-Langenbeck approach, particularly when there is impaction of a portion of the dome An extensile approach rarely may be preferable with comminution of the dome. Typical fixation is performed by fixing the transverse component with lag screws into the anterior column while plating the posterior wall, thus further stabilizing the posterior portion of the transverse fracture.

Transverse posterior wall acetabular fracture fixed through Kocher-Langenbeck approach with additional trochanteric osteotomy T-TYPE FRACTURES These fractures usually can be treated with the patient prone through a Kocher-Langenbeck approach. The anterior column fracture line can be reduced through the sciatic notch after reduction of the posterior column portion or reduced first with displacement of the posterior column, facilitating clamp placement. The anterior column is fixed with screws placed down the anterior column from a position above the acetabulum; the posterior column portion can be fixed with a lag screw and a reconstruction plate. These fractures can occasionally be treated through an ilioinguinal approach with a contoured plate placed along the pelvic brim and lag screws extending into the posterior column.

If both the anterior and posterior components of the fracture are significantly displaced, extensile or combined approaches may be required to obtain a reduction. On occasion, with T-type fractures as well as other associated fracture types, a separate medial fragment is present. If it is proximal enough to affect stability, a spring plate bent at a 100- to 110-degree angle can be placed under an anterior column plate to maintain reduction of this fragment. Another method of fixing this fragment is to place a plate along the quadrilateral surface through a split in the linea alba (Stoppa approach).

ANTERIOR COLUMNPOSTERIOR HEMITRANSVERSE FRACTURES These fractures frequently have minimal displacement of the hemitransverse component and can be treated through the ilioinguinal approach with typical fixation of the anterior column fracture and separate lag screws from the iliac fossa adjacent to the pelvic brim extending down the posterior column. Fractures with significant posterior displacement or intraarticular comminution with or without impaction may require combined or extensile approaches.

BOTH-COLUMN FRACTURES These fractures are sometimes described as T-type fractures that have their transverse component above the dome of the acetabulum. They have varying degrees of comminution and can be extremely complex and difficult to treat. Many both-column fractures can be treated through an anterior ilioinguinal approach but a posterior or extensile exposure is required for involvement of the sacroiliac joint, a significant posterior wall fracture, or intraarticular comminution that requires reduction under direct vision. In general, reduction is begun from the most proximal portion of the fracture and proceeds toward the joint. Each small fragment must be anatomically reduced because small malreductions in the ilium above the fracture become magnified at the level of the joint. Fixation is as varied as the fracture patterns and the approaches used.

POSTOPERATIVE CARE Postoperatively, closed suction drainage is used, antibiotic therapy is continued for 48 to 72 hours, and passive motion of the hip is begun on the second or third day. Touch-down ambulation with crutches usually is allowed by the second to fourth day and progresses gradually, depending on other injuries. This minimal weight bearing status is continued for approximately 8 weeks in patients with simple fractures and 12 weeks in most others.

COMPLICATIONS 1) Mortality - Overall mortality rates after acetabular fractures range from 0% to 2.5%. 2) Osteonecrosis - It occurs more frequently after fractures associated with posterior dislocation & is radiographically apparent within 2 years of injury in most patients. Letournel's reported rate of osteonecrosis after posterior dislocation was 7.5%. Osteonecrosis of the posterior wall can be caused by the injury or by excessive fracture site exposure because the only vascular supply of these fragments is the injured posterior capsule of the hip. 3) Infection - Infections are reported to occur in 1% to 5% of patients and may destroy the hip joint. Certain factors are thought to increase the risk of infection, including the presence of a suprapubic catheter in ilioinguinal approaches and the Morel-Lavalle lesion in Kocher-Langenbeck and extensile approaches. Obesity has been shown to increase the rate of multiple complications including infection. 4) Sciatic nerve palsies as a result of the initial injury occur in approximately 10% to 15% of patients with acetabular fractures. Sciatic nerve injury as a result of surgery occurs in 2% to 6% of patients and is more often associated with posterior fracture patterns treated through the Kocher-Langenbeck and extensile exposures. The peroneal component of the sciatic nerve was more often involved than the tibial component and that the tibial component had a greater chance of recovery; complete peroneal palsies had the worst prognosis. Functional recovery has been shown in approximately 65% of patients, and function may improve up to 3 years after injury. 5) Heterotopic ossification occurs after most extensile approaches, with moderate-to-severe heterotopic ossification occurring in 14% to 50% of patients when no prophylaxis is used; it occurs after the Kocher-Langenbeck approach in approximately 25% of patients in whom no prophylaxis is used

.Heterotopic ossification is rare after the ilioinguinal approach unless the external surface of the ilium is stripped. The effectiveness and choice of prophylactic measures to prevent heterotopic ossification remain controversial. Currently, for most patients treated with the Kocher-Langenbeck approach, use indomethacin (25 mg three times a day for 4 to 6 weeks) or radiation therapy with a onetime dose of 700 cGy in patients in whom indomethacin is contraindicated. 6) Thromboembolic complications can be devastating; the reported risk of pulmonary embolism ranges from 2% to 6%. Deep vein thrombosis has been reported to occur in 8% to 61% of patients with acetabular fractures. Current protocol involves the use of subcutaneous heparin or enoxaparin as well as intermittent compression boots while patients are awaiting surgery. Obtain a preoperative screening duplex Doppler scan in any patient in whom the injury is more than 4 days old. Use Greenfield vena cava filters in patients with abnormalities on duplex scans and also occasionally use them in high-risk groups, including patients older than 60 years, patients with contraindications to anticoagulation, and patients in whom morbid obesity, malignant disease, or a history of prior deep vein thrombosis is a factor. Postoperatively, anticoagulation with enoxaparin followed by warfarin is continued for 6 to 12 weeks unless it is medically contraindicated. Total Hip Arthroplasty as Treatment for Acetabular Fracture Acetabular fractures with extremely poor prognoses can be treated with primary total hip arthroplasty, using adjunctive fixation of the acetabular fracture with plates or cables and multiple screw fixation of the cup. Examples include a neglected comminuted, incongruous, both-column fracture , late presenting unreduced posterior fracture-dislocation of the hip with severe marginal impaction and femoral head erosion One concern with this technique is that the cementless acetabular component could fail to be incorporated adequately in the healing acetabular bed. Extensile approaches should be avoided to minimize the risk of infection