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Natural History

A search of the early literature on this subject may seem confusing because it is based on broad generalizations made by lumping all acetabular fractures together. It is important when reading this literature to remember that it is not the overall results that are important, since they may reflect a high proportion of inconsequential fractures. If one is making broad generalizations based on a number of acetabular fractures, a knowledge of the case mix of the series becomes essential. If a large percentage of the cases are of the type shown in Fig. 13.1a, then one would expect good results from simple closed treatment. On the other hand, if the majority of cases are like the one in Fig. 13.1b, poor results may be expected from closed treatment. Therefore, it is essential when reading the literature to separate the apples from the oranges, that is, to compare only similar fracture types (Fig. 13.1c).

For example,in the article by Rowe and Lowell (1961), closed methods using traction were recommended as the treatment of choice for acetabular fractures. However, close scrutiny of this paper describing 93 fractures in 90 patients revealed a large number of inconsequential fractures in older individuals with expected good results, and, in examining the high-energy injuries, 26 involved the superior weight-bearing dome of the acetabulum. When anatomical reduction was obtained, 13 of 16 had a good result, but when anatomical reduction of the dome fragment was not obtained, ten out of ten had a poor result. Of the posterior wall fractures, of which there were 17, closed management led to poor results in six out of nine cases, whereas open management led to good results in eight out of eight cases. The undisplaced fractures and the medial wall fractures in elderly individuals without protrusio gave satisfactory results with closed means. Thus, the conclusion from this early series should have been that high-energy displaced fractures involving the posterior wall or the superior weight-bearing dome were best treated by open reduction and internal fixation if the anatomy could not be restored by closed means. Conversely, the study also shows that both-column fractures (in this study called medial wall fractures) as well as some anterior types in elderly patients can be managed non-operatively with the expectation of a good result.

Judet et al. (1964) recommended open reduction and internal fixation for all displaced acetabular fractures and proposed a classification of these fractures based on the pattern of injury.

Pennal et al. (1980), reporting on 103 fractures of the acetabulum, indicated that of those with a poor reduction, 72% had clinical and radiographic osteoarthritis at 5-year follow-up, whereas of those with a good reduction, only 30% had such changes. Although the incidence of osteoarthritis in those with a good reduction in this series may seem high, the severity of the arthritis was much less and the incidence less than half of those with a poor result.

Displaced Acetabular Fracture

Fig. 13.1. a-c Comparing the undisplaced acetabular fracture

(a) to the grossly displaced comminuted acetabular fracture associated with a pelvic ring disruption

(b) is like comparing an orange to an apple (c). (From Tile 1984)

Fig. 13.1. a-c Comparing the undisplaced acetabular fracture

(a) to the grossly displaced comminuted acetabular fracture associated with a pelvic ring disruption

(b) is like comparing an orange to an apple (c). (From Tile 1984)

Letournel (1980) reported on 350 fractures of the acetabulum with very good results in 75%, good results in 8%, and poor results in 17%. Of the 74% of the patients with an anatomically reduced hip joint, 90% had a good result. Of the 26% imperfectly reduced, only 55% had a good result if some incongruity remained, only 11% if a degree of protrusio remained, and only 9% if there were major technical failures.

In a review of our own case material (Tile et al. 1984), 227 charts were examined. Ninety-five cases of minor trauma were excluded because displacement was less than 5 mm at the joint. Thus, all inconsequential fractures were removed from this series. Only two of those 95 had any difficulty with their hip at review. There were 13 deaths, eight in the posttrauma period, all in older individuals between 59 and 88 years of age, and five with subsequent trauma, a frequent finding in such a series. Fifteen cases were lost to follow-up; two were treated at 9 and 12 months and thereby excluded from the series, leaving 102 cases. At review, all patients were recalled, person ally examined by one of the authors, and standard radiographs taken. Our findings mirrored those in the literature. Excellent results could be attained if anatomical reduction was achieved and complications avoided.

Matta et al. (1986) stressed that anatomical reduction can rarely be achieved by closed means, therefore decision-making must be based on the specialized radiographic views of Letournel and Judet (1981). Displacement of greater than 3 mm, especially through the roof of the acetabulum, was considered an indication for open reduction and internal fixation.

Similar conclusions have been reported in the more recent literature (Goulet and Bray 1989; Pantazopoulos and Mousafiris 1989; Powell et al. 1988). Letournel and Judet (1993), in the largest series of operatively treated acetabular fractures, followed this same principle. His results, considered the gold standard in 1995, showed variations in the ability to achieve anatomical reduction (Table 13.1), depending on the type and severity of the fracture; even in b a

Table 13.1. Clinical results of acetabular fractures (from Letournel and Judet 1993)

Type of fracture

Clinical results Excellent Very good





Percentage ~ of excellent results

Posterior wall

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