The treatment of fractures of the acetabulum involving both anterior and posterior columns.

Over a period of 20 years, 35 cases of fracture of the acetabulum involving both columns were treated by operation in our unit. These were followed up after a minimum of 8 to a maximum of 20 years. The Iselin approach, even when extended forwards by partial disinsertion of the gluteal muscles, allowed good reduction only when there was little or no displacement of the ilio-pubic column. In the other cases, it was necessary to use a combined anterior and posterior approach, or the Letournel approach, but the latter was reserved for cases with very severe displacement or comminution of the fragments when it is essential to have access and control of the iliac and acetabular complex in its entirety. The clinical and radiographic results of fractures involving both columns are not unlike those observed in other complex fractures of the pelvis: good reduction and osteosynthesis is synonymous with good function even in the long term.

The surgical treatment of inveterate fractures of the acetabulum.

Any fracture of the acetabulum which is not adequately treated within 3 weeks poses a considerable surgical problem. Reduction is difficult, callus has already begun to form between the displaced fragments, and the risks of complications are therefore increased. Our material consists of 35 cases, subdivided into 18 fractures submitted for treatment between 3 and 12 weeks after injury, and 17 fractures submitted for treatment beyond the 12 week limit. In the first group the incidence of complications (ischaemic necrosis, arthrosis, infection) was high; satisfactory results were obtained only when the fracture was of the simplest type. In the second group, malunion had to be accepted, and treatment was concerned solely with improving function by correcting malposition and relieving or eliminating pain. The surgical methods adopted depended on the circumstances: corrective osteotomy, arthrodesis or total prosthetic replacement.

Transverse fractures of the acetabulum.

From a total case material of 356 fractures of the acetabulum we have been able to analyse in depth 188 fractures treated surgically--77 transverse, 21 T-fractures and 90 transverse associated with posterior rim fractures. These lesions, although sharing certain anatomical and radiographic features, have peculiar characteristics which are important to define for purposes of treatment. Posterior dislocation of the femoral head is frequently associated with posterior rim fractures and central dislocation with transverse and T-fractures. Traumatic arthritis as a late complication was studied with particular reference to the quality of reduction of the fracture. When this results in an irregular articular surface early arthritis is the usual outcome; when it results in an acetabular cavity wider than the diameter of the femoral head, arthritis is delayed usually for more than 10 years, and subsequently progresses very slowly.