At the request of our publishers, I accepted the task of preparing this second edition. I felt this was necessary for several reasons: new imaging technologies such as CT scanning and 3-D reconstructions are now used routinely, the in dications for employing improved approaches are clearer, and reconstructions are facilitated by new internal fixation devices. Above all, I thought it was time to report the long-term results of the 940 acetabular fractures, 90070 of which were treated surgically - a unique series. In spite of the experience acquired from the three previous reviews of cases (1966, 1971, and 1978), I failed to foresee the amount of time this revision would need. In fact, it took more than 3 years to follow up the larger number of cases, and 159 patients (out of 800, i. e. 22. 7%) were not included as they had moved since their last review and simply could not be located. At a time when it is in fashion to evaluate the cost of health care, it is strange to see how public administrators, so keen on evaluating the immediate cost of our opera tions, do not care about the quality of their long-term results, which appears to us, however, to be the best basis for the choice of the initial treatment.

Introduction: History and Development of Our Methods of Classification and Treatment of Acetabular Fractures

1 Anatomy of the Acetabulum
1.1 Columns of the Acetabulum
1.2 Posterior Column
1.3 Anterior Column
1.3.1 Iliac Segment
1.3.2 Acetabular Segment
1.3.3 Pubic Segment
1.4 Structure of the Innominate Bone in Relation to Load-Bearing..
1.5 Vascular Supply
1.5.1 Internal Surface
1.5.2 External Surface
1.5.3 Acetabulum
2 Mechanics of Acetabular Fractures
2.1 Force Applied to the Greater Trochanter in the Axis of the Femoral Neck
2.1.1 Neutral Abduction-Adduction
2.1.2 Abduction and Adduction
2.2 Force Applied to the Flexed Knee in the Axis of the Femoral Shaft
2.2.1 Hip Joint Flexed 90°
2.2.2 Different Degrees of Hip Flexion
2.3 Force Applied to Foot with Knee Extended
2.3.1 Hip Flexed
2.3.2 Hip Extended
2.4 Force Applied to Lumbo-sacral Region
2.5 Comment
2.6 Clinical Correlation
2.6.1 Blow on Knee or Dashboard Injuries
2.6.2 Blow on Greater Trochanter
2.6.3 Blow Under Foot
2.6.4 Blow on Sacro-iliac Region
2.6.5 Antero-posterior Compression
3 Radiology of the Normal Acetabulum
3.1 Standard Radiography
3.1.1 Anterior-posterior Radiograph of Pelvis
3.1.2 Anteroposterior Radiograph of Acetabulum
3.1.3 Obturator-oblique Radiograph
3.1.4 Iliac-oblique Radiograph
3.2 Computed Tomography
3.2.1 CT of a Normal Acetabulum
3.2.2 Special Advantages of CT
3.2.3 Disadvantages of CT
3.3 Tomography
3.4 Stereo-radiography
3.5 Interpreting the Radiographs
3.5.1 Interpreting the Standard Views
3.5.2 Interpreting the CT Sections to Aid or Complete the Diagnosis
4 Classification
5 Posterior Wall Fractures
5.1 Typical Posterior Wall Fractures
5.1.1 Morphology
5.1.2 Radiology
5.2 Postero-superior Fractures
5.2.1 Morphology
5.2.2 Radiology
5.3 Postero-inferior Fractures
5.3.1 Morphology
5.3.2 Radiology
5.4 Special Forms of Posterior Wall Fractures
5.4.1 Extended Posterior Wall Fractures
5.4.2 Horizontal Extension of Fracture Line
5.4.3 Massive Posterior Wall Fractures
5.4.4 Posterior Wall and Incomplete Transverse Fractures
5.5 CT Study of Posterior Wall Fractures
6 Fractures of the Posterior Column
6.1 Typical Posterior Column Fractures
6.1.1 Morphology
6.1.2 Radiology
6.2 Extended Posterior Column Fractures
6.2.1 Morphology
6.2.2 Radiology
6.3 Atypical Posterior Column Fractures
6.3.1 Other Associated Pelvic Ring Fractures
6.3.2 Epiphyseal Injury
6.4 Transitional Posterior Column Fractures
6.4.1 Partial Superior Fractures
6.4.2 Partial Inferior Fractures
6.5 CT Study of Posterior Column Fractures
7 Anterior Wall Fractures
7.1 Morphology
7.2 Radiology
7.2.1 Antero-posterior View
7.2.2 Obturator-oblique View
7.2.3 Iliac-oblique View
7.3 Atypical Examples
7.4 CT Study of Anterior Wall Fractures
8 Fractures of the Anterior Column
8.1 Morphology
8.1.1 Very Low Fractures
8.1.2 Low Fractures
8.1.3 Intermediate Fractures
8.1.4 High Fractures
8.1.5 Atypical Examples
8.2 Radiology
8.2.1 Very Low Fractures
8.2.2 Low Fractures
8.2.3 Intermediate Fractures
8.2.4 High Fractures
8.2.5 Atypical Examples
8.3 CT Study of Anterior Column Fractures
9 Pure Transverse Fractures
9.1 Morphology
9.1.1 Orientation of Fracture
9.1.2 Displacement in Transverse Fractures
9.2 Radiology
9.2.1 Antero-posterior View
9.2.2 Obturator-oblique View
9.2.3 Iliac-oblique View
9.3 Atypical Cases
9.4 CT Scan Study of Transverse Fractures
10 T-shaped Fractures
10.1 Morphology
10.1.1 Transverse Component
10.1.2 Stem Component
10.1.3 Displacement
10.2 Radiology
10.2.1 Transverse Component
10.2.2 Stem Component
10.3 Atypical Examples
10.3.1 Additional Vertical Fracture of Obturator Ring
10.3.2 Additional Fracture Line in Cotyloid Fossa
10.3.3 Association of a Posterior Column and an Anterior Hemitransverse Fracture
10.4 CT Study of T-Shaped Fractures
11 Associated Posterior Column and Posterior Wall Fractures
11.1 Morphology
11.1.1 Posterior Wall Component
11.1.2 Posterior Column Component
11.2 Radiology
11.2.1 Antero-posterior View
11.2.2 Obturator-oblique View
11.2.3 Iliac-oblique View
11.3 Atypical Examples
11.4 Comment
11.5 CT Study of Associated Posterior Column and Posterior Wall Fractures
12 Associated Transverse and Posterior Wall Fractures
12.1 Cases with Posterior Dislocation
12.1.1 Morphology
12.1.2 Radiology
12.1.3 Atypical Examples
12.2 Cases with Central Dislocation
12.2.1 Morphology
12.2.2 Radiology
12.3 Comment
12.4 Very Large Postero-superior Fragment Extending to the Iliac Crest
12.5 CT Study of Associated Transverse and Posterior Wall Fractures
13 Associated and Posterior Hemitransverse Fractures
13.1 Morphology
13.1.1 Anterior Fractures with Associated Complete Posterior Hemitransverse Fracture
13.1.2 Anterior Fractures with Associated Incomplete Posterior Hemitransverse Fractures
13.1.3 Important Remarks
13.2 Radiology
13.2.1 Anterior Fracture
13.2.2 Posterior Column Fracture
13.2.3 A Special Feature of this Group
13.3 Atypical Examples
13.4 Radiological Differential Diagnosis
13.5 CT Study of Associated Anterior and Posterior Hemitransverse Fractures
14 Associated Both-Column Fractures
14.1 Morphology
14.1.1 Posterior Column Components
14.1.2 Additional Posterior Components
14.1.3 Anterior Column Component
14.1.4 Result of Both-Column Fracture
14.1.5 Displacement of the Fragments and the Femoral Head .
14.1.6 Atypical Examples
14.1.7 The Key to Reconstruction
14.2 Radiology
14.2.1 Antero-posterior View
14.2.2 Obturator-oblique View
14.2.3 Iliac-oblique View
14.3 Summary
14.4 Atypical Examples
14.5 Differential Radiological Diagnosis
14.6 CT Study of Associated Both-Column Fractures
15 Transitional and Extra-articular Forms
15.1 Transitional Forms
15.2 Extra-articular Forms
16 Associated Injuries
16.1 Injury of the Femoral Head
16.1.1 Macroscopic Injury
16.1.2 Vascular Injury
16.1.3 Molecular Injury
16.2 Capsular Injury
16.3 Vascular Injury
16.3.1 Acetabular Wall
16.3.2 Pelvic Vessels
16.3.3 Retro-peritoneal Haematoma
16.4 Other Pelvic Injuries
16.5 Associated Hip Injuries
16.6 Other Skeletal Injuries
16.7 Urinary Tract Injuries
16.8 Other Visceral Injuries
16.9 Associated Skull Trauma
16.10 Sciatic Nerve Injuries
17 Distribution of the Clinical Series
17.1 Distribution According to Age
17.2 Distribution According to Sex
17.3 Distribution According to Time After Injury
18 Clinical Presentation
18.1 Clinical Findings
18.1.1 Posterior Dislocation
18.1.2 Central Dislocation
18.2 Early Complications
18.2.1 Traumatic Shock
18.2.2 Retro-peritoneal Haematoma
18.2.3 Pre-operative Sciatic Nerve Injury
18.2.4 Morel-Lavallé Lesion
18.2.5 Intra-articular Incarceration of Bone Fragments
18.2.6 Other Types of Palsies
18.3 Special Cases
18.3.1 Children
18.3.2 Elderly Patients
18.3.3 Pathological Fractures
19 General Principles of Management of Acetabular Fractures
19.1 Conservative Treatment
19.1.1 Indications
19.1.2 Methods
19.1.3 Results
19.2 Justification for Operative Treatment
19.3 Indications for Operative Treatment
19.4 Timing of Surgery
20 Surgical Approaches to the Acetabulum
20.1 Classical Approaches
20.2 Kocher-Langenbeck Approach
20.2.1 Technique
20.2.2 Application
20.2.3 Closure
20.2.4 Dangers
20.2.5 Complications
20.3 Ilio-femoral Approach
20.3.1 Technique
20.3.2 Application
20.3.3 Closure
20.3.4 Dangers
20.3.5 Complications
20.4 Ilio-inguinal Approach
20.4.1 Technique
20.4.2 Application
20.4.3 Closure
20.4.4 Dangers
20.4.5 Complications
20.5 Combined Anterior and Posterior Approaches
20.6 Extended Ilio-femoral Approach
20.6.1 Technique
20.6.2 Application
20.6.3 Closure
20.6.4 Dangers
20.6.5 Complications
20.7 Post-operative Care
20.8 Summary of the Use of Different Surgical Approaches
20.9 Addendum: The Kocher-Langenbeck Extended to a Triradiate Approach
21 Operative Treatment of Displaced Fractures Within Three Weeks of Injury
21.1 Pre-operative Care
21.2 Choice of Surgical Approach
21.2.1 Kocher-Langenbeck Approach
21.2.2 Ilio-femoral Approach
21.2.3 Ilio-inguinal Approach
21.2.4 Fracture Types for Which There Is a Choice of Approach
21.3 Operative Details
21.3.1 Where and How to Insert Screws
21.3.2 Special Instruments
21.3.3 Implants for Osteosynthesis
21.3.4 Method of Internal Fixation
21.3.5 Reduction of Dislocation
21.3.6 Reduction of Fracture
21.4 Post-opertive Care
21.4.1 Local Care
21.4.2 Physiotherapy
21.4.3 Medical Treatment. JEAN-PIERRE MOULINIE
22 Operative Treatment of Specific Types of Fracture
22.1 Posterior Wall Fractures
22.1.1 Postero-superior Fractures
22.1.2 Postero-inferior Fractures
22.1.3 Special Features
22.2 Posterior Column Fractures
22.2.1 Special Features
22.3 Anterior Wall Fractures
22.4 Anterior Column Fractures
22.4.1 Middle and Low Fractures
22.4.2 High Fractures
22.4.3 Special Features
22.4.4 Insertion of Screws Along the Pelvic Brim
22.5 Pure Transverse Fractures
22.5.1 Pure Juxta-tectal or Infra-tectal Transverse Fractures
22.5.2 Pure Trans-tectal Transverse Fractures
22.5.3 Special Features
22.6 Associated Posterior Column and Posterior Wall Fractures
22.7 Associated Transverse and Posterior Wall Fractures
22.7.1 Kocher-Langenbeck Approach
22.7.2 Extended Ilio-femoral Approach
22.7.3 Special Features
22.8 T-shaped Fractures
22.8.1 Special Features
22.9 Associated Anterior and Hemitransverse Posterior Fractures
22.10 Both-Column Fractures
22.10.1 Approach
22.10.2 Reduction and Fixation Through Posterior Approach
22.10.3 Reduction and Fixation Through Ilio-inguinal Approach
22.10.4 Reduction Necessitating Both Approaches
22.10.5 Reduction and Fixation Through Extended Ilio-femoral Approach
22.10.6 A Particular Both-Column Fracture
22.11 Special Examples
22.11.1 Incarcerated Intra-articular Fragments
22.11.2 Bilateral Acetabular Fractures
22.11.3 Fractures of Paralysed Hips
23 Anatomical Results of Operation Within Three Weeks After Injury
23.1 Analysis of the Immediate Radiological Results
23.2 Analysis of Imperfect Radiological Reductions
23.3 The Learning Curve
Appendix: CLAUDE MARTIMBEAU'S Method of Assessing Displacement in Acetabular Fractures
24 Early Complications of Operative Treatment Within Three Weeks of Injury
24.1 Death
24.2 Infection
24.2.1 Analysis of Post-operative Infections
24.2.2 Cause of Infection
24.2.3 Prophylaxis
24.2.4 Treatment
24.3 Nerve Damage
24.3.1 Sciatic Nerve Damage
24.3.2 Other Nerve Damage
24.4 Secondary Displacement of Fracture Site
24.5 Thrombo-embolism
24.6 Wound Complications
24.7 Miscellaneous Complications
25 Late Complications of Operative Treatment Within Three Weeks of Injury
25.1 Pseudarthrosis
25.2 Cartilage Necrosis
25.3 Avascular Bone Necrosis
25.3.1 Aetiology
25.3.2 Time of Presentation
25.3.3 Clinical and Radiological Course
25.3.4 Clinical and Radiological Results
25.3.5 Conclusion
25.4 Post-traumatic Osteoarthritis
25.4.1 Osteophytes
25.4.2 Osteoarthritis
25.5 Post-operative Ectopic Ossification
25.5.1 Clinical and Radiological Presentation
25.5.2 Aetiology
25.5.3 Treatment
25.5.4 Prevention
25.5.5 Results of Surgical Excision of Ectopic Bone
25.5.6 Ectopic Ossification and Cranio-cerebral Trauma
25.5.7 Ectopic Ossification and Type of Fracture
26 Clinical and Radiological Results of Operation Within Three Weeks of Injury
26.1 Clinical Results
26.1.1 Type of Fracture
26.1.2 Age of Patient
26.2 Radiological Results
26.3 Late Overall Clinical Results and Quality of Reduction
26.3.1 Perfect Reductions
26.3.2 Imperfect Reductions
26.3.3 Conclusions
26.4 Summary of Results
26.4.1 Early Results
26.4.2 Late Results
26.5 Conclusions
26.6 Comment
27 Reassessment of Patients Treated Operatively Within Three Weeks of Injury
27.1 Evolution in Patients Operated on Before 1966
27.2 Evolution in Patients Operated on 1966-1971
27.3 Evolution in Patients Operated on 1971 -1978
27.4 Assessment of Patients Operated on 1978-1990
27.5 Longitudinal Assessment of All Excellent or Very Good Results
28 Operative Treatment Between Three Weeks and Four Months After Injury
28.1 Condition of Fracture Healing
28.2 Surgical Approach
28.3 Surgical Technique
28.3.1 Cases with Visible Fracture Lines
28.3.2 Mal-union
28.3.3 Non-union/Mal-union
28.3.4 Neglected Posterior Dislocations of the Femoral Head..
28.3.5 Incarcerated Fragments
28.3.6 Review of Surgical Techniques
28.4 Intra-operative Complications
28.5 Early Post-operative Complications
28.6 Late Post-operative Complications
28.7 Results
28.8 Conclusion
29 Operative Treatment More Than Four Months After Injury
29.1 General Considerations and Condition of Fracture Healing
29.2 Preconditions for Surgery
29.3 Time of Operation After Injury
29.4 Choice of Surgical Approach
29.5 Surgical Techniques Employed
29.5.1 Cases in Which Reconstruction Was Impossible
29.5.2 Cases in Which Reconstruction Was Possible
29.6 Overview of the 123 Cases Treated More Than Four Months After Injury
29.6.1 Reconstruction Impossible (49 Cases)
29.6.2 Repositioning of Posteriorly Dislocated Femoral Head (11 Cases)
29.6.3 Missed Incarcerated Fragment (16 Cases)
29.6.4 Mal-unions, Non-unions, Mal-union/Non-unions
29.7 Conclusion
30 Exercises in Radiographic Diagnosis.