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Acetabular Fracture ORIF - Posterior Column/Wall

Comprehensive surgical technique guide for posterior column and posterior wall acetabular fracture ORIF via the Kocher-Langenbeck approach for FRCS exam preparation

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Kocher-Langenbeck approach | Associated Fracture Pattern

Understanding the Fracture Pattern

The posterior column/wall fracture is one of five ASSOCIATED patterns in the Judet-Letournel classification. Unlike simple posterior wall fractures, this pattern involves disruption of BOTH:

  1. Posterior Column: From iliac wing to ischial tuberosity (includes posterior half of articular surface)
  2. Posterior Wall: The weight-bearing dome fragment posterior to the hip joint

Critical Concept: Why This Pattern Matters

The posterior column provides the FOUNDATION for wall fixation. If you fix the wall without restoring column anatomy, the entire construct will fail. This is why the reduction sequence is critical:

Step 1: Reduce and fix posterior COLUMN (restores length, rotation, and articular continuity)

Step 2: Reduce and fix posterior WALL to the restored column

The column is the scaffold upon which the wall sits.

Absolute Indications:

  • Posterior column fracture with >2mm displacement
  • Associated posterior wall fracture with >40% wall involvement
  • Hip joint instability on dynamic examination
  • Marginal impaction requiring elevation
  • Incarcerated osteochondral fragments

Relative Indications:

  • Posterior wall 20-40% with marginal impaction
  • Posterior column fracture in polytrauma (staged approach)
  • Posterior component of transverse + posterior wall pattern

Contraindications:

  • Active infection
  • Severe medical comorbidities precluding major surgery
  • Fractures >3 weeks old with excessive callus (relative - may need extensile approach)
  • Severe osteoporosis with articular comminution (consider THA)
Mnemonic

S-C-O-P-ESCOPE - Pre-operative Assessment

Critical Danger Structures

Sciatic Nerve

Location: Exits greater sciatic notch below piriformis, 10-20mm posterior to posterior column

Risk: 10-15% temporary injury, 1-3% permanent

Protection: Identify early by palpation below piriformis, vessel loop, ribbon retractor throughout, avoid hip extension with retractors in place (stretches nerve)

EXAM KEY: Peroneal division more vulnerable than tibial - foot drop is classic presentation

Superior Gluteal NVB

Location: Exits greater sciatic notch ABOVE piriformis, 30-40mm superior to joint

Risk: Abductor insufficiency (Trendelenburg gait)

Protection: Stay distal to superior border of piriformis - this is the SAFE ZONE. Never dissect proximal to piriformis muscle.

EXAM KEY: Piriformis is the KEY LANDMARK - sciatic nerve below, superior gluteal above

MFCA (Femoral Head Blood Supply)

Location: Runs along posterior femoral neck in superior retinacular vessels

Risk: AVN of femoral head (2-5%)

Protection: LIMITED posterior capsulotomy only - preserve superior capsule. Gentle retraction of femoral head.

EXAM KEY: Most AVN from initial injury/dislocation, not surgery - but surgical technique matters

Obturator Vessels

Location: 5-15mm from medial surface of posterior column

Risk: Hemorrhage from anteromedial screw trajectory

Protection: Posterior column screws should be POSTERIOR to column axis and PARALLEL to joint - stay in Letournel safe zone

EXAM KEY: Bicortical screws are safe if trajectory correct - palpate anterior cortex

Equipment

Implants and Instruments

Implants Required:

  • 3.5mm reconstruction plates (multiple lengths: 8-14 hole)
  • 3.5mm cortical screws (various lengths 26-60mm)
  • 3.5mm cancellous screws (for metaphyseal bone)
  • 2.7mm plates and screws (for small fragments)
  • 2.0-2.5mm K-wires for provisional fixation

Reduction Instruments:

  • Ball spike pushers (essential for fragment manipulation)
  • Pointed reduction forceps (multiple sizes)
  • Weber clamps
  • Jungbluth clamps
  • Schanz pin (for femoral head manipulation if needed)
  • Bone hook and levers

Specialty Items:

  • Nerve stimulator (confirm sciatic nerve identity)
  • Vessel loops and ribbon retractors (nerve protection)
  • Cell saver (expected blood loss 1-2L)
  • Radiolucent table with C-arm access

Bone Graft:

  • Autograft from posterior iliac crest (accessible in field)
  • Allograft cancellous chips (backup)

Positioning and Preparation

Patient Position: Lateral decubitus on radiolucent table

  • Affected side UP
  • Bean bag or pelvic positioners for stability
  • Axillary roll in place
  • All pressure points padded (head, axilla, fibular head, malleoli)
  • Hip must be freely mobile for reduction maneuvers and dynamic testing

Surgical Approach: Kocher-Langenbeck (extensile posterior approach to hip)

Incision:

  • Starts 8-10cm proximal to greater trochanter along posterior border
  • Curves over greater trochanter
  • Extends 10-15cm distally along posterior femoral shaft
  • Total length: 20-25cm depending on body habitus

C-arm Setup:

  • Confirm all three views obtainable BEFORE draping
  • AP pelvis, obturator oblique (affected side down 45°), iliac oblique (affected side up 45°)

Prophylaxis:

  • Antibiotics within 60 minutes (cefazolin 2g IV)
  • TXA 1g IV at induction
  • Skin prep with alcoholic chlorhexidine

Operative Technique

Step 1: Positioning and Setup

Patient in lateral decubitus position on radiolucent table. Affected side up. Confirm pelvis perpendicular to floor with spirit level. Check C-arm access for all three views before draping. Ensure hip can be fully flexed, extended, and rotated - essential for reduction maneuvers and dynamic stability testing.

Clinical Pearl

Technical Tip: Lateral position is preferred over prone for this fracture pattern - allows better hip manipulation, dynamic testing, and fluoroscopy access. Prone may be considered for bilateral fractures or specific surgeon preference.

Step 2: Kocher-Langenbeck Incision

Incision centered over greater trochanter: 8-10cm proximal along posterior GT border, curving over GT apex, then 10-15cm distally along posterior femoral shaft. Total length 20-25cm. Mark anatomical landmarks (GT, PSIS) before incision as position may shift intraoperatively.

Step 3: Superficial Dissection - Gluteus Maximus

Split gluteus maximus in line with its fibers (running superolaterally to inferomedially). The split can be extended proximally and distally as needed. Identify and preserve the inferior gluteal neurovascular bundle running with the muscle.

Key Safety Point

The gluteus maximus split exposes the short external rotators and sciatic nerve. Proceed carefully once through the muscle - the nerve lies immediately deep.

Step 4: Sciatic Nerve Identification

CRITICAL STEP: Before any further dissection, identify the sciatic nerve by FINGER PALPATION below the piriformis muscle. The nerve is a thick, cord-like structure running from the greater sciatic notch, between the ischial tuberosity and greater trochanter, distally with the hamstrings.

Once identified by palpation:

  • Confirm visually
  • Trace proximally to greater sciatic notch
  • Trace distally 6-8cm
  • Place vessel loop or ribbon retractor for protection
  • Use nerve stimulator to confirm identity if any doubt

Clinical Pearl

EXAM KEY: "How do you identify the sciatic nerve?" - Answer: "Finger palpation below piriformis muscle first - it feels like a thick cord. Then visual confirmation, tracing from sciatic notch to distal thigh. I would use a nerve stimulator to confirm identity, then protect with vessel loop and ribbon retractor throughout the case."

Step 5: Short External Rotator Detachment

Identify the short external rotators from superior to inferior:

  1. Piriformis - KEY LANDMARK (sciatic nerve exits below)
  2. Superior gemellus
  3. Obturator internus tendon (thickest - easiest to identify)
  4. Inferior gemellus
  5. Quadratus femoris

Tag each tendon with heavy suture (number them 1-4 for anatomic repair later). Detach from femoral insertion leaving 5mm cuff for repair. Reflect posteriorly to expose posterior capsule.

Piriformis Rule

NEVER dissect proximal to the piriformis muscle. The superior gluteal neurovascular bundle exits ABOVE piriformis - injury causes permanent abductor weakness and Trendelenburg gait.

Step 6: Limited Posterior Capsulotomy

Perform LIMITED capsulotomy through the posterior capsule - small T-shaped or cruciate incision over the fracture site.

DO NOT perform complete capsulectomy - this sacrifices the superior retinacular vessels (MFCA branches) and increases AVN risk.

Inspect the joint for:

  • Intra-articular fragments (remove)
  • Marginal impaction ("gull sign")
  • Femoral head injury
  • Labral damage
  • Reduction quality

Step 7: Posterior Column and Wall Exposure

Subperiosteal elevation from the lateral ilium distally. Stay distal to superior gluteal nerve (below piriformis level). Expose:

  • Posterior column from greater sciatic notch to ischial tuberosity
  • Posterior wall fragments
  • Quadrilateral surface (palpation)

Place retractors carefully with sciatic nerve always visualized and protected.

Step 8: Address Marginal Impaction (If Present)

Present in 30-40% of posterior wall fractures. Recognition on CT: "gull sign" - articular cartilage depressed into subchondral bone.

Management:

  1. Create window through posterior wall fracture
  2. Use curved osteotome to elevate impacted osteochondral fragment
  3. Work from inferior to superior, preserving cartilage
  4. Pack resulting defect with cancellous bone graft (autograft from posterior iliac crest available in field)
  5. Support elevated fragment with bone graft before wall reduction

Clinical Pearl

Evidence Point: Addressing marginal impaction improves good outcomes from 50% to 80% (Letournel). Failure to recognize and treat is a major cause of poor results.

Step 9: Posterior Column Reduction

Reduce COLUMN before WALL - the column provides the foundation.

  1. Débride fracture hematoma
  2. Use ball spike in posterior column fragment for manipulation
  3. Restore length by pushing fragment distally
  4. Correct rotation (usually internally rotated)
  5. Provisional fixation with pointed reduction forceps or K-wires
  6. Assess reduction: direct vision, palpation of articular surface, fluoroscopy

Target: Anatomic reduction (<1mm step/gap)

Step 10: Posterior Column Fixation

Apply 3.5mm reconstruction plate along the lateral surface of the posterior column:

  • From posterior ilium to ischial tuberosity
  • Pre-contour plate to match anatomy
  • Minimum 3 screws each side of fracture (6 cortices each fragment)
  • Lag screws through plate for large fragments

SCREW TRAJECTORY: Letournel Safe Zone

  • Posterior column screws should be POSTERIOR to column axis
  • Parallel to joint surface
  • Avoid anteromedial trajectory (obturator vessels 5-15mm from medial surface)

Screw Safety

Palpate anterior cortex when drilling to confirm trajectory and prevent excess penetration. All screws must be checked with fluoroscopy - no intra-articular hardware.

Step 11: Posterior Wall Reduction

With column restored, reduce wall fragments to the now-anatomic column:

  1. Identify all wall fragments and their correct orientation
  2. Use ball spike and pointed reduction forceps
  3. Reduce largest fragments first
  4. Provisional K-wire fixation
  5. Check reduction through capsulotomy (articular surface step)

Step 12: Posterior Wall Fixation - Spring Plate Technique

For COMMINUTED posterior wall (multiple fragments), use the Spring Plate Technique:

  1. Contour 3.5mm reconstruction plate to match normal posterior wall anatomy (use contralateral CT or opposite hip as template)
  2. Position plate over reduced wall fragments
  3. Insert multiple (8-12) lag screws through the plate
  4. Screws compress fragments against the plate
  5. Plate acts as TEMPLATE - screws pull fragments to plate, restoring anatomy

For SIMPLE posterior wall (1-2 large fragments):

  • Direct lag screw fixation through plate
  • Buttress plating as needed

Clinical Pearl

Spring Plate Principle: The plate is pre-contoured to ideal anatomy and acts as a template. Multiple lag screws through the plate compress the comminuted fragments against the plate surface, recreating the anatomical contour. This is the key technique for comminuted posterior wall fractures.

Step 13: Dynamic Stability Testing

CRITICAL ASSESSMENT - determines if wall reconstruction adequate:

  1. Remove all retractors and provisional fixation
  2. Flex hip to 90°
  3. Internally rotate
  4. Assess for subluxation or dislocation

Result Interpretation:

  • Stable: Hip remains concentrically reduced → adequate wall restoration
  • Unstable: Hip subluxes → INADEQUATE wall fixation → add more fixation

Do Not Accept an Unstable Hip

If the hip subluxes with flexion/internal rotation, the posterior wall reconstruction is inadequate. You MUST add additional fixation - either more screws, larger plate, or address a missed component. Post-operative dislocation is a devastating complication.

Step 14: Final Fluoroscopic Check

Obtain all three standard views:

  1. AP pelvis: Overall alignment, hip congruency
  2. Obturator oblique (affected side down 45°): Best view of posterior wall
  3. Iliac oblique (affected side up 45°): Posterior column profile

Check for:

  • Anatomic reduction (<1mm step/gap)
  • No intra-articular hardware (use radiopaque probe if any question)
  • Adequate screw purchase (bicortical where possible)
  • Concentric hip joint
  • All fracture components addressed

Step 15: Closure and HO Prophylaxis

Wound Closure:

  1. Copious irrigation (3L+ warm saline)
  2. Meticulous hemostasis
  3. Repair posterior capsule (absorbable suture)
  4. Reattach short external rotators anatomically using tagged sutures
  5. Deep drain (19Fr) to gluteus maximus level
  6. Close gluteus maximus split
  7. Fascia lata, subcutaneous, skin closure

HETEROTOPIC OSSIFICATION PROPHYLAXIS - MANDATORY:

  • Indomethacin 75mg PO daily x 6 weeks (start POD#1)
  • OR Single-dose radiation 700cGy within 72 hours (if NSAID contraindicated)
  • HO rate 30-50% WITHOUT prophylaxis - highest of all approaches

HO Prophylaxis is NOT Optional

The Kocher-Langenbeck approach has the HIGHEST rate of heterotopic ossification of any pelvic approach. Without prophylaxis, 30-50% will develop significant HO. Indomethacin is first-line; radiation for NSAID intolerance, GI bleeding risk, or those on anticoagulation. EXAM NUANCE: if the patient has a concurrent long-bone fracture, prefer single-dose radiation over indomethacin - NSAIDs significantly increase long-bone nonunion (Burd RCT: 26% versus 7%).

Post-operative Protocol

Immediate (Recovery):

  • Neurovascular check documented (especially sciatic nerve - peroneal division)
  • Check X-ray (AP pelvis, Judet views)
  • VTE prophylaxis initiated (LMWH)
  • HO prophylaxis started (indomethacin POD#1)

Days 1-3:

  • Mobilize with physiotherapy
  • Toe-touch weight bearing for 6-12 weeks
  • Active hip ROM within comfort
  • Drain removal 48-72 hours

6 Weeks:

  • Clinical and radiological review
  • Progress weight bearing if healing
  • Assess for HO (X-ray)

12 Weeks:

  • Full weight bearing if united
  • Return to normal activities

Long-term Follow-up:

  • 6 months, 1 year, then annually
  • Monitor for post-traumatic arthritis
  • MRI if symptomatic for AVN (6-12 months)
  • EMG/NCS at 3 weeks if sciatic deficit (for prognosis)

Complications

Complication Management

Key Evidence

Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury

Level III
Matta JM • J Bone Joint Surg Am
Clinical Implication: Establishes anatomical reduction as the single most important controllable predictor of hip survival. The drop in reduction quality after delay supports the days 3-7 operative window for posterior column/wall ORIF.
Verify on PubMed (PMID 8934477)

Results of operative treatment of fractures of the posterior wall of the acetabulum

Level IV
Moed BR, WillsonCarr SE, Watson JT • J Bone Joint Surg Am
Clinical Implication: Prompt reduction of the dislocated hip is imperative to limit osteonecrosis, and intra-articular comminution (marginal impaction) must be recognised and addressed. Anatomic wall reconstruction reliably yields good long-term function.
Verify on PubMed (PMID 12004016)

Outcomes of acetabular fracture fixation with ten years' follow-up

Level IV
Briffa N, Pearce R, Hill AM, Bircher M • J Bone Joint Surg Br
Clinical Implication: Confirms durable function at a decade for most patients but tempers expectations - around one in five has a poor result. Reinforces fixation by specialist surgeons in dedicated units as early as feasible.
Verify on PubMed (PMID 21282764)

Operative treatment of displaced fractures of the acetabulum: a meta-analysis

Level III
Giannoudis PV, Grotz MRW, Papakostidis C, Dinopoulos H • J Bone Joint Surg Br
Clinical Implication: Provides the global benchmark complication and outcome figures used in consent and viva discussion, and frames reduction quality, approach selection and timing as the surgeon-controllable levers.
Verify on PubMed (PMID 15686228)

Heterotopic ossification prophylaxis with indomethacin increases the risk of long-bone nonunion

Level I
Burd TA, Hughes MS, Anglen JO • J Bone Joint Surg Br
Clinical Implication: In a posterior column/wall ORIF patient with concurrent long-bone fractures, favour single-dose radiotherapy for HO prophylaxis over indomethacin to avoid impairing union of the associated fractures.
Verify on PubMed (PMID 12892193)

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 35-year-old motorcyclist sustains a posterior hip dislocation and is found to have a posterior column and posterior wall acetabular fracture. The CT shows 50% posterior wall involvement and marginal impaction. How would you manage this patient?"

PRACTICAL APPROACH
This is an associated posterior column/wall acetabular fracture - one of the five associated patterns in the Judet-Letournel classification. The combination of 50% wall involvement and marginal impaction makes this a complex injury requiring surgical stabilization. **Initial Management**: After ATLS assessment and resuscitation, I would perform closed reduction of the hip dislocation under sedation in ED if not already done - prolonged dislocation increases AVN risk. I would document sciatic nerve function before and after reduction. Skeletal traction maintains reduction until surgery. **Pre-operative Planning**: CT with 3D reconstruction is essential. I would systematically assess: posterior column displacement, posterior wall percentage (50% confirms instability), marginal impaction location and extent, femoral head damage, and loose bodies. Surgery optimally performed days 3-7. **Surgical Approach**: Kocher-Langenbeck approach in lateral decubitus position. After incising through gluteus maximus, my priority is early identification of the sciatic nerve by finger palpation below piriformis, then vessel loop protection throughout. I detach and tag the short external rotators for later repair. **Reduction and Fixation Sequence**: 1. LIMITED capsulotomy to inspect joint and address marginal impaction - elevate with curved osteotome, bone graft the defect 2. Reduce COLUMN first - restore length and rotation, fix with reconstruction plate along lateral column surface 3. Then reduce WALL to the restored column - spring plate technique given comminution expected with 50% involvement 4. Multiple lag screws through contoured plate compress fragments **Critical Assessment**: Dynamic stability testing - hip 90° flexion with internal rotation must remain stable. If subluxes, wall reconstruction inadequate and needs augmentation. **Post-operative**: Toe-touch weight bearing 6-12 weeks. HO prophylaxis MANDATORY - indomethacin 75mg daily for 6 weeks. VTE prophylaxis extended 4-6 weeks.
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"During the Kocher-Langenbeck approach for the above patient, your assistant notes the patient has developed a foot drop after final positioning. What are your considerations?"

PRACTICAL APPROACH
An intraoperative sciatic nerve palsy is a serious complication requiring immediate and systematic management. **Immediate Assessment**: First, I would halt the procedure and assess what phase we are in. If we haven't started deep dissection, this suggests a positioning or traction injury. If we are mid-procedure, direct surgical trauma is more likely. **Positioning Causes**: - Excessive hip flexion stretching the nerve - Retractor pressure on nerve - Prolonged lateral position with fibular head compression (peroneal at fibular head) - Hip extension with posterior retractors in place (stretches sciatic) **Immediate Actions**: 1. Release ALL retractors immediately 2. Reposition the hip to neutral (mild flexion, neutral rotation) 3. Check fibular head padding 4. Visually inspect the sciatic nerve if exposed - look for contusion, laceration, transection 5. If nerve appears intact but edematous, likely neuropraxia from stretch/pressure **Decision to Continue vs Abort**: If the nerve appears intact with no obvious transection, I would continue with the fixation as: - The fracture still needs stabilization - Returning for a second procedure adds risk - Most positioning-related palsies are neuropraxia and will recover However, I would: - Minimize remaining operative time - Use only essential retraction - Avoid any hip extension - Consider shortening procedure if possible **Post-operative Management**: - Document findings and new deficit immediately - EMG/NCS at 3 weeks post-operatively for baseline and prognosis - Ankle-foot orthosis for foot drop - Physiotherapy to maintain ROM and prevent contractures - If complete peroneal palsy with no recovery at 3 months, consider tendon transfers **Prognosis**: Neuropraxia (most common): Full recovery expected 3-6 months Axonotmesis: Partial recovery, may take 12-18 months Neurotmesis: No spontaneous recovery - needs surgical repair
CLINICAL SCENARIOStandard

CLINICAL PROMPT

"At 6-month follow-up, a patient who underwent Kocher-Langenbeck ORIF for a posterior column/wall fracture complains of hip stiffness. X-ray shows Brooker Class III heterotopic ossification. How would you manage this?"

PRACTICAL APPROACH
This patient has developed significant heterotopic ossification - a well-recognized complication of the Kocher-Langenbeck approach with rates of 30-50% without prophylaxis. **Assessment**: First, I would establish whether prophylaxis was given. If it was, this represents prophylaxis failure (occurs in 5-10%). If not given, this is a preventable complication. **Brooker Classification**: - Class I: Bone islands within soft tissue - Class II: Exophytes from pelvis or femur with >1cm gap - Class III: Exophytes with <1cm gap - Class IV: Complete bony ankylosis Class III represents significant ossification that typically causes functional limitation. **Clinical Assessment**: - Document current ROM (likely significantly restricted) - Assess functional impact - can they sit, dress, walk comfortably? - Compare to immediate post-operative ROM - Assess whether HO is mature (usually takes 12-18 months) **Investigation**: - Plain X-rays confirm classification - Triple-phase bone scan or serum alkaline phosphatase can assess maturity - CT scan defines anatomy for surgical planning if excision considered **Non-operative Management**: - If minimally symptomatic despite X-ray appearance - observe - Physiotherapy to maintain current ROM (will not improve ROM) - NSAIDs for pain (may slow progression if immature) - Wait for maturation before considering surgery **Surgical Excision**: Indicated for symptomatic patients with mature HO causing significant functional limitation. **Timing**: Wait for maturation - 12-18 months post-injury **Evidence of Maturity**: - No uptake on bone scan - Normal alkaline phosphatase - Clear cortical margins on X-ray **Surgical Technique**: - Same Kocher-Langenbeck approach - Careful dissection - sciatic nerve often encased - Complete excision of heterotopic bone - Preserve underlying structures - Intraoperative ROM assessment **Peri-operative Prophylaxis** (CRITICAL - recurrence rate 100% without): - Radiation 700cGy within 24-48 hours post-excision - AND/OR Indomethacin 75mg daily x 6 weeks - I prefer radiation as compliance guaranteed **Post-operative Rehabilitation**: - Immediate ROM exercises - CPM machine may be helpful - Aggressive physiotherapy - Maintain prophylaxis full duration **Prognosis**: With proper timing and prophylaxis, 80-90% achieve satisfactory ROM improvement.

Posterior Column/Wall Acetabular Fracture - Exam Summary

Clinical summary

References

  1. Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Springer-Verlag; 1993.

  2. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78(11):1632-1645.

  3. Moed BR, Willson Carr SE, Watson JT. Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am. 2002;84(5):752-758.

  4. Briffa N, Pearce R, Hill AM, Bircher M. Outcomes of acetabular fracture fixation with ten years' follow-up. J Bone Joint Surg Br. 2011;93(2):229-236.

  5. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am. 1973;55(8):1629-1632.

  6. Burd TA, Hughes MS, Anglen JO. Heterotopic ossification prophylaxis with indomethacin increases the risk of long-bone nonunion. J Bone Joint Surg Br. 2003;85(5):700-705.

  7. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br. 2005;87(1):2-9.