Acetabular Fracture ORIF - Posterior Column/Wall

The pattern. The posterior column/wall fracture is one of the five associated (complex) patterns of the Judet-Letournel classification. Unlike a simple posterior wall fracture, it disrupts BOTH the posterior column (running from the iliac wing to the ischial tuberosity and carrying the posterior half of the articular surface) and a fragment of the posterior wall behind the hip joint. The classic mechanism is a posterior hip dislocation with axial load — the dashboard injury, often a motorcyclist. Absolute indications - Posterior column fracture with greater than 2 mm displacement

• Associated posterior wall fracture with greater than 40 percent wall involvement
• Hip joint instability on dynamic examination
• Marginal impaction requiring elevation
• Incarcerated osteochondral fragments Relative indications - Posterior wall of 20 to 40 percent with marginal impaction
• Posterior column fracture in polytrauma (a staged approach)
• Posterior component of a transverse plus posterior wall pattern Contraindications - Active infection
• Severe medical comorbidities precluding major surgery
• Fractures over 3 weeks old with excessive callus (relative — an extensile approach may be needed)
• Severe osteoporosis with articular comminution — consider total hip arthroplasty instead Timing — the optimal window is days 3 to 7. This allows resuscitation and medical optimisation, brings haemorrhage under control and swelling down, and leaves fracture lines visible before callus forms, while avoiding the inflammatory peak of days 2 to 3. Operating too early (days 0 to 2) risks ongoing haemorrhage in a haemodynamically unstable patient with inadequate imaging; operating too late (over 2 to 3 weeks) means callus obscures fracture lines, bleeding from granulation tissue increases, reduction is harder and complications rise. Pre-operative planning — imaging is decisive. Obtain an AP pelvis, Judet obliques (obturator and iliac) and a CT with 3D reconstruction, which is mandatory for pattern classification, marginal impaction (the 'gull sign'), fragment size and displacement, and femoral head injury. Systematically work through: - Confirm the posterior column/wall pattern
• Measure posterior wall involvement — greater than 40 percent means unstable
• Identify marginal impaction
• Assess for intra-articular fragments
• Check the femoral head for impaction or fracture
• Evaluate the contralateral hip for templating Patient optimisation. Start DVT prophylaxis on admission, have blood cross-matched (expected loss 1 to 2 L), arrange a cell saver, and apply skeletal traction if the hip is subluxed. Consent specifically for sciatic nerve injury (foot drop), heterotopic ossification and stiffness, femoral head avascular necrosis, post-traumatic arthritis, substantial blood loss, and the possibility of re-operation or late conversion to arthroplasty. Setup. Lateral decubitus on a radiolucent table, affected side up, secured with a bean bag or pelvic positioners, an axillary roll in place, and all pressure points padded (head, axilla, fibular head, malleoli). The hip must be freely mobile for reduction manoeuvres and dynamic testing. Confirm all three fluoroscopic views are obtainable BEFORE draping — AP pelvis, obturator oblique (affected side down 45 degrees) and iliac oblique (affected side up 45 degrees). Give antibiotics within 60 minutes (cefazolin 2 g IV) and tranexamic acid 1 g IV at induction, and prep with alcoholic chlorhexidine.

The goal: expose the posterior column and wall through the Kocher-Langenbeck approach, identify and protect the sciatic nerve, restore the column first and then the wall, and confirm a stable, concentric hip. The exposure is laid out in full below (and in depth on the Kocher-Langenbeck approach to the hip page).

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Rehabilitation | Phase | Timing | Weight-bearing | Focus | |-------|--------|----------------|-------| | Recovery | 0 to 2 days | — | Neurovascular check (peroneal division), check X-ray (AP and Judet), VTE prophylaxis (LMWH), HO prophylaxis from day 1, drain removal at 48 to 72 hours | | Early | Days 1 to 3 | Toe-touch for 6 to 12 weeks | Mobilise with physiotherapy, active hip ROM within comfort | | 6 weeks | 6 weeks | Progress if healing | Clinical and radiological review, assess for HO on X-ray | | 12 weeks | 12 weeks | Full weight bearing if united | Return to normal activities | | Long-term | 6 months, 1 year, then annually | — | Monitor for post-traumatic arthritis; MRI at 6 to 12 months if symptomatic for AVN; EMG/NCS at 3 weeks for any sciatic deficit | Most patients return to unrestricted activity by 12 weeks once the fracture is united. Long-term follow-up watches for post-traumatic arthritis and femoral head avascular necrosis, which may declare 6 to 24 months after injury. Complications

Classification. The Judet-Letournel system divides acetabular fractures into five elementary (simple) and five associated (complex) patterns. The posterior column/wall injury is one of the five associated patterns — it combines disruption of the posterior column (from the iliac wing to the ischial tuberosity, including the posterior half of the articular surface) with a posterior wall fragment. Posterior wall involvement greater than 40 percent renders the hip unstable and is the key threshold for fixation. Heterotopic ossification — the Brooker classification. The Kocher-Langenbeck approach carries the highest HO rate of any pelvic approach, so grading matters for both prognosis and the decision to excise.

What the evidence shows. Across operative acetabular fractures, anatomical reduction is the single most important surgeon-controllable predictor of hip survival: Matta achieved reduction within 1 mm in 71 percent of fractures operated within three weeks, with good or excellent clinical results in roughly three-quarters and femoral head osteonecrosis in 3 percent. Moed's posterior-wall series achieved anatomic reduction in 97 of 100 fractures with good-to-excellent results in roughly 90 percent, and identified delayed reduction of an associated dislocation, age 55 or older, intra-articular comminution and osteonecrosis as independent risk factors for a poor outcome. The Giannoudis meta-analysis of 3,670 operatively treated fractures sets the benchmark complication figures — late post-traumatic osteoarthritis in roughly 20 percent, heterotopic ossification and femoral head osteonecrosis each under 10 percent across treated cohorts, and only 8 percent needing further surgery — while framing reduction quality, approach selection and timing as the levers the surgeon controls. Finally, the Burd randomised trial is the reason to prefer single-dose radiotherapy over indomethacin for HO prophylaxis when a patient has a concomitant long-bone fracture: indomethacin raised long-bone non-union from 7 percent to 26 percent.