What are the key recommendations and landmark papers for managing acetabular fractures?

Landmark Papers on Acetabular Fracture Management

The foundational work by Judet, Judet, and Letournel in 1964 established the classification system and surgical approaches that remain the cornerstone of acetabular fracture treatment today, with Letournel's 1980 series demonstrating 80% good-to-excellent results and Matta's 2012 landmark study showing 79% survivorship in 816 patients—both definitively proving that anatomic reduction is the single most influential factor predicting clinical outcome. 1

Historical Foundations

The evolution of acetabular fracture surgery began with case reports in 1943 describing the first surgical fixations. 1 However, the true paradigm shift occurred with:

• Judet, Judet, and Letournel (1964): Published the landmark classification system and surgical approaches that revolutionized acetabular fracture treatment, fundamentally changing clinical outcomes after surgical fixation. 1

• Letournel (1980): Demonstrated 80% good-to-excellent results in 492 hips, establishing the critical principle that anatomic reduction is the most influential predictor of clinical outcome. 1

• Matta (2012): Confirmed long-term durability with 79% survivorship in 816 patients following surgical acetabular fixation, reinforcing Letournel's findings about the primacy of anatomic reduction. 1

Contemporary Evidence and Meta-Analyses

Giannoudis et al. (2005) provided the first comprehensive meta-analysis of acetabular fracture outcomes, which was subsequently updated with 15 years of additional data analyzing 8,389 fractures from 8,372 patients. 2 This contemporary review revealed critical epidemiological shifts:

• Mean patient age increased from 38.6 to 45.2 years 2
• Road traffic accidents decreased from >80% to 66.5% of cases 2
• Falls increased from 10.7% to 25.8% as injury mechanism 2
• Marked rise in anterior column-based fractures with decline in other patterns 2
• Substantial reduction in iatrogenic nerve damage, particularly sciatic nerve injury 2
• Post-traumatic osteoarthritis remains the major complication at 16.9% developing Matta grade III/IV changes by 44 months 2

Surgical Technique and Outcomes

The 2019 systematic review by Patient Safety in Surgery synthesized decades of outcome data, confirming that anatomic reduction remains the dominant factor affecting clinical results. 1 Key surgical principles include:

• Kocher-Langenbeck and Ilioinguinal approaches remain the primary surgical corridors 2
• Anterior Intra-Pelvic approach has gained relative popularity 2
• Surgery is now performed earlier than historical practice 2
• Heterotopic ossification remains a persistent complication 2

Role of Arthroplasty

The 2010 Orthopedics review established two critical scenarios where total hip arthroplasty (THA) plays a definitive role: 3

• Acute fractures in elderly patients with joint impaction (the "gull sign") or femoral head impaction—these do not benefit from internal fixation attempts 3
• Treatment of sequelae including post-traumatic arthritis or osteonecrosis 3

Technical recommendations for acute THA include restoration of columnar continuity with plates and uncemented acetabular components with multiple screw fixation, while cemented components demonstrate high failure rates and should be avoided. 3

Rehabilitation Protocols

The 2024 systematic review and meta-analysis in the Journal of Clinical Medicine addressed the critical gap in postoperative rehabilitation protocols, analyzing 494 articles with 22 studies (1,025 patients) meeting inclusion criteria. 4 Key findings:

• Most protocols favor isometric quadriceps and abductor strengthening starting postoperative day one 4
• Passive hip movement at 1-3 days postoperatively 4
• Active hip movement ranges from first postoperative day to 4 weeks 4
• Partial weight-bearing with walker or crutches permitted 1-12 weeks postoperatively 4
• Full weight-bearing typically allowed at 3 months based on fracture healing 4
• Only three studies permitted early weight-bearing (≤1 week) 4
• Accelerated rehabilitation with early permissive weight-bearing does not appear to increase loss of reduction or complication rates 4

The 2025 Journal of Clinical Medicine review specifically examined older adults (≥65 years), analyzing 929 patients across 20 studies. 5 Critical distinctions emerged:

• Isolated ORIF: 0% allowed immediate full weight-bearing, 62% recommended partial weight-bearing for 6-12 weeks 5
• Combined hip procedure (ORIF + acute THA): 53% allowed immediate full weight-bearing 5
• Functional outcomes: isolated ORIF mean HHS 63-82 points with 16.5-45% delayed THA conversion 5
• Combined procedures: mean HHS 70-92 points, higher satisfaction (74-90%), but increased dislocations (8-11%) and implant loosening (up to 18%) 5
• Mortality at 1 year: ORIF 0-25%, CHP 0-14%; at 5 years: up to 42% ORIF, up to 70% CHP 5

Critical Gaps and Future Directions

Despite decades of surgical refinement, rehabilitation protocols remain inconsistent and lack standardization. 5 Only 11% of studies monitored compliance with weight-bearing restrictions. 5 The heterogeneity of rehabilitation approaches prevents definitive meta-analysis, and there is inconsistent use of patient-reported outcome measures to objectively calculate effect sizes. 4