A thirty year perspective on posterior wall fractures of the acetabulum: Enigma or just another intra-articular injury

Investigators dealing with a relatively small number of patients with posterior wall fractures have found unsatisfactory clinical outcomes, estimated to be approximately 30%. Consequently, conventional wisdom has professed that these fractures do poorly relative to other acetabular fracture types and are somehow different. The main questions to be answered in the treatment of these injuries include: (1) how can the need for operative versus non-operative treatment best be determined, (2) can the fixation of comminuted and marginally impacted fracture fragments be improved, (3) what are the risk factors for an adverse outcome after operative fracture fixation, and (4) what are the expected clinical and functional outcomes after operative treatment?A review of my long-term body of work investigating posterior wall fractures of the acetabulum, published over an extended period of time, was conducted to address these questions. Answers to the proposed questions are as follows: (1) dynamic stress examination under anaesthesia is the only reliable way to determine hip joint stability; (2) fixation of comminuted and marginally impacted fracture fragments can be improved by using a two-level fixation construct, as well as a non-traditional surgical approach for certain fracture patterns; (3) delayed reduction of hip dislocation and comminuted fractures in older patients are associated with poor clinical outcome and the accuracy of surgical reduction is highly predictive of clinical outcome; and (4) good-to-excellent hip function should be expected in a high percentage of these patients. However, residual functional deficits may still remain.