Fractures to the Posterior Wall of the Acetabulum Managed With Screws Alone

Tricortical iliac crest graft as a salvageable option in the reconstruction of comminuted posterior wall acetabular fractures: our experience from a level 1 trauma centre

BACKGROUND

Comminuted fractures of the posterior acetabular wall, pose a significant challenge in the reduction and fixation of the fracture fragments and usually result in dubious functional outcomes. Primary reconstruction of the severely comminuted posterior wall using the autologous tricortical iliac crest graft has shown promising results, especially in fractures not amenable for anatomical reduction and fixation. Thus, the present study analyses the functional and radiological outcomes of severely comminuted posterior wall acetabular fractures, primarily reconstructed with an autologous tricortical iliac crest graft.

METHODOLOGY

This is a retrospective study, where all cases of comminuted posterior wall acetabulum fractures treated primarily with reconstruction using ipsilateral autologous tricortical iliac crest graft between January 2011 and November 2018 were included. The data of patients were retrieved from the hospital records and all the patients were assessed clinically and radiologically at the final follow-up.

RESULTS

Fourteen patients (ten males and four females) were operated on with a mean operative time of 160 min (range 125 to 190 min) and a mean blood loss of 410 ml (range 320 ml to 830 ml). At 2 years of follow-up, 11 patients (78.57%) had good to excellent functional outcomes based on the modified Merle d'Aubigne and Postel scoring system. The radiological assessment using Matta's criteria indicated excellent outcomes in two patients (14.48%), good in six patients (42.85%), fair in six patients (42.85%).

CONCLUSION

Primary reconstruction of the comminuted posterior wall acetabulum fractures is a potential alternative and salvageable option with favourable outcomes. However, it ought to be considered in severely comminuted fractures where anatomical reduction and internal fixation is not feasible.

Posterior wall fractures of the acetabulum: treatment using an anatomical plate through direct posterior approach

OBJECTIVES

This study was aimed to measure the application of W-shaped acetabular angular plate (WAAP) through direct posterior approach (DPA) on the reconstruction of acetabular posterior wall fractures when compared with reconstruction plates.

PATIENTS AND METHODS

A retrospective study was performed on patients treated with the WAAP or reconstruction plates via the DPA. The intraoperative data of operative time, blood loss and radiation exposure times were recorded. Radiographs of the pelvis and CT scan were obtained within one week post-operation to assess the reduction quality. The clinical outcome was evaluated by the modified Merle d'Aubigne and Postel score.

RESULTS

From May 2016 to October 2019, a total of 41 patients with simple acetabular posterior wall fractures were included in this study, 22 from the WAAP group and 19 from the reconstruction plates group. There were no significant differences between the two group in age, gender, time from injury to operation, cause of injuries, length of incision and follow-up time (P > 0.05). In comparison with the reconstruction plates group, the average operation time of the WAAP group was significantly shorter (46.1 ± 12.7 min vs 59.2 ± 17.4 min, P < 0.05), the average radiation exposure times were significantly less (2.3 ± 0.6 vs 3.6 ± 1.0, P < 0.001), the average blood loss was significantly less (240 ± 98.9 ml vs 301.1 ± 66.6 ml, P < 0.05). According to Matta radiology criteria and the modified Merle d' Aubigne and Postel score, no significant difference was observed between the two group, as for the quality of reduction and function outcomes.

CONCLUSION

The application of WAAP through DPA showed satisfactory preliminary clinical outcomes, showing promise to be an alternative technique for the treatment of acetabular posterior wall fractures.

Isolated Buttress Plating of Posterior Wall Acetabular Fractures: Is it Sufficient?

Background

Conventional fixation methods of posterior wall acetabular fractures feature the use of plating and lag screws. However, fixation of posterior wall fractures with buttress plating alone offers potential advantages by avoiding the hardware complications related to hardware placement through the wall fragment. The purpose of this study was to examine if buttress plating alone, without screw fixation through the wall would be a viable method of treating these fractures. Our hypothesis was that this technique would not result in loss of reduction.

Methods

Consecutive series of patients with isolated posterior wall acetabular fractures treated by two independent surgeons at two Level I Trauma centers without screw fixation across the fracture (Boston Medical Center/Harborview Medical Center).

Results

All 72 fractures treated without a screw through the posterior wall fragment maintained reduction at an average of 1.6 years post-operatively. For fractures fixed with buttress plating alone, 92 % were reduced within 2 mm of being anatomic compared to 94 % of fractures that had screws cross the fracture.

Conclusion

The described buttress plating technique without screw fixation in the wall is an acceptable form of fixation for posterior wall acetabular fractures without the theoretical risk of intra-wall screw fixation.

Biomechanical comparison of fixation systems in posterior wall fracture of acetabular by finite element analysis

BACKGROUND

The use of reconstruction plates and lag screws has been recommended for fractures to the posterior wall of the acetabulum. However, little information about the rigidity of recommended forms of fracture fixation is available. This study aimed to evaluate the biomechanical difference among the fixation systems.

METHODS

A posterior wall fracture, which is represented by softer elements with lower elastic modulus, was created along an arc of 40-90° about the acetabular rim. Three different fixation systems: screws alone, reconstruction plate with screws, reconstruction plate with T-shaped plates were used to fix the posterior wall fractures to the acetabulum.

RESULTS

All three fixation system can be used to obtain good functional outcomes. The reconstruction plate with T-shaped plates was beneficial to increasing the effective stiffness, decreasing the stress concentration and enhancing the rigidity of fracture fixation. So this fixation system served an ideal result in the analysis.

CONCLUSION

Theoretically, the reconstruction plate with T-shaped plates system may reduce many of the risks and limitations compared to the other fixation systems. This fixation system may result in a clinical benefit.

Use of Spring Plates in Fixation of Comminuted Posterior Wall Acetabular Fractures

OBJECTIVES

Surgical management of comminuted posterior wall acetabular fractures with marginal fragments remains difficult. The purpose of this study was to evaluate the use of spring plates as adjunctive fixation in comminuted posterior wall acetabular fractures.

METHODS

A retrospective review of patients treated for posterior wall acetabular fractures with the use of customized spring plates as adjunctive fixation between 2000 and 2017 was performed. Patients were evaluated radiographically according to the grading criteria of Matta. Complications including subsequent revision surgery and hardware failure were recorded.

RESULTS

Fifty-two patients underwent surgical fixation of posterior wall acetabular fractures with the use of customized 3.5-mm spring plates combined with posterior buttress compression plating over the spring plates as definitive fixation. Mean follow-up was 13.9 months (range: 3-140 months). Forty-two patients had radiographic grades of excellent, with 6 good, 1 fair, and 3 poor. There were no hardware complications. Five patients underwent revision surgery, including 4 patients (7.7%) who underwent a total hip arthroplasty due to advanced arthritis.

CONCLUSIONS

The use of customized spring plates is a viable method of adjunctive fixation for comminuted posterior wall fractures with marginal fragmentation.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A biomechanical comparison of different fixation techniques for fractures of the acetabular posterior wall

PURPOSE

This study aimed to evaluate the biomechanical stability of different fixation techniques for fractures of the acetabular posterior wall. The hypothesis was that a reconstruction plate, combined with compression screw fixation and a plate placed lateral to the screws, would achieve a higher peak load to failure and stiffness and reduced gapping during cycle loading than other fixation techniques.

METHODS

A total of 24 Sawbone pelvis models were created with simulated fractures at the posterior wall of the acetabulum. Anatomic reduction and internal fixation were performed randomly using one of four techniques: (A) reconstruction plate and compression screw fixation was placed with a plate medial to the screws; (B) plate and screw fixation with the plate located lateral to the screws; (C) plate fixation alone, and (D) screw fixation alone. Six models were tested in each group under cyclic and sustaining loading tests. Peak load to failure and stiffness were calculated from load displacement curves.

RESULTS

Peak load to failure and stiffness in group B (3698.71 N and 2900.48 N/mm, respectively), featuring reconstruction plate and compression screw fixation with the plate placed lateral to the screws, were significantly higher than groups C (2508.74 N, 1602.75 N/mm) and D (2332.06 N, 1454.26 N/mm). No statistical differences were observed when group A (2941.60 N, 2136.50 N/mm) was compared with the other groups. There were no significant differences in gapping between groups.

CONCLUSIONS

Fixation using a reconstruction plate and compression screws placed lateral to the screws may address acetabular posterior wall fractures in a more appropriate manner than techniques using only plates or screws. However, this study does not provide evidence to support the fact that placing the plate lateral to the screws is advantageous in comparison with other techniques.

Early Versus Late Weight-Bearing Protocols for Surgically Managed Posterior Wall Acetabular Fractures

Despite overall improved outcomes with open reduction and internal fixation of acetabular fractures, posterior wall fractures show disproportionately poor results. The effect of weight bearing on outcomes of fracture management has been investigated in many lower extremity fractures, but evidence-based recommendations in posterior wall acetabular fractures are lacking. The authors systematically reviewed the current literature to determine if a difference in outcome exists between early and late postoperative weight-bearing protocols for surgically managed posterior wall acetabular fractures. PubMed and MEDLINE were searched for posterior wall acetabular fracture studies that included weight-bearing protocols and Merle d'Aubigné functional scores. Twelve studies were identified. Each study was classified as either early or late weight bearing. Early weight bearing was defined as full, unrestricted weight bearing at or before 12 weeks postoperatively. Late weight bearing was defined as restricted weight bearing for greater than 12 weeks postoperatively. The 2 categories were then compared by functional score using a 2-tailed t test and by complication rate using chi-square analysis. Six studies (152 fractures) were placed in the early weight-bearing category. Six studies (302 fractures) were placed in the late weight-bearing category. No significant difference in Merle d'Aubigné functional scores was found between the 2 groups. No difference was found regarding heterotopic ossification, avascular necrosis, superficial infections, total infections, or osteoarthritis. This systematic review found no difference in functional outcome scores or complication rates between early and late weight-bearing protocols for surgically treated posterior wall fractures. [Orthopedics. 2017: 40(4):e652-e657.].

Assessment of functional outcomes of surgically managed acetabular fractures

We performed a systematic review of the literature pertaining to the functional outcomes of the surgical management of acetabular fractures. A total of 69 articles met our inclusion criteria, revealing that eight generic outcome instruments were used, along with five specific instruments. The majority of studies reported outcomes using a version of the d’Aubigne and Postel score, which has not been validated for use in acetabular fracture. Few validated outcome measures were reported. No psychometric testing of outcome instruments was performed. The current assessment of outcomes in surgery for acetabular fractures lacks scientific rigour, and does not give reliable outcome data for either scientific comparison or patient counselling.

Take home message: The use of non-validated functional outcome measures is a major limitation of the current literature pertaining to surgical management of acetabular fractures; future studies should use validated outcome measures to ensure the legitimacy of the reported results.

Cite this article: Bone Joint J 2016;98-B:690–5.

Long term results after surgical management of posterior wall acetabular fractures

BACKGROUND

Posterior wall fractures are the most common of all acetabular fractures, and there is universal consensus that displaced fractures are best treated with anatomical reduction and stable internal fixation. Though early and mid term results for such studies are available, few shed light on long term results. This study was performed to evaluate long term functional and radiological outcomes in patients with posterior wall acetabular fractures and to determine factors that may contribute adversely to a satisfactory final outcome.

MATERIALS AND METHODS

We retrospectively analysed the hospital records for patients who underwent open reduction and internal fixation (ORIF) for posterior wall acetabular fractures. Twenty-five patients (20 men, five women), including one with bilateral posterior wall fracture, with a mean age of 41.28 ± 7.16 years (range 25-60 years) and a mean follow-up of 12.92 ± 6.36 years (range 5-22 years) who met the inclusion criteria formed the study cohort. Matta's criteria were used to grade postoperative reduction and final radiological outcome. Functional outcome at final follow-up was assessed according to d'Aubigné and Postel score.

RESULTS

Anatomic reduction was achieved in 22 hips, imperfect in four and poor in none. Radiological outcome at final follow-up revealed excellent results in ten hips, good in eight, fair in five and poor in three. The final d'Aubigné and Postel scores were excellent in 14 hips, good in six and fair and poor in three each. Patients with anatomical reduction had a favourable functional and radiological long term outcome. However, the presence of associated injuries in lower limbs and a body mass index (BMI) >25 adversely affected the final functional outcome. Osteonecrosis was seen in three patients, heterotopic ossification in two and Morel Lavallee lesion in one. One patient had postoperative sciatic nerve palsy, which recovered 6 weeks after surgery.

CONCLUSION

Anatomic postoperative reduction leads to optimal functional and radiological outcome on long term follow-up; however, the presence of associated lower-limb injuries and BMI >25 adversely affects a satisfactory final outcome in patients with posterior wall acetabular fractures.

LEVEL OF EVIDENCE

(Level 4) Retrospective case series.

A prospective randomized comparison of two skin closure techniques in acetabular fracture surgery

Background

Recent publications have shown an infection rate of 5–7 % for acetabular fractures treated with the Kocher-Langenbeck (K-L) approach. Using metallic staples to close hip skin incisions has been considered the gold standard. The purpose of this study was to answer the following: (1) will closure of a K-L incision after acetabular fracture surgery with a running subcuticular monocryl suture, then sealing the wound with 2-octyl cyanoacrylate (OCA), result in a lower infection rate compared to metallic staple closure? (2) Do incisions closed with subcuticular monocryl and OCA exhibit decreased drainage? (3) Is there a cost difference between these two methods?

Materials and methods

In a prospective clinical study, 103 patients with acetabular fractures treated using the K-L approach were randomized into two groups: skin closure with metallic staples (n = 52) versus subcuticular running monocryl suture sealed with OCA (n = 51).

Results

Two postoperative deep infections (4 %) in the staples group required multiple debridements; no infections developed in the OCA group. However, there was no statistical difference between the groups, (p = 0.495). There was a statistically significant difference (p = 0.032) comparing days from surgery to a dry incision favoring OCA (4.2 versus 5.85 days). The patient charge was approximately $900 greater on average in the OCA group due to the increased time in the operating room required for the subcuticular closure.

Conclusions

Closure with OCA and subcuticular monocryl showed no clinical disadvantages and appears to have a clinical advantage when compared to standard metallic staple skin closure in acetabular fracture surgery. However, additional patient costs may be incurred.

Level of evidence

II.

Biomechanical comparison of different stabilization constructs for unstable posterior wall fractures of acetabulum. A cadaveric study

PURPOSE

Operative treatment of unstable posterior wall fractures of acetabulum has been widely recommended. This laboratory study was undertaken to evaluate static fixation strength of three common fixation constructs: interfragmentary screws alone, in combination with conventional reconstruction plate, or locking reconstruction plate.

METHODS

Six formalin-preserved cadaveric pelvises were used for this investigation. A posterior wall fracture was created along an arc of 40-90 degree about the acetabular rim. Three groups of different fixation constructs (two interfragmentary screws alone; two interfragmentary screws and a conventional reconstruction plate; two interfragmentary screws and a locking reconstruction) were compared. Pelvises were axial loaded with six cycles of 1500 N. Dislocation of superior and inferior fracture site was analysed with a multidirectional ultrasonic measuring system.

RESULTS

No statistically significant difference was found at each of the superior and inferior fracture sites between the three types of fixation. In each group, the vector dislocation at superior fracture site was significantly larger than inferior one.

CONCLUSIONS

All those three described fixation constructs can provide sufficient stability for posterior acetabular fractures and allow early mobilization under experimental conditions. Higher posterior acetabular fracture line, transecting the weight-bearing surface, may indicate a substantial increase in instability, and need more stable pattern of fixation.

Acetabular fracture: long-term follow-up and factors associated with secondary implantation of total hip arthroplasty

HYPOTHESIS

The present study sought to determine long-term outcome in acetabular fracture and the factors associated with secondary implantation of a total hip arthroplasty and/or with poor functional results.

MATERIAL AND METHODS

Seventy-two patients admitted between 2000 and 2005 were followed up for a maximum 11 years (mean, 6.8 years): 16 females, 56 males; mean age at injury, 41.6 years (median, 40 years). There were 45 simple acetabular fractures, 27 complex fractures and 27 dislocations. Late complications were: osteoarthritis (n=29), osteonecrosis of the femoral head (ONFH: n=8) and heterotopic ossification (n=2).

RESULTS AND DISCUSSION

Twenty-five total hip arthroplasties (THA) were performed, with a mean time to surgery of 3.7 years. Associated factors for THA were: VAS (P<0.0001), PMA (P<0.0001), osteoarthritis (P<0.0001), ONFH (P<0.0002), initial dislocation (P=0.0002), no functional treatment (P=0.0014), surgical treatment (P=0.0065), initial traction (P=0.0068), anterior and posterior congruency defect (P=0.0072 and P<0.0001), and initial intra-articular foreign body (P=0.045). Factors associated with poor or bad functional results were the same, plus: etiology (P=0.0021), BMI (P=0.03) and posterior wall fracture (P=0.0325).

LEVEL OF EVIDENCE

4; retrospective study.

Posterior wall reconstruction using iliac crest strut graft in severely comminuted posterior acetabular wall fracture

Osteosynthesis of comminuted posterior acetabular wall fractures is a challenging task for surgeons. We report a series of eight cases of such fractures where the comminuted fragments were excised and the defect in the posterior acetabular wall was reconstructed with iliac crest strut graft. The graft was buttressed with a reconstruction plate on its posterior aspect. The patients were followed up every week until radiological signs of union were seen. Subsequent follow-up was after six months, one year and annually. Patients were evaluated clinically by Merle d'Aubigne and Postel score and radiologically by Matta score at their final follow-up. All fractures united radiologically after an average follow-up of 3.2 months. The clinical outcome after mean follow-up of 3.34 years (minimum two years and maximum five years) was as follows: two (25%) were excellent, two (25%) were very good, three (37.5%) were good and one (12.5%) was fair. Radiological grading at last follow-up showed excellent in one (12.5%), good in four (50%) and fair in three (37.5%) patients. No complication in the form of infection, heterotopic ossification, neurovascular injury or graft resorption was noticed. To conclude, excision of the small comminuted fragments and reconstruction of the wall using iliac crest strut graft is a viable alternative technique for reconstruction of the comminuted posterior acetabular wall fracture. The medium-term clinical and radiological results of this technique are satisfactory.

Prone or lateral? Use of the Kocher-Langenbeck approach to treat acetabular fractures

PURPOSE

This retrospective, institutional review board approved study with no patients excluded was designed to test the hypothesis that the prone position is advantageous for repair of acetabular fractures, via a posterior approach.

METHODS

In 104 consecutive cases fixed by open reduction and internal fixation using the Kocher-Langenbeck approach, 50 were performed in the prone position and 54 in the lateral position by four attending surgeons at a level I trauma center. These cases were assigned to each surgeon according to the call schedule and positioned on the operating table depending on the preference of the assigned surgeon. Arbeitsgemeinschaft fuer Osteosynthese/Association for the Study of Internal Fixation (AO/ASIF) classification and radiologic outcome were evaluated by standard radiographs of the hip and computerized tomography scans, demographic data were taken from the medical records. Except for the time from injury to surgery (p = 0.003), both groups were comparable, nevertheless the fractures were more severe in the prone one.

RESULTS

With equivalent radiologic outcomes according to Matta, Brooker, Epstein, and Helfet between both groups, a significantly higher rate of infection (p = 0.017) and need for revision surgery (p = 0.009) were found in the prone group.

CONCLUSION

No advantage to either position for the posterior approach to acetabular fractures could be found. Because most of the severe fractures were performed prone, we propose that the larger number of more difficult fractures in this group may cause an increased likelihood of loss of reduction. The higher infection rate in the prone group may be caused by the longer inpatient wait for definitive fixation, leading to a higher risk of nosocomial colonization.

Changes in the treatment of acetabular fractures over 15 years: Analysis of 1266 cases treated by the German Pelvic Multicentre Study Group (DAO/DGU)

Epidemiological, clinical and radiological data of 1266 patients with a unilateral acetabular fracture of up to 29 hospitals was reviewed. Three time periods, 1991-1993 (Registry I; n=359), 1998-2000 (Registry II; n=503), and 2005-2006 (Registry III; n=404) were compared with regard to injury pattern and severity, fracture type, and chosen nonoperative vs. operative treatment to elucidate changes over time in the treatment of acetabular fractures. In the operatively treated group, time to operation, surgical approach, fracture fixation implants and fracture reduction quality were examined. 641 (50.6%) patients with isolated acetabular fractures, 410 (32.4%) multiple injured and 215 (17.0%) polytrauma patients with 642 (50.7%) simple and 624 (49.3%) associated acetabular fractures were evaluated. In the time period from 1991 to 2006, the rate of operative treatments increased nationwide to 77% (rho<0.001). The distribution of fracture types involving the anterior and posterior wall changed with age (rho<0.001). Across all registries, 583 (68.0%) operations were performed within 7 days, 212 (24.7%) operations between 7 and 14 days and 54 (6.3%) operations were performed later than 14 days after injury. An anatomical reduction (0-1mm displacement) was achieved in 551 (64%) acetabular fractures. The obtained reduction quality did not correlate with time to operation, was lower in associated than in simple fracture types, and also lower in patients with isolated acetabular fractures than in polytrauma patients. Most importantly, the fracture reduction quality did not improve over time despite a higher frequency of surgical interventions. The Kocher-Langenbeck approach was preferred in the nineties in nearly three quarters of all operative procedures. Currently, the Kocher-Langenbeck and the ilioinguinal approaches are used equally often. The fracture fixation did not change over time and is achieved in 51% with plates in combination with single screws. This multisurgeon series illustrates a nationwide performance in acetabular fracture management. Despite changes in the chosen approaches and an increased surgical frequency, the operative treatment of acetabular fractures of the last 15 years did not lead to an increased reduction quality. Therefore, the rarity and complexity of acetabular fractures demands further specific teaching by experienced acetabular surgeons, scientific research and clinical outcome evaluation.

Biomechanical study of posterior wall acetabular fracture fixation using acetabular tridimensional memory alloy-fixation system

BACKGROUND

We developed the acetabular tridimensional memory alloy-fixation system (ATMFS), which is made of NiTi shape memory alloy, according to the specific mechanical properties of biological memory material, nitinol alloy and measured distribution of contact area and pressure between the acetabulum and the femoral head of cadaveric pelvis.

METHODS

Six formalin-preserved cadaveric pelvis were used for this investigation. Pressure-sensitive film was used to measure contact area and pressure within the anterior, superior, and posterior regions of the acetabulum. The pelvis were loaded under the following four conditions: (1) intact; (2) following a creation posterior wall fracture defect; (3) following reduction and standard internal fixation with reconstruction plate; (4) following reduction and internal fixation with a new shape memory alloy device named ATMFS. A posterior wall fracture was created along an arc of 40-90 degrees about the acetabular rim.

FINDINGS

Creation of a posterior wall defect resulted in increased load in the superior acetabulum (1422N) as compared to the intact condition (762N, P=0.007). Following reduction and internal fixation, the load distributed to the superior acetabulum (1486N) was not statistically different from the defect condition. Following the fixation with ATMFS, the load seen at the superior region of the actabulum (936N) was less than fixation with reconstruction plate and was not different from intact state (P=0.4).

INTERPRETATION

These data indicate that the use of ATMFS as a fracture internal fixation device resulted a partial restoration of joint loading parameters toward the intact state. ATMFS fixation may result in a clinical benefit.

Application of a shape-memory alloy internal fixator for treatment of acetabular fractures with a follow-up of two to nine years in China

Displaced acetabular fractures should be treated surgically. Over the past decade, surgical approaches to the acetabulum and the surgical technique for repair of common fracture patterns have advanced. Excellent outcomes after repair of these injuries can be achieved. The aim of this study was to assess the medium-term results of reconstruction of acetabular fractures by using shape-memory alloy designed by the authors. This is a retrospective review conducted at a level 1 trauma centre. From October 1999 to July 2009, 19 patients with acetabular fractures were treated with our patented Ni-Ti shape-memory alloy acetabular tridimensional memory alloy-fixation system (ATMFS). The ATMFS device was cooled with ice before implantation and then warmed to 40-50°C after implantation to produce balanced axial and compression forces that would stabilise the fracture three dimensionally. Our results are as follows; according to the D'Aubigne-Postel scoring system: Fifteen cases out of 19 (79%) achieved excellent or good clinical results. In two patients, late complications included avascular necrosis of the femoral head (ANFH) associated with posterior dislocation of the hip joint two years after the operation. We also observed two cases of grade II or III ectopic ossification, with good hip function, and one case of traumatic arthritis. In conclusion, these results demonstrate the effectiveness of the ATMFS device for the management of acetabular fracture. The device provides continuous compression of the fracture with minimal disruption to the local blood supply.

Reconstruction of comminuted posterior wall fractures using the buttress technique: a review of 32 fractures

Fractures of the posterior wall are the most common of the acetabular fractures. The aim of this study was to assess the medium-term results of reconstruction of comminuted posterior wall fractures of the acetabulum by using the buttress technique. This is a retrospective review conducted at a level 1 trauma centre. Thirty-two patients (25 men, 7 women, mean age 41 years, range 14-80 years) with comminuted posterior wall fracture of the acetabulum underwent reconstruction of the posterior wall during the period of July 1998 to February 2004. The average follow-up was 43 months (range 24-70 months). Clinical evaluation was based on modified Merle d'Aubigne and Postel scoring. Radiographic evaluation was according to criteria developed by Matta. The postoperative reduction was graded as anatomical in 28 patients (88%) and imperfect in 4 patients (12%). The clinical outcome was excellent in 11 (34% ), very good in 9 (28%), good in 4 (12%), fair in 3 (9%) and poor in 5 (15%). Radiological grading at the final follow-up was excellent 12 (37%), good 11 (34%), fair 4 (12%) and poor 5 (15%). Reconstruction of comminuted posterior wall acetabular fractures by buttress technique can be expected to produce good results. It can provide a stable fixation of the posterior wall amenable to early range of motion and weight bearing.