title: Rationale for more consistent choice of surgical approaches for acetabular fractures.
abstract: OBJECTIVE
  All acetabular fractures are difficult to treat surgically, but there are four types involving two columns that are particularly challenging. The choice of surgical approach is crucial. The purpose of the study was to determine and evaluate the factors influencing the choice of surgical approach for two-column acetabular fractures. We hypothesised that more accurate preoperative planning, sophisticated technical capabilities, and evolution of surgeon experience will result in more consistent use of non-extensile single surgical approaches. We also evaluated the outcomes of surgical treatment and the correlation with the surgical approach used.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  A total of 156 patients with 157 acetabular fractures involving two columns (Letournel T-types and both-column) treated surgically in a 25-year period (1988-2013) were included in the study. The acetabular fractures in this study were divided into two groups according to the date of surgery: 81 in Group 1 (1998-2002) and 76 in Group 2 (2003-2013). All fractures were classified preoperatively according to the Judet and Letournel classification system and Matta's categorisation of surgical approach. Four surgical approaches were used: single Kocher-Langenbeck (KL), single ilioinguinal (II), combined Kocher-Langenbeck and ilioinguinal (KL+II), and extended iliofemoral (EIF). The efficacy of the surgical approach utilised was assessed using three parameters: anatomical reduction, surgical time and intraoperative complications.
  
  
  RESULTS
  There was no statistical difference between Group 1 and Group 2 in the distribution of T-type (p=0.424) and both-column (p=0.425) fractures. In Group 2 more acetabular fractures were treated through single non-extensile approaches compared with Group 1 (90.8% vs. 54.3%, p<0.001). Increase in single approach surgery resulted in shorter mean surgical time (p<0.001) and significant increase in anatomical reduction (p=0.039). The frequency of intraoperative complications was not statistically different (p=0.07) between the two groups, but there was a trend to fewer complications in Group 2.
  
  
  CONCLUSIONS
  The surgical approaches chosen for acetabular fractures that involve two columns (Letournel T-types and both-column) should become more consistent. The results of this study indicate that the majority of such acetabular fractures can be treated successfully through single surgical approaches.
authors.affiliation: Department of Traumatology and Orthopaedics, Pula County Hospital, Pula, Croatia. Electronic address: nadomir.gusic@pu.t-com.hr.
authors.forename: N
authors.initials: N
authors.lastname: Gusic
authors.affiliation: Clinic of Traumatology, Clinical Hospital Centre "Sestre milosrdnice", Zagreb, Croatia.
authors.forename: S
authors.initials: S
authors.lastname: Sabalic
authors.affiliation: Department of Traumatology, Clinical Hospital Centre Split, Split, Croatia.
authors.forename: A
authors.initials: A
authors.lastname: Pavic
authors.affiliation: Department of Orthopaedic Surgery, University Hospital Sveti Duh, Zagreb, Croatia.
authors.forename: A
authors.initials: A
authors.lastname: Ivkovic
authors.affiliation: Department of Anaesthesiology, Reanimatology and Intensive Care, Clinical Hospital Centre Rijeka, Rijeka, Croatia.
authors.forename: V
authors.initials: V
authors.lastname: Sotosek-Tokmadzic
authors.affiliation: Department of Traumatology, Clinical Hospital Centre Rijeka, Rijeka, Croatia.
authors.forename: T
authors.initials: T
authors.lastname: Cicvaric
mesh_terms: D000077:Acetabulum / Q000000981:diagnostic imaging / Q000293:injuries / Q000601:surgery*; D000465:Algorithms; D016063:Blood Loss, Surgical / Q000517:prevention & control; D017523:Croatia / Q000453:epidemiology; D005260:Female; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D006620:Hip Fractures / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control*; D008297:Male; D061646:Operative Time; D017410:Practice Guidelines as Topic; D011300:Preoperative Care; D012189:Retrospective Studies; D013997:Time Factors; D014057:Tomography, X-Ray Computed
keywords: Acetabular fractures; Both-column fracture; Surgical approaches; Surgical treatment; T-type fractures; Treatment algorithms