A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five ‘windows’ for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called ‘Pararectus’ approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8 mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues.

In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.

Acetabular retroversion is a well-documented cause of femoro-acetabular impingement (FAI). There are few reports of long-term outcomes following correction of retroversion. We hypothesized that correction of acetabular retroversion with peri-acetabular osteotomy (PAO) in young adults with symptomatic FAI can lead to symptomatic relief, improvement of function and thus potentially delay the progression of osteoarthritis.

Twenty-two patients (29 hips) underwent Bernese PAO for treatment of symptomatic FAI with acetabular retroversion between April 1997 and August 1999. Mean age at surgery was 23 years (14–41). Mean duration of symptoms was 17 months (6–24). All pre-operative radiographs demonstrated Tönnis grade 0 of degenerative changes. Mean follow up was 127 months (109–142). Clinical, functional and radiographic outcomes are presented.

The overall mean Merle d’Aubigné score improved from 14.0 points (12–16) pre-operatively to 16.3 points (14 to 18) at the time of last follow-up. There were three reoperations due to loss of correction, posterior impingement and cam impingement. There were no major vascular or neurologic complications and none related to non- healing of the osteotomies. All patients had symptomatic relief at final follow-up. Range of motion and functional scores improved in all cases (even in those with repeat procedures). The vast majority of patients continued to demonstrate no signs of osteoarthritis (Tönnis greade 0) at final follow-up.

Acetabular retroversion is a mechanical factor that can lead to FAI. In symptomatic cases, PAO is a safe and reliable method for correction of the retroversion and can relief symptoms, improve function and prevent rapid progression of osteoarthritis.

Traumatic posterior dislocation of the hip associated with a fracture of the posterior acetabular wall and of the neck of the femur is a rare injury. A 29-year-old man presented at a level 1 trauma centre with a locked posterior dislocation of the right hip, with fractures of the femoral neck and the posterior wall of the acetabulum after a bicycle accident. An attempted closed reduction had failed. This case report describes in detail the surgical management and the clinical and radiological outcome. Open reduction and fixation with preservation of the intact retinaculum was undertaken within five hours of injury with surgical dislocation of the hip and a trochanteric osteotomy. Two years after operation the function of the injured hip was good. Plain radiographs and MR scans showed early signs of osteoarthritis with some loss of joint space but no evidence of avascular necrosis. The patient had begun skiing and hiking again.

The combination of fractures of the neck of the femur and of the posterior wall of the acetabulum hampers closed reduction of a posterior dislocation of the hip. Surgical dislocation of the hip with trochanteric flip osteotomy allows controlled open reduction of the fractures, with inspection of the hip joint and preservation of the vascular supply.