Abstract Objective To investigate the relationship between the surgical approach of acetabular fracture and fracture typing and surgical indications through the analysis and summary of the results of surgical treatment of acetabular fracture. Methods Fifty-four cases of acetabular fractures were repositioned by selecting surgical approaches according to different types to reconstruct plate and screw internal fixation. Results The quality of postoperative fracture repositioning was assessed by Matta imaging: anatomical repositioning in 31 cases, satisfactory repositioning in 20 cases, and unsatisfactory repositioning in 3 cases; the postoperative clinical score was 83.3% excellent according to the modified Merle d’Aubigne and Postel scoring system. Conclusion Correct determination of the fracture type, selection of the best surgical approach, accurate repositioning, selection of appropriate internal fixation materials, and early surgical internal fixation are reliable methods for the treatment of acetabular fractures. Keywords: acetabular fracture; fracture fixation; treatment outcome Acetabular fracture is a consequence of high-energy trauma, and surgical treatment is mostly adopted for displaced acetabular fractures [1]. From January 2001 to December 2004, the author performed 54 cases of acetabular fracture surgery with satisfactory results, which are reported as follows. 1. Clinical data 1.1 General data Among the 54 cases, 42 were male and 12 were female; age ranged from 24 to 55 years old, with an average of 36 years old; among them, 30 cases were left-sided and 24 cases were right-sided. Causes of injury: traffic accident injury in 36 cases, fall from height injury in 15 cases, heavy object crushing injury in 3 cases. According to Letournel and Judet, there were 8 cases of posterior wall fracture, 3 cases of posterior column fracture, 2 cases of anterior wall fracture, 4 cases of anterior column fracture, 6 cases of transverse fracture, 9 cases of transverse with posterior wall fracture, 5 cases of posterior column with posterior wall fracture, 2 cases of T-shaped fracture, 2 cases of anterior with posterior semi-transverse fracture, and 13 cases of double column fracture. The fractures were displaced by 10 to 45 mm. 1.2 Surgical treatment After admission, the whole body physical examination was performed and other important organ combined injuries were treated. After stabilization, anteroposterior, closed-hole oblique and oblique iliac radiographs and CT examinations of the injured hip were performed, and some patients needed CT 3D reconstruction to clarify the fracture classification and displacement. If the hip joint was dislocated, closed reduction was performed. Bone traction was routinely performed in all cases, and bedside radiographs were taken 3-5 days later to observe the femoral head and fracture reduction. The time of surgery in this group ranged from 24 h to 18 d after injury, with an average of 7.2 d. The relationship between the choice of surgical access and the type of fracture is shown in Table 1. the fracture was fully exposed, the fracture mass was examined, and special instruments were used for the repositioning. For complex fractures, each step was done as anatomically as possible to ensure an anatomical repositioning of the overall fracture. The fracture is fixed using an accurately plasticized titanium reconstruction plate, and the fracture fragments can be fixed with titanium screws. After surgery, the wound was drained by negative pressure for 24-48 h. After 2 weeks, passive extension and flexion of the hip joint was exercised, and after 4 weeks, walking without weight-bearing with the help of crutches, and after 8-12 weeks, walking with weight-bearing gradually. 2, Results The quality of fracture repositioning was evaluated according to Matta imaging [2]: 31 cases of anatomical repositioning (Figure 1, 2), 20 cases of satisfactory repositioning, and 3 cases of unsatisfactory repositioning. There was no loosening of internal fixation or fracture displacement at a mean follow-up of 18 months. The postoperative clinical score was based on the modified Merle d’ Aubigne and Postel scoring system. 33 cases were excellent, 12 cases were good, 7 cases were average and 2 cases were poor, with an excellent rate of 83.3%. 3. Discussion 3.1 Fracture staging and surgical approach selection The Letournel and Judet staging was chosen because it is simple and clear, and includes almost all types of acetabular fractures, which is important for developing treatment plans and assessing prognosis, and has an important guiding role for surgical approach and surgical methods, and most of the acetabular fractures can be completed by one approach. The surgical approach plays a key role in the treatment outcome. Mayo et al[3] reported 110 cases of acetabular fractures, of which 10 cases were poorly repositioned due to improper incision selection. In our group, six types of fracture approaches were relatively fixed, namely, posterior wall fractures, posterior column fractures, and posterior column with posterior wall fractures usually used the K-L approach; anterior wall fractures, anterior column fractures, and anterior with posterior hemi-transverse fractures usually used the ilioinguinal approach; because the modified T-shaped iliofemoral approach must be performed with lateral iliac gluteal muscle stripping and osteotomy of the greater trochanter, it easily leads to muscle weakness, heterotopic ossification, joint ankylosis, and flap Therefore, most scholars advocate a combined anterior-posterior approach to treat acetabular fractures that require anterior-posterior exposure [4]. No single incision can reveal the entire fracture, and the author believes that the choice of incision depends on the type of fracture, the operator’s habits, and familiarity with the approach. 3.2 Indications for acetabular fracture and timing of surgery The following are the indications for acetabular fracture [5]: ① fracture displacement ≥3 mm; ② combined femoral head dislocation or subluxation; ③ free fragmented bone pieces in the joint cavity; ④ posterior wall fracture pieces accounting for more than 40% of the entire posterior wall; ⑤ displaced fracture involving the apex of the socket (Matta apex arc angle criteria); ⑥ no osteoporosis. The author believes that it is best to postpone surgery until 2-3d after the injury, when local bleeding has stopped and the patient’s condition has stabilized. The formation of bone scabs 3 weeks after the injury makes the repositioning more difficult. The ideal operation time should be 4-7d after the injury, generally not more than 2 weeks. All 54 cases in this group were operated within 3 weeks after the injury. In patients with combined injuries of other important organs, the operation time of acetabular fracture should be delayed appropriately by first resuscitating the life-threatening combined injuries, but should not exceed 3 weeks. 3.3 Reset and internal fixation of acetabular fracture Traction is the most basic reset method. Preoperative supracondylar femoral traction is used, and greater trochanteric traction is added for combined femoral head central dislocation. The quality of intraoperative fracture repositioning depends on adequate exposure, specialized acetabular-pelvic repositioning instruments, and the sequence of repositioning and fixation. Therefore, the correct surgical approach should be chosen according to the type of fracture, adequate repositioning instruments should be prepared and the sequence of repositioning and fixation should be well planned. For example, if a double column fracture is combined with a central dislocation of the femoral head and a sacroiliac joint dislocation, the sacroiliac joint should be repositioned and fixed first, then the dislocation of the femoral head should be corrected, and finally the anterior column and posterior column should be repositioned and fixed in turn; for a posterior column with a posterior wall fracture, the posterior column should be repositioned and fixed first, and then the posterior wall should be repositioned and fixed; for a transverse or transverse shape with a posterior wall fracture, when the fracture on one side (anterior or posterior) is severely crushed, the internal fixation should be performed first from the non-crushed or crushed The internal fixation should be performed on the non-comminuted or non-severe side. The titanium pelvic reconstruction plate should be used for internal fixation, and attention should be paid to the direction of nail entry when drilling to avoid penetration into the joint. For some fractures that are not easily fixed with steel plates, tension screws can be used. After completion of internal fixation, X-ray must be performed before wound closure to understand the quality of repositioning and internal fixation, which is the last chance to further improve the effect of repositioning and fixation.