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C OPYRIGHT Ó 2018 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

There Is No Column: A New Classification for

Acetabular Fractures
Amir Herman, MD, PhD, Shay Tenenbaum, MD, Vladislav Ougortsin, MD, and Nachshon Shazar, MD

Investigation performed at Sheba Medical Center, Tel HaShomer, Israel

Background: The surgical treatment of acetabular fractures relies on the understanding of fracture architecture and their
classification. The Judet and Letournel classification has been the cornerstone in understanding and treating acetabular
fractures. Recently, there has been growing evidence of discrepancies and incompleteness in the Judet and Letournel
classification, adversely affecting its clinical use. This study describes a novel comprehensive classification system that
will direct surgical approach and fixation methods.
Methods: A retrospective study of patients with acetabular fractures treated at a level-I trauma center also serving as a
referral center for acetabular fractures was performed. Fractures were classified according to both the novel and Judet and
Letournel classification systems. The novel classification developed integrates the displacement vector (posterior, su-
peromedial, or combined) and the fractured anatomic structures (anteroposterior wall, pelvic brim, iliac wing, quadrilateral
plate, and ischium). Furthermore, postoperative malreduction was evaluated on the basis of intra-articular gap mea-
surements in either anteroposterior or Judet oblique views.
Results: The study included 229 patients with acetabular fractures treated between 2007 and 2016. The mean patient
age (and standard deviation) was 46.7 ± 21.75 years, and 172 patients (75.1%) were surgically treated. According to the
novel classification system, the posterior displacement vector group included 60 patients, the superomedial displace-
ment vector group included 130 patients, the combined displacement vector group included 36 patients, and 3 patients
were unclassified by the new system. Forty-six patients (20.1%) could not be classified by the Judet and Letournel
classification. Pelvic-brim fracture patterns were described as along the pelvic brim, across the pelvic brim, or commi-
nuted. The quadrilateral plate primary fracture line was shown to be perpendicular to the pelvic brim. The selection of
surgical approach and fixation methods depends on the fracture type.
Conclusions: This study presents a novel classification system for acetabular fractures. It offers a complete classification
system, encompassing nearly all fracture patterns. As the selection of surgical approach and fixation methods depends on
fracture classification and understanding, the novel classification system can aid the surgeon with decision-making.

A
cetabular fractures are among the most challenging
fractures encountered by orthopaedic surgeons. De-
cades ago, Judet and Letournel1,2 published their
groundbreaking ideas with regard to fracture classification. At
the core of their classification system is the concept of the
columnar structure of the acetabulum.
The acetabulum is supported by anterior and posterior
columns, which further define the anterior and posterior walls
as respective rims. Judet and Letournel regarded a column
fracture as a complete fracture and a wall fracture as an in-
complete fracture.
The Judet and Letournel classification divides acetabular
fractures into 2 groups: elementary (simple) and associated
(complex). The elementary fracture group includes anterior
and posterior wall fractures, anterior and posterior column
fractures, and transverse fractures. The transverse fracture is
not a simple fracture, but it was included in the elementary
fracture group because of its relatively simple geometric shape.
The associated acetabular fracture group includes both-
column fractures, anterior column posterior hemitransverse
fractures, T-type fractures, and transverse or posterior column
with posterior wall fractures. Although all of the first 4 asso-
ciated fractures involve both the anterior and posterior col-
umns, the both-column fracture pattern is reserved only for
fractures leading to discontinuity between the sacroiliac joint
and the acetabular joint.

Disclosure: There was no external funding used for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version
of the article (http://links.lww.com/JBJS/E525).

J Bone Joint Surg Am. 2018;100:e8(1-10) d http://dx.doi.org/10.2106/JBJS.17.00600

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TABLE I Fracture Pattern Definition and Classification*

Judet and Letournel

Fracture Definition Patients† Classification‡

Posterior displacement vector group 60 (26.2%)

1. Isolated posterior wall 29 (12.7%) Posterior wall
2. Posterior wall, ischium, and quadrilateral 29 (12.7%) (1) Posterior wall and posterior column;
plate if quadrilateral plate is displaced <2 mm (2) transverse and posterior wall, both if
quadrilateral plate is <2 mm
3. Ischium, with or without quadrilateral plate, 2 (0.9%) Posterior column
without posterior wall
Superomedial displacement vector group 130 (56.8%)
1. Iliac wing, pelvic brim, and quadrilateral 70 (30.6%) (1) Both columns; (2) anterior column
plate, with or without ischium posterior hemitransverse
2. Pelvic brim and quadrilateral plate, with or 44 (19.2%) (1) Transverse; (2) T-type
without ischium; does not include the iliac wing
3. Pelvic brim and iliac wing 16 (7.0%) Anterior column
Combined displacement vector group 36 (15.7%)
1. Superomedial type 1 and posterior wall 18 (7.9%) (1) Both columns and posterior wall;
(2) anterior column posterior hemitransverse
and posterior wall
2. Superomedial type 2 and posterior wall 18 (7.9%) (1) T-type and posterior wall;
(quadrilateral plate is displaced ‡2 mm) (2) transverse and posterior wall
if quadrilateral plate is displaced ‡2 mm

*Three patients (1.3%) had an anterior wall fracture that was not included in the classification. †The values are given as the number of patients,
with the percentage in parentheses. ‡The Judet and Letournel classification is included according to the subtypes of the new classification for
comparison.

TABLE II New Fracture Classification According to the Specific Anatomic Structures*

Pelvic Iliac Posterior Anterior

Fracture Definition Brim Wing Quadrilateral Plate Ischium Wall Wall

Posterior displacement vector <2-mm displacement Mostly

(>90%)
Subtype 1: Posterior wall only No No No No Yes No
Subtype 2: Posterior wall, ischium, Maybe No <2-mm displacement Yes Yes No
and <2-mm displaced quadrilateral plate
Subtype 3: Ischium, without posterior wall No No <2-mm displacement Yes No No
Superomedial displacement vector Always Always Never
Subtype 1: Quadrilateral plate, pelvic brim, Yes Yes Yes Maybe No Maybe
and iliac wing, with or without the ischium
Subtype 2: Quadrilateral plate and pelvic Yes No Yes Maybe No Maybe
brim, with or without the ischium
Subtype 3: Pelvic brim and iliac wing Yes Yes No No No Maybe
Combined displacement vector Yes ‡2-mm displacement Always
Subtype 1: Superomedial type 1 and Yes Yes Yes Maybe Yes Maybe
posterior wall
Subtype 2: Superomedial type 2 and Maybe No Yes Maybe Yes Maybe
posterior wall (quadrilateral plate
is displaced ‡2 mm)

*Maybe indicates that a fracture of the specific anatomic structure may or may not be included.
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TABLE III Fractures Not Classified in the Judet and Letournel Classification
Fracture Description
Both columns and posterior wall
Anterior column posterior hemitransverse and
posterior wall
T-type and posterior wall
Anterior column and quadrilateral plate
Anterior column and anterior wall
Total
*The values are given as the number of patients, with the percentage in parentheses. †The distinction between superomedial displacement
vector subtypes 1 and 2 depends on whether the iliac crest is broken (subtype 1) or not (subtype 2).
The successful reduction of acetabular fractures has been
shown to directly relate to clinical outcome scores and the risk of
hip arthroplasty3-6. Correct understanding of fracture architecture
is cardinal to proper classification. The fracture type dictates the
treatment options, from choosing the appropriate surgical ap-
proach to reduction techniques and fixation methods.
The Judet and Letournel classification has received much
criticism over the years. It is cumbersome and complex, re-
sulting in interobserver agreement of 0.5 to 0.77-12.
Hutt et al. reported that 45% of the studied fractures in
their cohort were unclassifiable by >1 researcher13.
In this study, a novel classification system for ace-
tabular fractures is presented. This classification system is
based on the combination between the displacement vector
of the fractures and the specific fracture architectural
structures. The new classification was devised with the cli-
nician in mind, to aid with fracture understanding and
decision-making with regard to surgical approach and fix-
ation strategies.
Materials and Methods
Study Design
A retrospective study in a level-I trauma center that also
serves as a referral center for acetabular fractures was
performed. Following approval by the institutional review
board, records were reviewed for adult patients (‡18 years of
age) with acetabular fractures between 2007 and 2016. The
clinical charts and radiographic studies (radiographs and
computed tomography [CT] images) were reviewed.
Data Collected
Demographic characteristics, clinical data (age at the time of
injury, sex, injury side), and treatment type (conservative or
surgical) were recorded.
In surgically treated patients, the surgical approach and
fixation methods used were recorded on the basis of reviews of
clinical charts and radiographic studies.
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New Classification Patients*
Combined type 1 11 (23.9%)
Combined type 1 8 (17.4%)
Combined type 2 8 (17.4%)
Superomedial displacement vector, 18 (39.1%)
types 1 or 2†
Superomedial displacement vector, 1 (2.2%)
type 3
46 (100%)
The preoperative radiographic and CT scans were
reviewed by 3 orthopaedic trauma surgeons dedicated to
acetabular surgical procedures. Fractures were classified
according to both the novel and the Judet and Letournel
classification systems. In cases of disagreement about a
fracture’s classification, consensus was reached by a joint
discussion.
Postoperative malreduction was assessed by measuring
the maximal gap of the acetabular articular surface in either the
anteroposterior radiographic view or the Judet oblique radio-
graph view. Digital calibrations of the images were done on the
basis of the screw’s diameter. The articular gap measurements
were then graded according to Matta3 as anatomic reduction
(up to 1 mm), imperfect reduction (2 to 3 mm), and poor
reduction (>3 mm).
Novel Classification System
This classification system is based on the combination between
3 possible displacement vectors of the fracture and 6 possible
broken anatomic structures.
The anatomic structures include the iliac wing, pelvic
brim, quadrilateral plate, ischium, posterior wall, and ante-
rior wall. The fractures were divided into 3 groups according
to the direction of the displacement vector. These were the
posterior displacement vector group, the superomedial dis-
placement vector group, and the combined displacement
vector group.
The first fracture group is the posterior displacement
vector group. This group includes subtype 1, which is a fracture
only of the posterior wall; subtype 2, which is a fracture of the
posterior wall and the ischium, with or without the quadri-
lateral plate and with or without the pelvic brim, only if the
quadrilateral plate was medially displaced <2 mm; and subtype
3, which is a fracture of the ischium and the quadrilateral plate
without the posterior wall (formerly a posterior column frac-
ture). Note that fracture subtype 2 includes the posterior wall
and the posterior column and some posterior wall and
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Fig. 1-A Fig. 1-B

Figs. 1-A, 1-B, and 1-C A both-column fracture, superomedial

displacement vector subtype 1. Fig. 1-A The fracture starts
from the iliac wing and descends along the pelvic brim. Fig. 1-
B The angle between the pelvic brim and the quadrilateral
plate fracture is marked as alpha. Fig. 1-C The fracture in the
posterior column causes discontinuity between the acetab-
ular joint and the sacroiliac joint (red arrow).

Fig. 1-C
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Fig. 2-A Fig. 2-B

Figs. 2-A, 2-B, and 2-C An anterior column posterior hemi-

transverse fracture, superomedial displacement vector
subtype 1. Fig. 2-A The fracture starts from the iliac wing and
descends along the pelvic brim. Fig. 2-B The fracture does
not cause discontinuity between the acetabular joint and the
sacroiliac joint. The fracture pattern is similar to that of the
both-column fracture shown in Figure 1. Fig. 2-C The quad-
rilateral plate is broken perpendicular to the pelvic brim.

Fig. 2-C
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Fig. 3-A
Figs. 3-A and 3-B A transverse fracture, superomedial displacement vector subtype 2. Fig. 3-A The fracture line in the quadrilateral plate is perpendicular to
the pelvic brim. Fig. 3-B The fracture in the pelvic brim crosses through the brim.
transverse fractures, only if the quadrilateral plate is displaced
<2 mm.
Superomedial displacement vector group fractures are
fractures in which the main displacement vector is super-
omedial. The hallmark of this fracture group is the medial
displacement of the quadrilateral plate. Subtype 1 includes the
iliac wing, pelvic brim, and quadrilateral plate, with or without
the ischium. It includes associated both-column fractures,
anterior column posterior hemitransverse fractures, and an-
terior column with quadrilateral plate fractures when the is-
chium is not broken. Subtype 2 includes the quadrilateral plate
and the pelvic brim, with or without the ischium, not including
the iliac wing. It includes transverse and T-type fractures.
Subtype 3 includes fractures that start from the iliac wing and
descend along the pelvic brim. This subtype does not include
the quadrilateral plate. Subtype 3 here is equivalent to anterior
column fracture.
The combined displacement vector group includes
fractures in which combined force vectors were applied, re-
sulting in substantial superomedial (quadrilateral plate) dis-
placement and posterior wall fractures. In this group, subtype
1 involves superomedial displacement vector subtype 1 and
subtype 2 involves superomedial displacement vector subtype
2, both with posterior wall fracture.
Pure anterior wall fractures were not included because of
their rare occurrence and to allow symmetry and coherence in
the classification.
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Fig. 3-B
Statistical Analysis
Statistical analysis was performed by an experienced biostatis-
tician using SPSS version 23 (IBM). Continuous variables were
reported as the mean and the standard deviation. Categorical
variables were reported as counts and frequencies. Comparisons
between continuous variables were done using the Wilcoxon-
Mann-Whitney rank-sum test. Comparisons between categori-
cal variables were done using the chi-square or the Fisher exact
test. The latter was used if cell counts were <5. All p values
reported are two-sided. Significance was set at p < 0.05.
Results
Patients
he study included 229 patients with a mean age of 46.7 ±
T 21.75 years. Of these, 169 (73.8%) were men and 60
(26.2%) were women. The fracture was on the left side in 108
patients (47.2%) and the right side in 121 patients (52.8%).
Fracture Types
In this study cohort, the posterior displacement vector group
included 60 fractures (26.2%), the superomedial displacement
vector group included 130 fractures (56.8%), and the combined
displacement vector group included 36 fractures (15.7%) (Tables
I and II). Three fractures were unclassified by the new system.
There were 46 patients (20.1%) with a fracture that
could not be classified according to the Judet and Letournel
classification. These included mostly anterior column and
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Fig. 4-A Fig. 4-B

Figs. 4-A and 4-B A T-type fracture with posterior wall fracture, combined displacement vector subtype 2. This fracture is not included in the Judet and Letournel
classification. Fig. 4-A The primary fracture line through the quadrilateral plate is perpendicular to the pelvic brim. The fracture of the pelvic brim is across the
brim. Fig. 4-B The posterior wall fracture. The fracture was approached with both anterior intrapelvic and Kocher-Langenbeck surgical approaches.

quadrilateral plate fractures. Other major subtypes that could
not be included in the Judet and Letournel classification are the
associated both-column, anterior column posterior hemi-
transverse, or T-type with posterior wall fragment fractures.
Table III summarizes the nonclassifiable fractures according to
the Judet and Letournel system.
Quadrilateral and Pelvic-Brim Fracture Patterns
We suggest considering the pelvic brim as the main axis of
the pelvis. There are 3 distinct fracture patterns: fractures
along the pelvic brim (Figs. 1 and 2), those across the pelvic
brim (Figs. 3 and 4), and comminuted pelvic brim fractures.
Fractures along the pelvic brim were found in 90.0% of the
superomedial displacement vector group subtype 1 fracture
type and in 87.5% of the superomedial displacement vector
group subtype 3 fracture type. Fractures across the pelvic
brim were found in 52.3% of the superomedial vector group
subtype 2 and in 55.6% of the combined displacement
vector group subtype 2. Comminution of the pelvic brim
was found in 50.0% of the combined displacement vector

TABLE IV Pelvic-Brim Fracture Patterns*

Displacement Vector Group Along the Pelvic Brim† Across the Pelvic Brim† Comminuted Pelvic Brim†

Posterior type 2 0 (0%) 5 (100%) 0 (0%)

Superomedial type 1 63 (90.0%) 6 (8.6%) 1 (1.4%)
Superomedial type 2 13 (29.5%) 23 (52.3%) 8 (18.2%)
Superomedial type 3 14 (87.5%) 2 (12.5%) 0 (0%)
Combined type 1 8 (44.4%) 1 (5.6%) 9 (50.0%)
Combined type 2 3 (16.7%) 10 (55.6%) 5 (27.8%)

*Significantly different at p = 0.001. †The values are given as the number of patients, with the row percentage in parentheses.
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TABLE V Surgical Data According to the New Classification*

Posterior Superomedial Combined

Nonclassifiable Type 1 Type 2 Type 1 Type 2 Type 3 Type 1 Type 2

Operative Treatment (N = 172) (N = 3) (N = 25) (N = 26) (N = 48) (N = 32) (N = 6) (N = 14) (N = 18)

Surgical approaches†
Anterior intrapelvic 45 (93.8%) 24 (75.0%) 4 (66.7%) 11 (78.6%) 6 (33.3%)
approach and lateral
window
Ilioinguinal 3 (6.3%) 1 (7.1%)
Kocher-Langenbeck 25 (100%) 26 (100%) 5 (15.6%) 6 (33.3%)
Extended iliofemoral 1 (7.1%) 2 (11.1%)
Kocher-Langenbeck 1 (7.1%) 4 (22.2%)
and anterior intrapelvic
approach
Percutaneous with or 3 (9.4%) 2 (33.3%)
without lateral window
Smith-Petersen 3 (100%)

Fixation devices used

Pelvic-brim (anterior 6 (23.1%) 2 (4.2%) 7 (21.9%) 2 (33.3%) 2 (14.3%) 11 (61.1%)
column) screw
Pelvic-brim (anterior 1 (33.3%) 42 (87.5%) 19 (59.4%) 2 (33.3%) 11 (78.6%) 6 (33.3%)
column) plate
Quadrilateral buttress 43 (89.6%) 23 (71.9%) 13 (92.9%) 4 (22.2%)
plate
Ischial (posterior 2 (7.7%) 29 (60.4%) 16 (50.0%) 2 (33.3%) 6 (42.9%) 5 (27.8%)
column) screw
Ischial (posterior 11 (42.3%) 4 (12.5%) 1 (7.1%) 8 (44.4%)
column) plate
Posterior-wall plate 25 (100%) 25 (96.2%) 1 (7.1%) 10 (55.6%)
Anterior inferior iliac 12 (25.0%) 2 (33.3%) 1 (7.1%)
spine screw
Iliac wing screw 1 (33.3%) 21 (43.8%) 1 (3.1%) 4 (66.7%) 7 (50.0%) 2 (11.1%)
Iliac wing plate 1 (33.3%) 19 (39.6%) 1 (3.1%) 2 (33.3%) 5 (35.7%) 2 (11.1%)
Interfragmentary screw 3 (11.5%) 11 (22.9%) 7 (21.9%) 5 (35.7%) 6 (33.3%)
Reduction‡
Anatomic (£1 mm) 3 (100%) 23 (92.0%) 24 (92.3%) 40 (83.3%) 22 (68.8%) 5 (83.3%) 6 (42.9%) 12 (66.7%)
Imperfect (2 to 3 mm) 0 (0%) 1 (4.0%) 1 (3.8%) 4 (8.3%) 8 (25.0%) 1 (16.7%) 5 (35.7%) 3 (16.7%)
Poor (>3 mm) 0 (0%) 1 (4.0%) 1 (3.8%) 4 (8.3%) 2 (6.3%) 0 (0%) 3 (21.4%) 3 (16.7%)

*The values are given as the number of patients, with the percentage in parentheses. †Significantly different at p < 0.001. ‡Significantly different at p = 0.039.

group subtype 1 fractures (Table IV). These differences in
the pelvic-brim fracture pattern were found to be significant
(p < 0.001).
The quadrilateral plate has a distinct facture pattern as
well; the fracture is perpendicular to the pelvic brim (Figs.
1 through 4). The mean angle between the quadrilateral plate
fracture and the pelvic brim was 88.84° ± 20.12°.
Surgical Approaches, Fixation Methods, and Reduction
Results
Of the presented cohort, 172 fractures (75.1%) were surgi-
cally reduced and fixed. The surgical approaches and fixation
methods used were found to be closely related to the afore-
mentioned classification (Table V). In the posterior dis-
placement vector group (44 patients), all patients underwent
surgical procedures that used the Kocher-Langenbeck ap-
proach. In the superomedial displacement vector group
(76 patients), the predominant surgical approach was ante-
rior intrapelvic with a lateral window in 63 patients (82.9%).
In the combined displacement vector group (32 patients),
the anterior intrapelvic approach was used in 17 patients
(53.1%), the Kocher-Langenbeck approach was used in 6
patients (18.8%), both anterior intrapelvic and Kocher-
Langenbeck approaches were used in 5 patients (15.6%), the
extended iliofemoral surgical approach was used in 3 patients
(9.4%), and the ilioinguinal surgical approach was used in
1 patient (3.1%).
A summary of fixation devices used is presented in Table
V. In each fracture type, either screw or plate fixation was used
for each pelvic osseous structure.
In the patients who underwent operative treatment,
anatomic reductions (£1 mm) were achieved in 135 patients
(78.5%), imperfect reductions (2 to 3 mm) were achieved in
23 patients (13.4%), and poor reductions (>3 mm) were
achieved in 14 patients (8.1%). In 3 patients, the reduction
quality could not be assessed. When the quadrilateral plate
was medially displaced ‡2 mm, the use of a quadrilateral plate
buttress plate was associated with better reduction, and the
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mean reduction gap was 0.914 ± 1.39 mm compared with
2.17 ± 3.51 mm with and without the use of the quadrilateral
plate buttress plate (p = 0.029). The surgical technique in-
volving the infrapectineal quadrilateral plate buttress plate is
presented in the Appendix.
Discussion
I n this study, a novel classification for acetabular fractures
is presented. The classification has 2 steps: first, identify
the primary displacement vector; and second, according to
the displacement vector, identify the anatomic structures
that are fractured. In this classification, the fractures are first
divided into 3 main groups according to the direction of the
displacement vector: the posterior displacement vector
group (subtypes 1, 2, and 3), the superomedial displace-
ment vector group (subtypes 1, 2, and 3), and the combined
displacement vector group (subtypes 1 and 2). Each group
has a hallmark feature that is most important. In the pos-
terior displacement vector group, it is the posterior wall
fracture; in the superomedial displacement vector group, it
is the medially displaced quadrilateral plate and superiorly
displaced pelvic-brim fractures; and in the combined dis-
placement vector group, it is a combination of a posterior
wall fracture and a medially displaced quadrilateral plate
fracture.
The classification continues the work of Tile, and the
posterior displacement vector group can be viewed as in-
cluding fracture types a3,b3, and the superomedial dis-
placement vector group can be viewed as including fracture
types a2,b2. However, Tile’s classification continues to
describe the acetabulum of the femoral-head chondral le-
sion or marginal impaction as part of the basic classifica-
tion14; these are factors not included in the classification
proposed here.
In the suggested classification, the fracture groups are
then further divided into subcategories. In the posterior dis-
placement vector group, subtypes are based on whether there is
an ischial fracture (posterior column or transverse fracture). In
a superomedial displacement vector group fracture, the sub-
types are determined according to whether the fracture pattern
starts from the iliac wing and goes down along the pelvic brim,
meeting the quadrilateral plate fracture in the acetabulum
(subtype 1), or, alternatively, if the fracture is through the pelvic
brim, continuing the quadrilateral plate fracture line (subtype
2). The combined displacement vector group includes fracture
subtypes similar to the superomedial group (subtypes 1 and 2)
with an additional posterior wall fracture.
The novel classification system offers a more com-
prehensive approach to acetabular fractures, as it suggests
the surgical approach and/or fixation methods to be used. In
the posterior displacement vector group, the surgical ap-
proach should be Kocher-Langenbeck and fixation to the
posterior wall must be included. For the superomedial dis-
placement vector group and the combined displacement
vector superomedial fracture group, the anterior intrapelvic
approach should be used because it allows better reduction
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of the medial displacement, with a buttress plate on the
quadrilateral plate to reduce and fix the medial displace-
ment. We have shown that using a quadrilateral plate but-
tress plate leads to better reduction. The infrapectineal
buttress plate is placed parallel to the pelvic brim. It is suc-
cessful in reducing the medial displacement of the quadri-
lateral plate fracture because the fracture is perpendicular to
the pelvic brim15-20. Other well-established techniques are
also available for quadrilateral plate buttressing16. This is
especially important in subtype 2 of either the superomedial
group or combined group fractures (transverse and T-type
with or without posterior wall fractures), in which Matta
indicated that he usually uses the Kocher-Langenbeck pos-
terior surgical approach3.
Furthermore, the novel classification system is more
complete and inclusive compared with the traditional Judet
and Letournel classification. Hutt et al. reported the exam-
ination of 100 images of acetabular fractures by several
orthopaedic surgeons dedicated to acetabular fractures
treatment13. In their initial assessment, 46% of acetabular
fractures were thought to be unclassifiable by >1 surgeon.
There was moderate agreement on which these were (kappa =
0.42). Authors reported that the unclassifiable fractures were
65% anterior column and quadrilateral plate fractures, 26%
incomplete fracture lines, and 9% fractures with extensive
comminution.
In the current study, one-fifth (20%) of fractures were
deemed nonclassifiable by the Judet and Letournel classifica-
tion. For example, the important both-column, anterior col-
umn posterior hemitransverse, or T-type with posterior wall
fractures are not included in the traditional classification.
Our proposed classification does not represent a mere
change of semantics; the new classification not only represents
a terminology change but also reflects a change in the thought
process with regard to acetabular fractures. That is, language is
not only a communication method; it is thought itself. The
primary displacement vector might offer better understanding
and surgical decision-making. For example, a failure to ac-
knowledge that a both-column fracture has a posterior wall
component, making it a combined displacement vector frac-
ture, might lead to suboptimal reduction and might adversely
affect its outcome. For the latter fractures, we suggest using a
dual surgical approach, anterior intrapelvic for reduction of the
superomedial displacement and Kocher-Langenbeck for re-
duction and fixation of the posterior wall. It is interesting to
note that even Judet and Letournel, in their book, acknowl-
edged that 15.5% of the both-column fractures have a
posterior-wall component20. Because this modification would
require different management, we believe that it needs to be
included in the classification.
Another fracture type that is not included in the Judet
and Letournel classification is when the ischium is intact and
the quadrilateral plate is fractured and is displaced medially13.
In the novel classification system, these fractures are included
as part of the superomedial displacement vector group sub-
types 1 or 2, depending whether the iliac wing is broken or not.
 e8(10)
TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
d
V O LU M E 1 00-A N U M B E R 2 J A N UA R Y 17, 2 018
d d
The current study also points to the fact that the pelvic
brim has a standard fracture pattern, either along or through
the brim. Furthermore, the quadrilateral plate’s typical fracture
pattern is perpendicular to the pelvic brim. Because of the
quadrilateral plate’s typical fracture pattern, our preferred
technique for its fixation is an infrapectineal buttress plate
placed parallel to the pelvic brim. Data presented in the study
show that the presented technique helps to achieve and
maintain better reduction.
This study had several limitations. First, it was a ret-
rospective study in which not all data were available for all of
the patients, such as clinical outcome scores. However,
classification studies are often retrospective, because the
creation of a classification is a retrospective process, re-
flecting on fractures and analyzing them. Second, evaluation
of the classification in terms of interobserver agreement was
not performed and should be done by an independent re-
searcher group.
Further studies are required to evaluate the proposed
novel classification. Comparing the interobserver agreement,
the additional data obtained by 3-dimensional CT, and its
overall effect on clinical outcomes should be assessed in fu-
ture studies.
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T H E R E I S N O C O LU M N : A N E W C L A S S I F I C AT I O N FOR A C E TA B U L A R
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Appendix
Figures showing the surgical techniques for placement of
an infrapectineal buttress plate (with examples) are
available with the online version of this article as a data sup-
plement at jbjs.org (http://links.lww.com/JBJS/E526). n
Amir Herman, MD, PhD1,2,3
Shay Tenenbaum, MD1,2
Vladislav Ougortsin, MD1,2
Nachshon Shazar, MD1,2
1Department of Orthopaedic Surgery, Sheba Medical Center,
Tel HaShomer, Israel
2Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
3TalpiotMedical Leadership Program, Sheba Medical Center,
Tel HaShomer, Israel
E-mail address for A. Herman: amirherm@gmail.com
ORCID iD for A. Herman: 0000-0001-6053-7414
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