Fragment specific fixation technique using 2.7 mm VA LCP for comminuted posterior wall acetabular fractures: a novel surgical technique

Using calcaneal plates in fixation of comminuted posterior wall acetabular fractures with cranial or posterior extension: a prospective case series and novel technique

BACKGROUND

This study aims to evaluate the outcomes of using calcaneal plate in fixation of comminuted posterior wall (PW) acetabular fractures especially that have cranial (dome) or posterior extension (posterior column edge), and to evaluate its safety. To our knowledge, this is the first study that utilizes this off label implant technique in fixation of such fracture.

METHODS

Twenty-two patients enrolled in the study with a minimum follow up of one year. After reducing the PW fragments sequentially, calcaneal plate was applied, fixing its distal part at ischial tuberosity upper ends using 3 screws in a triangular fashion, while its proximal part and radial wings were firmly fixed along the acetabular rim together with the classic longitudinal anchorage. Any fixation failure or head subluxation was recorded.

RESULTS

Radiological outcome showed 18 cases scored as excellent, 2 were good, and 2 were poor. The functional outcome revealed 2 patients were excellent, 6 were very good and 14 were good. There was no loss of reduction or fixation failures throughout the follow up period.

CONCLUSION

Calcaneal plate may offer an alternative method of fixation of comminuted PW fractures with acceptable radiological and functional results. Our study result may encourage the comprehensibility and replicability of this practice, however randomized multicentered studies should be conducted to validate this assumption. This method provides valuable trick strategy, stable and soft-tissue-friendly fracture fixation where modern implantations may be unavailable or of high cost. Calcaneal plates show some fascinating features that allow using them outside their field being flexible with large footprint area for fracture buttressing beside numerous hole choices with diverse paths providing suitable fixation, articular stability and wide zone of coverage in PW comminuted fracture patterns with cranial or posterior extensions. The plate proximal triangular configuration together with distal triangular screw fixation gives a stiff rigid anchorage and buttressing similar to a metal mesh covering and fixing any fragment numbers up to dome level.

Novel implant design for comminuted posterior wall acetabular fractures

BACKGROUND

In recent years, the medical community has witnessed a notable increase in high-energy traumatic injuries, leading to a surge in complex fracture patterns that challenge existing treatment methodologies. Among these, the posterior approach to acetabular fractures stands out for offering direct visualization of the retro-acetabular surface, with current fixation methods relying on 3.5 mm low-profile reconstruction plates and various other implants. Despite the effectiveness of these methods, there is a burgeoning demand for a singular, adaptable implant that not only streamlines the surgical process but also optimizes patient outcomes.

METHODS

In an innovative approach to address this need, three-dimensional (3D) models of the posterior acetabular wall were meticulously crafted using AutoCAD® software. The chosen material for the implant was 316L surgical steel for its durability and strength. The design of the implant featured a low-profile mesh structure, which was instrumental in facilitating osteosynthesis. This design allowed for the placement of screws of varying lengths in multiple directions, ensuring the initial reconstruction of the joint in an anatomical position without hindering the placement of the definitive implant. The primary objective was to secure the fixation and stabilization of the fracture by specifically targeting the smaller bone fragments. A comparative analysis was then conducted between this novel plate and a conventional 316L surgical steel, seven-hole, 3.5 mm reconstruction plate through finite element analysis.

RESULTS

The comparative analysis unveiled that both plates demonstrated comparable deformation capacities, with no significant differences in load-bearing capabilities observed. This finding suggests that the innovative plate can match the performance of traditional plates used in such surgeries.

CONCLUSIONS

The finite element analysis revealed that the newly developed anatomical plate for posterior wall acetabular fractures meets the necessary physical and mechanical criteria for permanent implementation in patients with these fractures. This breakthrough represents a promising advancement that could simplify surgical procedures and potentially elevate patient outcomes.

LEVEL OF EVIDENCE II

This study is classified as a Level II, diagnostic study.

Biomechanical Comparison of Fixation Methods for Posterior Wall Fractures of the Acetabulum: Conventional Reconstruction Plate vs. Spring Plate vs. Variable Angle Locking Compression Plate

Background and Objectives: Acetabular fractures, though infrequent, present considerable challenges in treatment due to their association with high-energy trauma and poor prognoses. Posterior wall fractures, the most common type among them, typically have a more favorable prognosis compared to other types. Anatomical reduction and stable fixation of the posterior wall are crucial for optimal treatment outcomes. This study aimed to biomechanically compare three commonly used fixation methods for posterior wall fractures of the acetabulum-a conventional reconstruction plate, a spring plate, and a 2.7 mm variable angle locking compression plate (VA-LCP). Materials and Methods: The study utilized 6 fresh-frozen cadavers, yielding 12 hemipelvises free from prior trauma or surgery. Three fixation methods were compared using a simple acetabulum posterior wall fracture model. Fixation was performed by an orthopedic specialist, with prebending of plates to minimize errors. Hemipelvises were subjected to quasi-static and cyclic loading tests, measuring fracture gap, stiffness, and displacement under load. Results: It showed no significant differences in fracture gap among the three fixation methods under cyclic loading conditions simulating walking. However, the conventional reconstruction plate exhibited a greater stiffness compared to the spring and variable angle plates. Fatigue analysis revealed no significant differences among the plates, indicating a similar stability throughout cyclic loading. Despite differences in stiffness, all three fixation methods demonstrated adequate stability under loading conditions. Conclusions: While the conventional reconstruction plate demonstrated a superior stiffness, all three fixation methods provided sufficient stability under cyclic loading conditions similar to walking. This suggests that postoperative limitations are unlikely with any of the three methods, provided excessive activities are avoided. Furthermore, the variable angle plate-like the spring plate-offers an appropriate stability for fragment-specific fixation, supporting its use in surgical applications. These findings contribute to understanding the biomechanical performance of different fixation methods for acetabular fractures, facilitating improved surgical outcomes in challenging cases.

Modified one third tubular plate (spring plate) augmented with reconstruction plates for treatment of comminuted posterior wall acetabular fractures, Short to midterm outcomes of 24 patients

The most common form of acetabular fracture is believed to be the posterior wall; its incidence ranges from 25% to 47%. Managing such fractures has been difficult in the past and until recently. To obtain a favorable functional outcome, an accurate diagnosis and a well-executed treatment strategy are essential.

Objective

To evaluate the clinical and functional outcomes of employing a spring plate augmented by a traditional 3.5 mm reconstruction plate for the treatment of comminuted posterior wall acetabular fractures.

Patients and Methods

A prospective case series was performed on 24 patients with comminuted fractures of the posterior wall. After an average of 6 days, the patients underwent surgery. Eighteen patients were fixed with one spring plate, six patients were fixed with two spring plates, and all were reinforced with a 3.5-mm reconstruction plate. Each case was followed once every three months until the fracture healed and then regularly every six months thereafter.

Results

There were 21 men and 3 women. The average follow-up period was 14 months, and the median age was 34.5 years. The main reason for injuries was motor vehicle collisions. The mean operation time was 107.5 min. The clinical results were evaluated by the MAP and m HHS, and the means were 10.2 (5-12) and 86 (64-96), respectively. Only two patients developed avascular necrosis and were treated by total hip replacement, another three (12.5%) had mild arthritis.

Conclusion

Comminuted acetabulum posterior wall fractures can be stabilized with spring plates. It could be used in conjunction with the primary reconstruction plate as a viable alternative for stable and anatomical reduction. High patient satisfaction and good functional results make this approach effective.

Adjunct fixation in upper extremity long bone fracture plating

PURPOSE

A variety of adjunct fixation methods to supplement primary plate and screw constructs are available. There are no large clinical series of these techniques in the upper extremity. The purpose of this study was to review patients with upper extremity fractures that underwent primary plating with adjunct fixation.

METHODS

This study was a retrospective review of plate fixation of humeral, radial and ulnar fractures over a 12-year period. Measurable outcomes for this study included rates of non-union, complications, and implant removal.

RESULTS

Thirty-nine humeral shaft fractures had supplemental fixation 97% of the time, with a 100% union rate. Supplemental fixation was used in 79% of forearm cases. There was a 98% initial union rate in 48 acutely plated forearm fractures.

CONCLUSION

Although a variety of techniques were employed, the mini-fragment (2.7 mm or smaller) was the most common strategy for adjunctive fixation of long bone fractures in the upper extremity.

Spring Plates as a Valid Additional Fixation in Comminuted Posterior Wall Acetabular Fractures: A Retrospective Multicenter Study

BACKGROUND

The posterior wall fracture is the most frequent pattern of acetabular fractures. Many techniques of fixation have been described in the literature and involve plates, screws, or a combination of both. This study aims to investigate the clinical and radiological outcomes of spring plates in the treatment of comminuted posterior wall acetabular fractures. (2) Methods: A retrospective multicenter (four level I trauma centers) observational study was performed. Patients with a comminuted posterior wall acetabular fracture treated with a spring plate (DePuy Synthes, West Chester, PA) were included. Diagnosis was made according to the Judet and Letournel classification. Diagnosis was confirmed with plain radiographs in an antero-posterior view and Judet views, iliac and obturator oblique views, and thin-slice CT with multiplanar reconstructions. (3) Results: Forty-six patients (34 males and 12 females) with a mean age of 51.7 years (range 19-73) were included. The most common mechanism of injury was motor vehicle accident (34 cases). In all cases, spring plates were placed under an overlapping reconstruction plate. The mean follow-up was 33.4 months (range 24-48). The mean period without weight-bearing was 4.9 weeks (range 4-7), and full weight-bearing was allowed at an average of 8.2 weeks (range 7-11) after surgery. (4) Conclusions: According to the present data, spring plates can be considered a viable additional fixation of the posterior wall acetabular fractures.

Application of computerized virtual preoperative planning procedures in comminuted posterior wall acetabular fractures surgery

Background

The treatment of comminuted posterior wall acetabular fractures remains challenging due to the difficulty in understanding of fracture patterns and lack of appropriate preoperative planning process. Virtual preoperative planning procedures are now being commonly used in orthopedic surgery to aid in management of such complex problems. Our aim was to evaluate the feasibility and clinical value of a new method by applying computerized virtual preoperative planning procedures in the treatment of comminuted posterior wall acetabular fractures.

Methods

A total of 45 patients with comminuted posterior wall acetabular fractures from June 2014 to December 2018 were retrospectively analyzed. Based on the usage of computerized virtual preoperative planning procedures, they were assigned to group A and group B. In group A (24 patients), the new method was applied before surgery. In group B (21 patients), the conventional surgery was performed without assistance of computerized virtual preoperative planning procedures. The two groups were assessed in terms of blood loss, surgical time, reduction quality, fracture healing time, postoperative complications, and hip function.

Results

There were no significant differences in demographic data between the two groups. Patients in group A had significantly less intraoperative blood loss (429.58 vs 570.24 ml, P < 0.001) and shorter operation time (154.79 vs 181.90 min, P < 0.01) compared to group B. Using the Matta scoring system, the reduction was graded as anatomic in 20 cases, imperfect in three cases and poor in one case in group A, versus 16 cases was graded as anatomic, three as imperfect and two as poor for group B. According to the modified Merle d’Aubigné score, hip function was graded as excellent in 15 cases, good in seven cases, fair in one and poor in one for group A in comparison to 11 cases, seven cases, two cases, and one case for group B, respectively. The reduction quality and hip function did not differ within the two groups (P > 0.05). The general postoperative complication rate in group A and group B was 12.5% and 28.6%, respectively, but the difference between the two groups was not statistically significant.

Conclusion

The application of computerized virtual preoperative planning procedures is feasible in comminuted posterior wall acetabular fractures. It helps orthopedic surgeons better understand the fracture characteristics, enables simulation of the reduction process and preoperative planning of internal fixation methods. This new preoperative planning method using a 3D virtual model is a more effective method than conventional method in surgical treatment of comminuted posterior wall acetabular fractures.

Trial registration retrospectively registered.

Fragment-specific fixation of posterior wall acetabular fractures

PURPOSE

Fractures of the posterior wall (PW) of the acetabulum have a wide variety of patterns; treating them as a single entity using the standard ilio-ischial plate would be inappropriate. We are presenting our experience with a fragment-specific fixation technique in which each PW fragment is reduced and fixed with separate buttress/anti-glide plate(s) in a tailored fashion, abandoning the use of the ilio-ischial plate.

PATIENTS AND METHODS

Fragment-specific fixation was applied to 46 patients with PW fractures (33 simple and 13 associated fracture types) with a mean follow-up of 34.9 ± 20.5 months (range: 12-72). Kocher-Langenbeck approach was utilized for all patients with dissection limited to the fracture site (a limited form of the approach was used in three patients).

RESULTS

Anatomical reduction of the fracture was achieved in 41 (89.1%) patients, imperfect reduction in four (8.7%), and poor reduction in one (2.2%) patient. Excellent to good radiological and functional results were achieved in 91.3% of cases. A single case had recurrent subluxation which was related to avascular necrosis of the highly comminuted wall fragments. Four patients developed post-traumatic arthritis and required total hip arthroplasty. None of our cases developed clinically significant heterotopic bone formation.

CONCLUSION

With a versatile yet a strong-enough construct and limited soft tissue dissection, fragment-specific fixation yielded very good results with few complications.

Mapping of acetabular posterior wall fractures using a three-dimensional virtual reconstruction software

INTRODUCTION

The aim of this study was to analyze and describe the fracture patterns of the acetabular posterior wall based on quantitative measurements of the fracture characteristics.

MATERIALS AND METHODS

Computed tomography images of 51 patients with acetabular posterior wall fractures from an initial cohort of 216 acetabular fractures were imported into a three-dimensional (3D) virtual software. The reconstructed 3D images were utilized to evaluate the following: (i) fracture line mapping on the inner articular and retro-acetabular surfaces, (ii) common zones of fracture and marginal impaction, and (iii) categorization by location and pattern of comminution. The clock-face position was applied for description: the midpoint of the transverse acetabular ligament served as the +180° reference point, and the 0° reference point was set perpendicular to the ligament. The fracture angle on the articular surface was defined as the intersection between the start and end points. The fracture span on the retro-acetabular surface was defined as the ratio of the perpendicular distance, which is between the fracture beak and acetabular rim, to the entire length, which is from the edge to the rim. Quantitative measurements were performed, and the fracture patterns were analyzed. A color scale bar was used to visualize the common and marginal impaction zones.

RESULTS

The articular surface mapping of all the cases demonstrated that the average starting point of the fracture line was +6.2° (±12.8°) and the endpoint was 96.7° (±13.3°), and the average fracture angle was 119.6° (±7.6°) with 80.6% of the fragments having angles within 18.7-117°. The retro-acetabular surface mapping demonstrated that the average fracture span was 0.65 ±0.20, and 61.7 % of the fracture lines were located within 0.6 to 0.9. Marginal impaction was found in 21 cases (21/51, 41.2%; range: between +7° and +105°).

CONCLUSION

The fracture maps showed fracture patterns and recurrent fracture zones on the articular and retro-acetabular surfaces. However, there was no remarkable pattern of marginal impaction.

LEVEL OF EVIDENCE

Retrospective cohort study.

[Application of new H-shaped anatomical titanium plate for posterior wall/posterior column acetabular fractures]

Objective

To explore the effectiveness of a new H-shaped anatomical titanium plate in treatment of posterior wall/posterior column acetabular fractures.

Methods

Between March 2012 and April 2019, 46 patients with acetabular fractures involving posterior wall/posterior column were treated with the new H-shaped anatomical titanium plates. There were 28 males and 18 females. The age ranged from 20 to 70 years, with an average of 45.5 years. Among the patients, 34 cases were injured by traffic accidents and 12 cases by falling from height. The time from injury to operation ranged from 2 to 14 days, with an average of 7 days. According to Letournel-Judet classification, there were 12 cases of posterior wall fractures, 1 case of posterior column fracture, 3 cases of transverse fractures, 9 cases of transverse fractures involving posterior walls, 8 cases of posterior column and posterior wall fractures, 2 cases of anterior column and posterior semi-transverse fractures, 3 cases of T-shaped fractures, and 8 cases of double column fractures. Matta reduction standard was used to evaluate fracture reduction and Merle d'Aubign-Postel score was used to evaluate hip joint function.

Results

All operations were successfully completed. The time of posterior operation was 60-120 minutes, with an average of 80 minutes. The amount of intraoperative blood loss ranged from 200 to 600 mL, with an average of 300 mL. All the incisions healed by first intention and no infection, deep vein thrombosis, or sciatic nerve injury occurred. All 46 patients were followed up 6-72 months, with an average of 37 months. According to Matta reduction standard, 40 cases obtained anatomic reduction, 4 cases satisfactory reduction, 2 cases unsatisfactory reduction, and the satisfaction rate was 95.7% (44/46). All fractures healed, and the healing time was 3-6 months, with an average of 4.3 months. No internal fixation failure occurred during the follow-up. At last follow-up, the Merle d'Aubign-Postel score ranged from 6 to 18 (mean, 15.5), including 38 cases of excellent, 4 cases of good, 2 cases of fair, and 2 cases of poor, with an excellent and good rate of 91.3% (42/46). Heterotopic ossification occurred in 4 cases, traumatic arthritis in 4 cases, and osteonecrosis of femoral head in 2 cases after operation.

Conclusion

For acetabular fractures involving posterior wall/posterior column, the new H-shaped anatomical titanium plate can provide stable fixation, satisfactory reduction, and good recovery of hip function.

Miniplate osteosynthesis in fracture surgeries: Case series with review of concepts

PURPOSE

Miniplates were initially developed as targets for foot and hand fractures, but they have been used in the treatment of fixation of small bone fragments, reduction of long bone fractures and non-union treatment, which have been difficult to treat. In this study, the authors used miniplates to treat fractures of the upper extremities, lower extremities, and pelvis obtained good outcomes. Herein, the authors report these good outcomes and review the current concept of miniplates.

PATIENTS AND METHODS

Forty-two patients treated with miniplates between March 2012 and March 2017 who attended follow-up for > 1 year were included in this retrospective study. Miniplates were selected according to purpose, which was classified into three categories: fixation, reduction, and stability enhancement. For fixation, miniplates were used to fix distal fibular fractures occurring distal to the syndesmosis and treat patellar and olecranon fractures with severe comminution. For reduction, miniplates were used to reduce the tibia during intramedullary nailing in tibiofibular shaft fractures, while reduction was performed in advance of definitive plating fixation in patients with humeral and pelvic fractures. To enhance stability, the miniplate was inserted after autobone graft for atrophic nonunion at the humeral shaft following nail insertion. The validity of a miniplate was analyzed by reviewing the published literature on the use of miniplates in orthopedic fracture surgeries.

RESULTS

Bony union was achieved in all cases. No specific postoperative complications were observed; however, mild pain and limited range of motion observed in two patients were resolved after implant removal. Sixteen studies on fracture treatment using miniplates reported clinically fair outcomes.

CONCLUSION

Miniplates are not just small metal plates. Depending on the location and treatment of the fracture, the miniplate can effectively fix small bone fragments, help the main plate to maintain the reduction of large bone fragments, and increase the fixation force for nonunion treatment.