Internal fixation of acetabular quadrilateral plate fractures in elderly patients: Could the fracture reduction quality affect their functional recovery?

Functional, radiological, and quality of life outcome of unstable acetabular fracture with quadrilateral plate involvement at a tertiary care center in Jakarta, Indonesia

INTRODUCTION

Unstable acetabular fracture remains a complex fracture that requires technically demanding surgery for orthopedic surgeons. Quadrilateral plate (QP) fractures of the acetabulum are a challenging group of acetabular fractures to manage. However, the literature regarding the management of these injuries are limited. The QP is a relatively thin medial wall of the acetabulum and intra-articular; thus, anatomical reduction and stable fixation are required for satisfactory outcome. This study aims to determine the functional, radiological, and quality of life outcome of unstable acetabular fracture with QP involvement.

METHODS

This was a retrospective cohort study conducted at Cipto Mangunkusumo General Hospital during the period of 2010-2020. Patients with unstable acetabular fractures with and without QP involvement were included in this study. They were followed up postoperatively at 1, 6, and 12 months. Functional outcome was assessed using the Harris Hip Score (HHS), Merle D'Aubigne, and Oxford Hip Score (OHS); while radiology outcome was assessed using Matta Outcome Grading; and quality of life was assessed using the SF-36.

RESULTS

This study involved 53 subjects with a median age was 29 (18-75) years of age. Twenty-eight (52.8%) subjects had unstable acetabular fracture with QP involvement. Twenty-five (47.2%) subjects had unstable acetabular fracture without QP involvement. Twenty-five (47.2%) subjects were fixed using quadrilateral hook plate, 3 (5.7%) with infrapectineal plate, 10 (18.8%) with posterior column plate, and 15 (28.3%) with suprapectineal plate. The median intraoperative bleeding in those with unstable acetabular fracture with QP involvement was 600 (300-4000) ml, which was higher than those without QP involvement (400 [100-1700] ml). Those with QP involvement achieved anatomical reduction in 20 (71.4%) subjects. Whereas, the subjects without QP involvement achieved anatomical reduction 23 patients (92%). Subjects with QP involvement had significantly lower functional, radiological, and quality of life outcomes compared to those without quadrilateral plate involvement based on Harris Hip Score (p = 0.046), Merle D'Aubigne (0.001), Oxford Hip Score (0.001), Matta Outcome Grading (0.004), and SF-36 (0.001). Patients with quadrilateral hook plate showed no significant functional, and radiological outcome difference compared to patients with infrapectineal plate based on Harris Hip Score (p = 0.582), Merle D'Aubigne (0.698), Oxford Hip Score (1.000), and Matta Outcome Grading (1.000). In addition, we also found no significant functional, radiological, and quality of life outcome difference between posterior column plate and suprapectineal plate group based on Harris Hip Score (p = 0.200), Merle D'Aubigne (0.643), Oxford Hip Score (0.316), Matta Outcome Grading (1.000), and SF-36 (0.600).

CONCLUSIONS

Patients with unstable acetabular fracture with quadrilateral plate involvement subject had significantly lower functional, radiological, and quality of life outcomes compared to those without quadrilateral plate involvement. Both quadrilateral hook and infrapectineal plates demonstrated non-significant functional and radiological outcomes difference. Posterior column plate also resulted in the same functional, radiological, and quality of life outcome compared with suprapectineal fixation.

Finite element analysis of the use of two new types of internal fixation for acetabular fractures

BACKGROUND

Both-column fracture is a common type of acetabular fracture and is sometimes accompanied by a comminuted fracture of the quadrilateral area. Such fractures are difficult to anatomically reduce and securely fix. In this study, the authors compared the application value and mechanical properties of the Bespoke 3D-printed titanium alloy plates and Union Plate in acetabular both-column fractures.

METHODS

A both-column fracture model of the acetabulum was established, and the Bespoke 3D-printed titanium alloy plates, Union Plate and a common reconstruction plate were used for fixation. External loads were applied to the model at different angles, and the effects on the plates and the stress and displacement of the screws were determined.

RESULTS

Under different states of hip joint activity, the maximum stress experienced by the Bespoke 3D-printed titanium alloy plates and Union Plate was significantly smaller than the maximum stress experienced by the common reconstruction plate. The Bespoke 3D-printed titanium alloy plates experienced the lowest maximum stress under different hip joint motions. There was no statistically significant difference between the maximum displacement of the Bespoke 3D-printed titanium alloy plates and Union Plate and that of the common reconstructed plate.

CONCLUSIONS

The design of the Bespoke 3D-printed titanium alloy plates imparts a smaller maximum stress and better mechanical properties when repairing acetabular both-column fractures.

A new classification for quadrilateral plate fracture of acetabulum

BACKGROUND

Recently, quadrilateral plate (QLP) fractures of acetabulum have attracted increasing attention. However, evidence for the appropriate classification of QLP fractures is still lacking, making it difficult to understand and manage these fractures. This study aimed to introduce a new classification for QLP fractures and evaluate its reproducibility.

METHODS

A series of 1101 consecutive patients with acetabular fractures from 8 level-I trauma centers were enrolled in this study. All patients underwent preoperative radiograph and computed tomography imaging. QLP fractures were identified and classified using the new and Judet-Letournel classification system. The inter- and intra-observer reliabilities (kappa coefficients, κ) of these two systems were investigated by 4 observers. Furthermore, surgical approaches and fixation methods for each fracture type are described.

RESULTS

In total, 243 (243/1101, 22%) patients with QLP fractures were identified and included in this analysis. The mean κ value of the intra-observer reliability was 0.84 (range, 0.763-0.919) for the new classification, indicating excellent agreement, and the inter-observer reliability was 0.762 (range, 0.625-0.876), indicating substantial agreement. The values were 0.649 (range, 0.523-0.708) and 0.584 (0.497-0.646), respectively, according to the Judet-Letournel classification. Six cases (6/243, 2.5%) could not be classified using the Judet-Letournel classification. The selection of surgical approaches and fixation methods depends on the fracture type; however, an anterior intra-pelvic approach and buttressing fixation using the plate or screw are preferred for QLP fractures.

CONCLUSION

This study presents a new classification for QLP fractures, showing higher intra- and inter-observer reliabilities than those obtained using the Judet-Letournel classification. This allowed us to obtain an in-depth and comprehensive understanding of QLP fractures. Additionally, the new classification might guide further studies on surgical strategies for QLP fractures.

LEVEL OF EVIDENCE

Level II.

Third-Generation Dynamic Anterior Plate-Screw System for Quadrilateral Fractures: Digital Design Based on 834 Pelvic Measurements

Background and Objectives: To investigate the digital measurement method for the plate trajectory of dynamic anterior plate-screw system for quadrilateral plate (DAPSQ), and then design a third-generation DAPSQ plate that conforms to the needs of the Chinese population through collating a large sample anatomical data. Materials and Methods: Firstly, the length of the pubic region, quadrilateral region, iliac region, and the total length of the DAPSQ trajectory were measured by a digital measurement approach in 22 complete pelvic specimens. Then, the results were compared with the direct measurement of pelvic specimens to verify the reliability of the digital measurement method. Secondly, 504 cases (834 hemilateral pelvis) of adult pelvic CT images were collected from four medical centers in China. The four DAPSQ trajectory parameters were obtained with the digital measurement method. Finally, the third-generation DAPSQ plate was designed, and its applicability was verified. Results: There was no statistically significant difference in the four trajectory parameters when comparing the direct measurement method with the digital measurement method (p > 0.05). The average lengths of the pubic region, quadrilateral region, iliac region, and the total length in Chinese population were (60.96 ± 5.39) mm, (69.11 ± 5.28) mm, (84.40 ± 6.41) mm, and (214.46 ± 10.15) mm, respectively. Based on the measurement results, six models of the DAPSQ plate including small size (A1,A2), medium size (B1,B2), and the large size (C1,C2) were designed. The verification experiment showed that all these six type plates could meet the requirement of 94.36% cases. Conclusions: A reliable computerized method for measuring irregular pelvic structure was proposed, which not only provided an anatomical basis for the design of the third-generation DAPSQ plate, but also provided a reference for the design of other pelvic fixation devices.

Finite element analysis of the Union Plate in treating elderly acetabular fracture patients

BACKGROUND

Elderly acetabular fractures are one of the more difficult types of fractures to resolve. For patients at this age, the more common type of fracture is comminuted. How to better fix this type of fracture has always been an issue of concern. This study was performed to observe the mechanical properties of different internal fixation methods used in treating elderly acetabular fracture patients.

METHODS

A model of a comminuted acetabular fracture in osteoporosis was established, consisting of an anterior column-posterior hemitransverse fracture with disruption of the quadrilateral surface. Fixation of the acetabular fracture model using a reconstruction plate and Union Plates was simulated. For the different internal fixation methods, static and transient modal analyses were performed under different loads, with an action time of 0.21 s and an analysis time of 0.7 s. The stress of the model was observed in the static analysis, and the displacement of the nodes and the entire model in the U1 direction was observed in the transient modal analysis.

RESULTS

In the static analysis, the stress of the osteoporosis model, the suprapectineal pelvic reconstruction plate model, the infrapectineal quadrilateral surface buttress plate model, and the suprapectineal quadrilateral surface buttress plate model were 42.62 MPa, 37.49 MPa, 44.39 MPa, and 46.15 MPa, respectively. The stress was mainly distributed near the suprapubic branch. The corresponding displacement in the U1 direction was 0.1500 mm, 0.1020 mm, 0.0836 mm, and 0.0990 mm, respectively. In the transient modal analysis, there was a significant difference in displacement between the different models (P < 0.05). When different loads were applied with the same fixation method, there was no significant difference in model displacement (P > 0.05).

CONCLUSION

Static and transient modal analyses show that the infrapectineal quadrilateral surface buttress plate or the suprapectineal quadrilateral surface buttress plate has an advantage in maintaining the stability of fracture fragments when fixing comminuted acetabular fractures in elderly individuals. The infrapectineal quadrilateral surface buttress plate also presents better biomechanical results.