Epidemiology and treatment of acetabular fractures in a level-1 trauma centre: Retrospective study of 414 patients over 10 years

Comparison of patient demographics and patient-specific risk factors for readmissions following open reduction and internal fixation for acetabular fractures

PURPOSE

Acetabular fractures are highly complex injuries often resulting from high-energy trauma. The gold standard treatment for these injuries has become open reduction internal fixation (ORIF). The purpose of this study is to further this understanding and investigate how (1) patient demographics and (2) patient-specific risk factors affect 90-day readmission rates.

METHODS

A retrospective, nationwide query of private insurance database from January 1st, 2010 to October 31st, 2020 was performed using ICD-9, ICD-10, and CPT codes. Patients who underwent acetabular ORIF and were readmitted within 90 days following index procedure were included, patients who were not readmitted served as controls. Patients were divided by demographics and specific risk factors associated with readmission.

RESULTS

The query yielded a total of 3942 patients. Age and sex were found to be non-significant contributing risk factors to 90-day readmissions. Data also showed that statistically significant comorbidities included arrhythmia, cerebrovascular disease, coagulopathy, fluid and electrolyte abnormalities, and pathologic weight loss.

CONCLUSION

This study illustrated how several patient-specific risk factors may contribute to increased 90-day readmission risk following acetabular ORIF. A heightened awareness of these comorbidities in patients requiring acetabular ORIF is required to improve patient outcomes and minimize rates of readmission. Further investigation is needed to improve patient outcomes, and increase awareness of potential post-operative complications in these higher-risk patient populations.

Unclassified acetabular fractures: Do they really exist?

PURPOSE

Although Letournel classification is considered the corner stone for classifying acetabular fractures, however, it might not be perfectly inclusive. Unclassified fractures were reported by many authors. The aim of this case series is to report the incidence of unclassified acetabular fractures and description of these rare patterns and why they are considered unclassified acetabular fractures.

METHODS

This is a retrospective consecutive case series. In the period between 1st January 2016 and 31st December 2017, 235 patients with 236 acetabular fractures were identified from our hospital records. Classification of the acetabular fractures according to Letournel was done by two surgeons. Any discrepancy in the classification between the two surgeons was resolved by the senior author. Before considering the fracture unclassifiable, all fractures were reviewed again by the two surgeon and the senior author.

RESULTS

In the period between 1st January 2016 and 31st December 2017, 235 patients with 236 acetabular fractures were included in our study. Twenty-two fractures (9.3%) did not fit into any of the fracture types according to Letournel Classification as follows: 1 case (4.5%) was pure Quadrilateral plate fracture, 1 case (4.5%) was labral avulsion with tiny posterior wall rim, 1 case (4.5%) was pure articular impaction, 1 case (4.5%) was both columns fracture with posterior wall, 4 cases (18.2%) were anterior column and quadrilateral plate fracture, and 14 cases (63.8%) were T with posterior wall.

CONCLUSION

Several acetabular fracture pattern could be considered unclassified fractures. These unique patterns may require special approaches or special fixation methods. However, this is not a call for a new classification for acetabular classification to include these new types. Subclassification or adding modifiers to Letournel classification can do the job.

Anterior approaches in acetabular fractures: a true learning curve analysis

Today, acetabular surgeons in training have to learn ilioinguinal and anterior intrapelvic approaches (AIP). The aim of this study was to describe the 5-years learning curve of a surgeon. Objective was to assess clinical and radiological results; and to assess factors which could influence this learning curve. Between November 2015 and May 2020, patients with an acetabular fracture operated by the surgeon during the 5-years learning curve with an anterior approach were included in this single-center retrospective study based on a prospective database. Epidemiological, operative, clinical, radiological and complications data's were collected. To assess learning-curve effect the series was divided into two groups: first 2.5-years and last 2-years. Subgroup analysis were performed according to the surgical approach, to the reduction quality and the prognostic factors. In total, 46 patients were included, 23 in period 1 and 23 in period 2. 16 patients (35%) had ilioinguinal approach and 30 patients (65%) had modified Stoppa-Cole approach. At mean follow-up of 24 months, 38 patients (83%) were reviewed. Anatomical reduction (< 1 mm) was achieved in 28 patients (60.9%) with a 9% rate of perioperative complications and 37% rate of post-operative complications. In conclusion, this study gives a realistic overview of the learning curve of anterior approaches in acetabular fractures surgery. Our results should encourage surgeons, while keeping in mind how much this surgery can be challenging, with high rate of complications and difficulty to obtain a systematic anatomical reduction.

The use of a plate for fixation of the acetabulum

This study aimed to share our experience of a self-developed plate for acetabular fracture fixation through the presentation of clinical cases. Eight patients with complex acetabular fractures (Letournel classification) underwent surgery using a modified Stoppa approach and the novel plate design between 2021 and 2023 at the National Scientific Center for Traumatology and Orthopedics. Criteria such as the mechanism of injury, type of fracture, surgical approach, intraoperative and postoperative complications, quality of reduction, and functional and radiological results were evaluated. All patients included in the study presented complex types of acetabular fractures according to the Letournel classification. In all cases, surgical interventions were performed using a modified Stoppa approach. The assessment of reduction quality was conducted based on the radiological standards established by Matta. The reduction in quality was excellent in two patients, good in four, and satisfactory in two. One patient developed a post-traumatic false joint requiring additional surgery. The remaining patients achieved fracture healing with satisfactory Harris Hip Score (HHS) scores, indicating good overall function. The results of the self-developed plate for acetabular fracture fixation in our series were satisfactory.

Update on post-traumatic periprosthetic acetabular fractures

Aims

Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

Methods

Patients with this type of fracture were identified retrospectively over a period of six years (January 2016 to December 2021). The following data were collected: demographic characteristics, date of insertion of the prosthesis, details of the intervention, date of the trauma, characteristics of the fracture, and type of treatment. Functional results were assessed with the Harris Hip Score (HHS). Data concerning complications of treatment were collected.

Results

Our series included 20 patients, with a mean age of 77 years (46 to 90). All the patients had at least one comorbid condition. Radiographs showed that 75% of the fractures were pure transverse fractures, and a transverse component was present in 90% of patients. All our patients underwent surgical treatment: open reduction and internal fixation, revision of the acetabular component, or both. Mean follow-up was 24 months, and HHS at last follow-up was 75.5 (42 to 95). The principal complications observed were dislocations of the prosthesis (30%) and infections (20%). A need for revision surgery was noted in 30% of patients. No dislocation occurred in patients undergoing osteosynthesis with acetabular reconstruction. We did not note either mechanical loosening of the acetabular component nor thromboembolic complications. In all, 30% of patients presented acute anemia requiring transfusion, and one death was reported.

Conclusion

Post-traumatic periprosthetic acetabular fractures frequently have a transverse component that can destabilize the acetabular implant. The frequency of complications, principally dislocations, led to a high rate of revision surgery. Improvements in preoperative planning should make it possible to codify management to reduce this high rate of complications. The best results were obtained when the surgical strategy combined osteosynthesis with acetabular reconstruction.

Acute total hip replacement by direct anterior approach combined with intrapelvic fixation for geriatric acetabular fracture of the anterior column

Management of anterior column acetabular fracture in the elderly is challenging. Open reduction and internal fixation do not allow early weight bearing and are associated with a high risk of failure compared to younger patients. Therefore, acute fixation and total hip arthroplasty may be an option. This technical note describes a combined procedure: anterior intrapelvic approach for fracture fixation and a direct anterior approach to the hip for THR. Fracture reduction and arthroplasty were achievable in all five patients. The mean operative time was 289min, and the mean blood loss was 2120mL. At short term, no complication was noticed. Combining these two "muscle-sparing" approaches could help manage anterior column fractures in elderly patients. Level of evidence: IV.

Efficacy and safety of pararectus approach for the treatment of acetabular fractures: A systematic review and meta-analysis

BACKGROUND

The pararectus (PR) approach combines the advantages of the second window of the ilioinguinal approach and the medial view of the modified Stoppa approach. However, it is unclear whether the PR approach is more effective or safer than the other approaches, as few clinical studies have compared the PR approach with the other approaches. The aim of this study was to provide a systematic review and meta-analysis comparing the PR approach with the other approaches for the treatment of acetabular fractures and to answer the following question: Are the results of the PR approach superior to those of the other approaches in terms of reduction quality, operative time, operative blood loss, complications, and clinical outcomes for treatment of acetabular fractures?

PATIENTS AND METHODS

A systematic literature review was conducted using relevant original studies from various databases. Pooling of data was performed using RevMan software (version 5.3, Cochrane Collaboration, Oxford, UK). A p-value<0.05 was considered to be significant. We calculated the mean differences for continuous data and odds ratio for dichotomous data with 95% confidence intervals for each outcome. Statistical heterogeneity was assessed based on I2 using the standard χ2 test.

RESULTS

Five studies were included in this meta-analysis. The findings demonstrated that operative blood loss was significantly lower in the PR approach than in the other approaches (p=0.04). There was no significant difference in the rate of anatomical reduction, the operative time, the rate of complications, and the rate of excellent or good clinical score between the PR approach and the other approaches.

DISCUSSION

The PR approach provided lower operative blood loss, although there was no significant difference in reduction quality, operative time, complications, and excellent or good clinical score between the PR approach and the other approaches.

LEVEL OF EVIDENCE

III.

Anterior column acetabulum fracture fixation with a screw-augmented acetabular cup-a biomechanical feasibility study

BACKROUND

The beneficial effects of unrestricted postoperative full weight bearing for elderly patients suffering hip fractures have been demonstrated. However, there is still existing disagreement regarding acetabular fractures.The aim of this biomechanical study was to evaluate the initial load bearing capabilities of different fixation constructs of anterior column fractures (ACFs) in osteoporotic bone.

METHODS

Artificial pelvises with ACFs were assigned to three groups (n = 8) and fixed with either a 7.3 mm partially threaded antegrade cannulated screw (group AASS), an anteriorly placed 3.5 mm plate (group AAPF), or a press-fit acetabular cup with screw augmentation (group AACF). All specimens underwent ramped loading from 20 N preload to 200 N at a rate of 18 N/s, followed by progressively increasing cyclic testing at 2 Hz until failure performed at a rate of 0.05 N/cycle. Relative displacements of the bone fragments were monitored by motion tracking.

FINDINGS

Initial stiffness (N/mm) was 118.5 ± 34.3 in group AASS, 100.4 ± 57.5 in group AAPF, and 92.9 ± 44.0 in group AACF, with no significant differences between the groups, p = 0.544. Cycles to failure were significantly higher in groups AACF (8364 ± 2243) and AAPF (7827 ± 2881) compared to group AASS (4440 ± 2063), p ≤ 0.041.

INTERPRETATION

From a biomechanical perspective, the minimally invasive cup fixation with screw augmentation demonstrated comparable stability to plate osteosynthesis of ACFs in osteoporotic bone. The results of the present study do not allow to conclusively answer whether immediate full weight bearing following cup fixation shall be allowed. Given its similar performance to plate osteosynthesis, this remains rather an utopic wish and a more conservative approach deems more reasonable.

Epidemiology and socioeconomic consequences of work-related pelvic and acetabular fractures recorded in the German Social Accident Insurance

INTRODUCTION

Pelvic and acetabular fractures can result from work-related accidents and frequently require lengthy medical treatments. Consequently, high medical costs as well as delayed or absent return to work can be the consequence. Therefore, we aimed to study the socioeconomic consequences of work-related pelvic and acetabular fractures.

MATERIALS AND METHODS

This retrospective study investigated work-related pelvic and acetabular fractures recorded in the German Social Accident Insurance in 2011 and 2017, in terms of age, sex, type of accident, duration of incapacity to work, reductions in earning capacity, costs for outpatient and inpatient treatment and costs for pension and severance pay.

RESULTS

Among a total of 606 injuries in 2011 and 619 injuries in 2017, male patients and patients between 40 and 65 years were predominantly affected. Acetabular fractures caused higher rates of long absence from work of 6-12 months (2011: 24.7% vs. 9.5-16.9%; 2017: 26.1% vs. 6.1-11.0%) and >12 months (2011: 15.8% vs. 9.8-10.2%; 2017: 13.3% vs. 1.9-8.2%) as well as more cases with a reduction in earning capacity of at least 20% (2011: 61 vs. ≤27 cases; 2017: 39 vs. ≤12 cases) compared to pelvic ring fractures. The total costs for pelvic ring and acetabular fractures in the German social accident insurances amounted € 18,726,630 and € 9637,189 in the periods 2011-2020 and 2017-2020, respectively. The average costs per case for treatment and rehabilitation until 2020 was € 19,079 for injuries from 2011 and € 13,629 for injuries from 2017. Acetabular fractures were found to be the most cost-intensive injuries compared to anterior, posterior or complex pelvic ring fractures.

CONCLUSIONS

Work-related pelvic and especially acetabular fractures have a considerable socioeconomic impact in the German Social Accident Insurance. Measures to prevent work-related accidents and to improve treatment of pelvic injuries can help to reduce their socioeconomic burden.

Surgeon Accuracy in Prediction of Stability of Posterior Wall Acetabular Fractures. A Survey of Orthopaedic Trauma Surgeons

OBJECTIVES

This study aims to investigate surgeon accuracy in prediction of the stability of posterior wall acetabular fractures by comparing "examination under anesthesia" findings to submitted estimations on the basis of radiograph and computed tomography (CT) imaging across a range of experience in orthopaedic surgeons and trainees.

METHODS

Records of patients who underwent examination under anesthesia after presenting with posterior wall acetabular fractures at 2 different institutions were pooled for data collection, totaling 50 cases. Radiographs, CT images, and information regarding the presence of a hip dislocation requiring procedural reduction were provided to participants for review. A survey was generated for submission of impressions of stability for each individual case and disseminated among orthopaedic trainees and surgeons in practice.

RESULTS

The submissions of 11 respondents were analyzed. Mean accuracy was calculated to be 0.70 (SD = 0.07). Sensitivity and specificity of respondents were 0.68 (SD = 0.11) and 0.71 (SD = 0.12), respectively. Positive predictive value and negative predictive value for respondents were 0.56 (SD = 0.09) and 0.82 (SD = 0.04), respectively. There was poor correlation of accuracy with years of experience with R 2 calculated to be 0.0004 and poor agreement between observers with Kappa measurement of interobserver reliability of 0.46.

CONCLUSIONS

Our study suggests that surgeons are unable to consistently differentiate between stable and unstable patterns on the basis of assessments based on x-ray and CT. Years of experience in training or practice was not found to be associated with improved accuracy of stability prediction.

Simulated full weight bearing following posterior column acetabular fracture fixation: a biomechanical comparability study

PURPOSE

The incidence of acetabular fractures (AFs) is increasing in all industrial nations, with posterior column fractures (PCFs) accounting for 18.5-22% of these cases. Treating displaced AFs in elderly patients is a known challenge. The optimal surgical strategy implementing open reduction and internal fixation (ORIF), total hip arthroplasty (THA), or percutaneous screw fixation (SF), remains debated. Additionally, with either of these treatment methods, the post-surgical weight bearing protocols are also ambiguous. The aim of this biomechanical study was to evaluate construct stiffness and failure load following a PCF fixation with either standard plate osteosynthesis, SF, or using a screwable cup for THA under full weight bearing conditions.

METHODS

Twelve composite osteoporotic pelvises were used. A PCF according to the Letournel Classification was created in 24 hemi-pelvis constructs stratified into three groups (n = 8) as follows: (i) posterior column fracture with plate fixation (PCPF); (ii) posterior column fracture with SF (PCSF); (iii) posterior column fracture with screwable cup fixation (PCSC). All specimens were biomechanically tested under progressively increasing cyclic loading until failure, with monitoring of the interfragmentary movements via motion tracking.

RESULTS

Initial construct stiffness (N/mm) was 154.8 ± 68.3 for PCPF, 107.3 ± 41.0 for PCSF, and 133.3 ± 27.5 for PCSC, with no significant differences among the groups, p = 0.173. Cycles to failure and failure load were 7822 ± 2281 and 982.2 ± 428.1 N for PCPF, 3662 ± 1664 and 566.2 ± 366.4 N for PCSF, and 5989 ± 3440 and 798.9 ± 544.0 N for PCSC, being significantly higher for PCPF versus PCSF, p = 0.012.

CONCLUSION

Standard ORIF of PCF with either plate osteosynthesis or using a screwable cup for THA demonstrated encouraging results for application of a post-surgical treatment concept with a full weight bearing approach. Further biomechanical cadaveric studies with larger sample size should be initiated for a better understanding of AF treatment with full weight bearing and its potential as a concept for PCF fixation.

Epidemiology of high-energy blunt pelvic ring injuries: A three-year retrospective case series in a level-I trauma center

BACKGROUND

High-energy pelvic ring injuries (PRI) represent a heavy burden for institutions treating severely injured patients. Epidemiological data knowledge may help to provide them appropriate management. Only two epidemiologic studies about high-energy PRI were published during last decade. This study aimed to determine the gender-specific and global incidences of high-energy blunt AO/OTA type B or C PRI and their frequency among high-energy blunt trauma. It further reports the spectrum of these injuries and compares their characteristics and outcomes to high-energy blunt trauma without type B or C PRI.

HYPOTHESIS

Type B or C PRI incidence isn't gender specific and approximates 5/100,000/year.

PATIENTS AND METHODS

A prospective database of a level-I trauma center serving approximately 500,000 inhabitants was retrospectively queried for all high-energy trauma patients injured between 01.01.2014 and 12.31.2016. Inclusion criteria were: alive emergency department delivery; entire acute treatment at the authors' institution; age >16. Exclusion criteria were: penetrating, blast, burn and electrical injuries; drownings; low-energy trauma; patients living outside the institution's catchment area. Three authors performed PRI classifications. Clinical data were extracted from the database.

RESULTS

We analyzed 434 patients. High-energy blunt type B or C PRI incidence was 3.8/100,000/year without gender disparity (p=0.6697). High-energy blunt trauma incidence was lower in women than in men (20.5 vs. 51.6/100,000/year, p<0.001). Type B or C PRI frequency during high-energy blunt trauma was higher in women than in men (17.6% vs. 7.9%, p=0.003). Type B or C PRI patients were more severely injured and needed more treatment resources than other high-energy blunt trauma patients but didn't present higher complication or death rates.

DISCUSSION

The incidence of high-energy blunt type B or C PRI was comparable to previously published data. Women were less likely to sustain a high-energy blunt trauma, but when they sustained one, they were more likely to have a type B or C PRI. Despite higher injury severity score and resource requirements, complication and death rates weren't different between type B or C PRI patients and other high-energy blunt trauma patients.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Clinical application of the anterior pelvic wall locking plate (APWLP) in acetabular fractures involving the quadrilateral surface

BACKGROUND

The management of acetabular quadrilateral surface fractures remains challenging for surgeons, and the treatment options for such fractures remain controversial. Quadrilateral surface surgery is a complex procedure involving combined approaches, and the quality of fracture reduction closely depends upon the surgical procedure, as well as the skill and experience of the surgeon. This study aimed to explore the clinical effects of applying an anterior pelvic wall locking plate (APWLP) through the lateral-rectus approach for treating acetabular fractures involving the quadrilateral surface.

METHODS

This retrospective analysis was comprised of 35 patients with acetabular fractures involving the quadrilateral surface who were treated with an APWLP in our hospital between June 2016 and December 2020. The patients included 25 males and ten females, with an average age of 52.45 years. All the patients were exposed through the lateral-rectus approach, six patients were exposed with an additional iliac fossa approach, and the fractures were fixed by combining an APWLP with a reconstruction plate. The Matta imaging standard was used to assess the quality of the fracture reduction, and the final follow-up clinical outcome was classified as excellent (18 points), good (15-17), fair (13-14), or poor (< 13) according to the modified Merle d'Aubigné-Postel scoring standard.

RESULTS

All patients successfully completed the operation, and there was no blood vessel or nerve injury during any of the operations. The average follow-up period was 26.11 months. The mean time of resuming full-weight-bearing activities was 12.88 weeks. Hip flexion and extension and internal and external rotation ranges of motion significantly increased over time. At the last follow-up, Matta's imaging evaluation showed that 24 cases were anatomically reduced, seven cases were satisfactory, and four cases were unsatisfactory. The satisfaction rate was 88.6% (31/35). According to the modified Merle d'Aubigné-Postel scoring standard, the hip function was excellent, good, fair, and poor in 23, 6, 4, and 2 cases, respectively. The excellent and good rates represented 82.9% of the total cases (29/35).

CONCLUSION

The findings suggest that the APWLP for acetabulum quadrilateral surface fracture achieve good to excellent clinical and radiological outcomes, and an APWLP may be a new treatment option for these fractures involving the quadrilateral surface.

A review of Risk Factors for Post-traumatic hip and knee osteoarthritis following musculoskeletal injuries other than anterior cruciate ligament rupture

Post-traumatic osteoarthritis (PTOA) is a common form of osteoarthritis that might occur after any joint trauma. Most PTOA publications mainly focus on anterior cruciate ligament (ACL) injuries. However, many other traumatic injuries are associated with PTOA, not only for the knee but also for the hip joint. We aim to identify and summarize the existing literature on the musculoskeletal injuries associated with knee and hip PTOA and their risk factors in determining those with a worse prognosis, excluding ACL injuries. Despite the narrative nature of this review, a systematic search for published studies in the last twenty years regarding the most relevant injuries associated with a higher risk of PTOA and associated risk factors for OA was conducted. This review identified the six more relevant injuries associated with knee or hip PTOA. We describe the incidence, risk factors for the injury and risk factors for PTOA of each. Meniscal injury, proximal tibial fracture, patellar dislocation, acetabular, femoral fractures and hip dislocations are all discussed in this review.

Clinical outcomes of percutaneous screw fixation of acetabular fracture: A minimally invasive procedure

Objective

Open reduction with internal fixation is the surgical intervention of choice for acetabular fractures (AFs). Percutaneous screw fixation for AFs is a new procedure that is desirable because of the complex anatomy of the pelvis. In this study, we aimed to assess the functional outcomes, mobility, healing, and distal neurovascular abnormalities in patients who underwent percutaneous retrograde screw fixation.

Methods

Our study included 36 patients with AFs treated with percutaneous screw fixation between January 2016 and June 2021. There were 18 cases with anterior column AF, 7 cases with transverse AF, and 11 cases with associated AF, 6 of which had a T-shaped AF. Frequencies and percentages were used to describe characteristics and clinical outcomes. Mean and standard deviation were used for continuous variables. SPSS version 23 (IBM Corporation, Armonk, NY, USA) was used for statistical analysis.

Results

The average time to regain full mobility with full weight bearing was 12.9 ± 5.4 weeks, and approximately 11.1 ± 2.8 weeks was required for patients to be pain-free with satisfactory fracture healing. Only a minority (8.3%) of patients had abnormalities affecting the distal neurovascular system, and 11.1% experienced sexual dysfunction. Pain severity was assessed with a visual analogue scale. The average pain severity on the first and third post-operative days was 4 ± 2.4 and 3.8 ± 2.6, respectively. However, the average pain intensity before discharge was 1.7 ± 2.6.

Conclusion

Percutaneous screw fixation is the most efficient surgical choice for most pelvic/AFs.

Quantitative Three-Dimensional Measurements of Acetabular Fracture Displacement Could Be Predictive for Native Hip Survivorship

This study aims to develop a three-dimensional (3D) measurement for acetabular fracture displacement, determine the inter- and intra-observer variability, and correlate the measurement with clinical outcome. Three-dimensional models were created for 100 patients surgically treated for acetabular fractures. The ‘3D gap area’, the 3D surface between all the fracture fragments, was developed. The association between the 3D gap area and the risk of conversion to a total hip arthroplasty (THA) was determined by an ROC curve and a Cox regression analysis. The 3D gap area had an excellent inter-observer and intra-observer reliability. The preoperative median 3D gap area for patients without and with a THA was 1731 mm2 versus 2237 mm2. The median postoperative 3D gap area was 640 mm2 versus 845 mm2. The area under the curve was 0.63. The Cox regression analysis showed that a preoperative 3D gap area > 2103 mm2 and a postoperative 3D gap area > 1058 mm2 were independently associated with a 3.0 versus 2.4 times higher risk of conversion to a THA. A 3D assessment of acetabular fractures is feasible, reproducible, and correlates with clinical outcome. Three-dimensional measurements could be added to the current classification systems to quantify the level of fracture displacement and to assess operative results.

How to improve the performance of acetabulum fracture diagnoses: investigating the use of three-dimensional CT-scan reconstructions

PURPOSE

The classification of acetabular fractures remains a challenge for the junior radiologist, although he is the first line of diagnosis in Emergency Department. The advantages of three-dimensional reconstructions have yet to be evaluated on a large scale.

METHOD

A total of 212 fractures were classified according to Letournel and Judet by a senior orthopaedic surgeon, a senior radiologist, and a resident radiologist. The CT scans were first analysed in 2D and then a second time using 2D + 3D reconstructions of the acetabulum excluding the femoral head.

RESULTS

3D reconstructions improved correct classification not only for the radiologist resident (+ 5%) but also for senior radiologist and orthopaedist (+ 2 and + 3%). 3D reconstructions also more significantly improved the diagnoses of complex fractures (+ 8.3%) compared to simple fractures (+ 0.4%).

CONCLUSIONS

3D reconstructions have improved the routine diagnosis of acetabular fractures, especially for junior radiologist or in cases of complex fractures.

Clinical and radiological outcomes of antegrade posterior column screw fixation of the acetabulum

INTRODUCTION

Antegrade posterior column screw fixation (APCS) provides stable fixation while reducing the complications related to dual acetabular approaches. The objective of this study was to present the radiological and clinical outcomes of fixation of the posterior column of the acetabulum through a single anterior approach.

HYPOTHESIS

APCS will produce better clinical and radiological outcomes relative to not placing any screws in the posterior column.

PATIENTS AND METHODS

This was a retrospective single-center study of 69 patients operated through a single anterior approach for a both-column fracture of the acetabulum between 2014 and 2018. Patients were divided into two groups (APCS+, n=24 and APCS-, n=45) depending on whether the posterior column was fixed with an antegrade lag screw or not. The radiological outcomes were defined by the quality of the reduction according to Matta. The clinical outcomes were evaluated using the Harris Hip score and Merle Postel D'Aubigné (MDP) score at the final assessment. A sequential hierarchical analysis was done with a Chi² test for the radiological criterion and Student's t test for the clinical outcomes.

RESULTS

In the APCS+ group, the reduction was anatomical in 71% (17/24) of patients, imperfect in 12% (3/24) and poor in 17% (4/24). In the APCS- group, the reduction was anatomical in 33% (15/45) of patients, imperfect in 31% (14/45) and poor in 35% (16/45). This difference between groups was statistically significant (p=.012). The differences between groups in the Harris (p=.201) and MDP (p>.05) scores were not significant. Mean irradiation in the APCS+ group was significantly higher (114.8 cGy.cm^-2) relative to the APCS- group (39.8 cGy.cm^-2) (p<.001). None of the patients in the APCS+ group underwent a subsequent total hip arthroplasty, while 8 patients from the APCS- group did (p=.031). The differences in the postoperative complications were not statistically significant.

DISCUSSION

APCS yields satisfactory radiological and clinical outcomes without increasing the complication rate; this must be balanced out against the additional irradiation.

LEVEL OF EVIDENCE

III.

Pararectus approach vs. Stoppa approach for the treatment of acetabular fractures - a comparison of approach-related complications and operative outcome parameters from the German Pelvic Registry

PURPOSE

The Pararectus approach has been introduced as an alternative anterior approach to the Stoppa approach in acetabular surgery. There is no evidence which approach should be preferred, especially regarding approach-related complications. Therefore, aim of this registry study was to compare the Pararectus approach to the Stoppa approach regarding complications and quality of reduction.

METHODS

Patients from the German Pelvic Registry with a surgically treated acetabular fracture, either through the Pararectus approach or the Stoppa approach, were analyzed or compared regarding demographic, clinical and operative parameters.

RESULTS

In total, 384 patients with an acetabular fracture received a surgical procedure with either the Pararectus approach (n=120) or the Stoppa approach (n=264). There were no differences between the two groups regarding demographic parameters and fracture pattern. The overall complication rate (35.0% vs. 31.4%), the mortality rate (5.0% vs. 3.0%) and the osteosynthesis-associated complication rate (5.8% vs. 4.2%) tended to be higher in the Pararectus group with no statistical significance. There were significantly more anatomical reductions in the Pararectus group (56% vs. 43%; p=0.01). However, operation time was significantly longer in the Pararectus group (255±125 vs. 205±103 minutes; p<0.001).

CONCLUSION

Despite a longer operation time, the Pararectus approach and the Stoppa approach are equivalently applicable for the treatment of acetabular fractures regarding complication rates and quality of reduction.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Identification and treatment of atypical acetabular fractures having an independent acetabular roof fragment: Three-column fractures

INTRODUCTION

A unique type of both-column fracture of the acetabulum that also has an independent roof fragment seems to occur relatively often. It is challenging to diagnose, thus our ability to detect it and its frequency are not known. This led us to analyze a database of acetabular fractures to 1) determine the incidence of this type of fracture, 2) describe its radiological characteristics, 3) attempt to set out a specific treatment strategy.

HYPOTHESIS

The need for a dual surgical approach depends on the type and displacement of the independent roof fragment.

METHODS

Four surgeons and radiologists independently analyzed a set of acetabular fractures that occurred between 2007 and 2017. The diagnosis was made using two-dimensional (2D) and three-dimensional (3D) CT reconstructions. Once the fractures had been identified, a detailed description was made of all 2D and 3D slices. A retrospective analysis was done of the reduction and fixation of the independent roof fragment relative to the chosen surgical approach.

RESULTS

The study comprised 534 acetabular fractures, of which 96 where both-column fractures. In that subset, 41% (39 fractures) had an independent roof fragment. A detailed analysis resulted in the identification of two subtypes of three-column fracture with independent fragment: type 1 has a posterosuperior fragment (22 cases); type 2 has an independent fragment separated by a juxtatectal fracture line (17 cases). The best radiological outcomes were achieved when the independent fragment was minimally displaced and did not require additional reduction.

CONCLUSION

The isolated roof fragment is common, as it occurs is more than one-third of both-column fractures. We were able to identify two subtypes that require different surgical strategies. Surgical treatment of these fractures is difficult; thus a combined surgical approach (anterior followed by posterior) may provide the best reduction, especially for subtype 1.

LEVEL OF EVIDENCE

IV.

Biomechanical analysis of fixation methods in acetabular fractures: a systematic review of test setups

Purpose

Optimal anatomical reduction and stable fixation of acetabular fractures are important in avoiding secondary dislocation and osteoarthritis. Biomechanical studies of treatment options of acetabular fractures aim to evaluate the biomechanical properties of different fixation methods. As the setup of the biomechanical test can influence the experimental results, this review aimed to analyze the characteristics, comparability and clinical implications of studies on biomechanical test setups and finite element analyses in the fixation of acetabular fractures.

Methods

A systematic literature research was conducted according to the PRISMA guidelines, using the PubMed/MEDLINE and Web of Science databases. 44 studies conducting biomechanical analyses of fixation of acetabular fractures were identified, which met the predefined inclusion and exclusion criteria and which were published in English between 2000 and April 16, 2021. The studies were analyzed with respect to distinct parameters, including fracture type, material of pelvis model, investigated fixation construct, loading direction, loading protocol, maximum loading force, outcome parameter and measurement method.

Results

In summary, there was no standardized test setup within the studies on fixation constructs for acetabular fractures. It is therefore difficult to compare the studies directly, as they employ a variety of different test parameters. Furthermore, the clinical implications of the biomechanical studies should be scrutinized, since several test parameters were not based on observations of the human physiology.

Conclusion

The limited comparability and restricted clinical implications should be kept in mind when interpreting the results of biomechanical studies and when designing test setups to evaluate fixation methods for acetabular fractures.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01936-9.

Functional outcomes more than 5 years following acetabulum fracture

Objectives:

The purposes of this project were to evaluate functional outcomes more than 5 years after acetabulum fracture and to determine factors related to function.

Methods:

This retrospective study consisted of 205 adult patients treated for acetabulum fracture who completed the Musculoskeletal Function Assessment (MFA) a minimum of 5 years following injury. The MFA includes survey of daily activities, gross and fine mobility, social and work function, sleeping, and mood. Higher scores indicate worse function.

Results:

Two hundred five patients with 210 fractures, 69.3% of whom were male, with mean age of 45.7 and mean body mass index 30.1 were included after mean 128 months follow-up. Fracture patterns included OTA/AO 62A (37.1%), 62B (40.5%), or 62C (22.4%), and 80.0% were treated surgically. Late complications were noted in 35.2%, including posttraumatic arthrosis (PTA: 19.5%), osteonecrosis and/or heterotopic ossification. Mean MFA of all patients was 31.4, indicating substantial residual dysfunction. Worse MFA scores were associated with morbid obesity (body mass index >40: 42.3, P>.09), and current tobacco smoking history vs former smoker vs nonsmoker (45.2 vs 36.1 vs 23.0, P < .002). Patients with late complications had worse mean MFA scores (38.7 vs 27.7, P = .001); PTA was the most common late complication, occurring in 19.5%.

Conclusions:

More than 5 years following acetabulum fracture, substantial residual dysfunction was noted, as demonstrated by mean MFA. Worse outcomes were associated with late complications and tobacco smoking. While fracture pattern was not associated with outcome, those patients who had late complications, mostly PTA, had worse outcomes.

A Systematic Review and Meta-Analysis of 3D Printing Technology for the Treatment of Acetabular Fractures

Purpose

Three-dimensional (3D) printing technology has been widely used in orthopedics surgery. However, its efficacy in acetabular fractures remains unclear. The aim of this systematic review and meta-analysis was to examine the effect of using 3D printing technology in the surgery for acetabular fractures.

Methods

The systematic review was performed following the PRISMA guidelines. Four major electronic databases were searched (inception to February 2021). Studies were screened using a priori criteria. Data from each study were extracted by two independent reviewers and organized using a standardized table. Data were pooled and presented in forest plots.

Results

Thirteen studies were included in the final analysis. Four were prospective randomized trials, and nine used a retrospective comparative design. The patients aged between 32.1 (SD 14.6) years and 51.9 (SD 18.9) years. Based on the pooled analyses, overall, 3D printing-assisted surgery decreased operation time by 38.8 minutes (95% CI: -54.9, -22.8), intraoperative blood loss by 259.7 ml (95% CI: -394.6, -124.9), instrumentation time by 34.1 minutes (95% CI: -49.0, -19.1). Traditional surgery was less likely to achieve good/excellent function of hip (RR, 0.53; 95% CI: 0.34, 0.82) and more likely to have complications than 3D printing-assisted surgery (RR, 1.19; 95% CI: 1.07, 1.33).

Conclusions

3D printing technology demonstrated efficacy in the treatment of acetabular fractures. It may improve surgery-related and clinical outcomes. More prospective studies using a rigorous design (e.g., randomized trial with blinding) are warranted to confirm the long-term effects of 3D printing technology in orthopedics surgeries.

The horizontal shear fracture of the pelvis

PURPOSE

Various classification systems describe fractures of the acetabulum and pelvis separately. Horizontal shear fractures involve the pelvic ring and both acetabula and have not been previously described. The aim of this study is to describe the horizontal shear fracture of the pelvis.

METHODS

At a level 1 trauma centre over 10 years from December 2008 to December 2018, 1242 patients had pelvic and acetabular fractures. Six patients had horizontal shear fractures, comprising 0.5% of all pelvic and acetabular fractures. Demographic, clinical and radiological data was collected. Clinical outcomes were pain and mobility level, sciatic nerve symptoms, further acetabular or pelvic surgery, or total hip arthroplasty. Radiological outcomes included fracture displacement, implant migration, femoral head osteonecrosis, and post-traumatic arthritis. Outcomes were assessed at a minimum 12 month follow-up.

RESULTS

The median patient age was 35 years. Five of six shear fractures were due to motorcycle crashes. No mortalities occurred. At follow-up, three patients reported pain, two patients had difficulty mobilising associated with traumatic sciatic nerve injury, and one patient underwent total hip arthroplasty for femoral head osteonecrosis. No fracture displacement or implant migration occurred. The Matta arthritis grade was excellent or good in all except one hip. Median follow-up time was 1.8 (range 1.1-7.8) years.

CONCLUSION

The horizontal shear fracture of the pelvis is a high-energy injury characterised by separation of the anterior and posterior pelvic ring through the acetabula. Good outcomes can be achieved with open reduction and internal fixation of displaced fractures.

Three-dimensional printing combined with open reduction and internal fixation versus open reduction and internal fixation in the treatment of acetabular fractures: A systematic review and meta-analysis

PURPOSE

This meta-analysis compared the clinical outcome of three-dimensional (3D) printing combined with open reduction and internal fixation (ORIF) to traditional ORIF in the treatment of acetabular fractures.

METHODS

We searched the Cochrane Library, PubMed, Embase, VIP database, CNKI, and Wanfang database with keywords "acetabular fracture", "3D printing", "three-dimensional printing", "open reduction and internal fixation", "Acetabulum", "Acetabula" from January 2000 to March 2020. Two reviewers independently selected articles, extracted data, assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration' s tools and/or Newcastle-Ottawa scale. When the two analysts had different opinions, they would ask the third analyst for opinion. Randomized controlled trials or retrospective comparative studies of 3D printing combined with ORIF (3D printing group) versus traditional ORIF (conventional group) in the treatment of acetabular fractures were selected. The data of operation time, intraoperative blood loss, intraoperative fluoroscopy times, incidence of complications, excellent and good rate of Matta score for reduction, and excellent and good rate of hip function score were extracted. Stata14.0 statistical software was used for data analysis.

RESULTS

Altogether 9 articles were selected, including 5 randomized controlled trials and 4 retrospective studies. A total of 467 patients were analyzed, 250 in the conventional group, and 217 in the 3D printing group. The operation time in the 3D printing group was less than that in the conventional group and the difference was statistically significant (standardized mean difference (SMD) = -1.19, 95% CI: -1.55 to -0.82, p < 0.05). The intraoperative bleeding volume of the 3D printing group was significantly lower than that of the conventional group (SMD = -1.08, 95% CI: -1.65 to -0.51, p < 0.05). The fluoroscopy times were less in the 3D printing group than in the conventional group and the difference was statistically significant (SMD = -1.64, 95% CI: -2.35 to -0.93, p < 0.05). The total incidence of complications in the 3D printing group was significantly lower than that in the conventional group (OR = 0.43, 95% CI: 0.24-0.79, p < 0.05). There was no significant difference in the excellent and good rate of Matta score for reduction between the two groups (OR = 0.60, 95% CI: 0.34-1.06, p > 0.05). There was no significant difference in the excellent and good rate of hip function score at the end of postoperative follow-up between the two groups (OR = 0.84, 95% CI: 0.46-1.56, p > 0.05), but the follow-up time varies from 6 months to 40 months.

CONCLUSION

Compared with traditional ORIF, 3D printing combined with ORIF has certain advantages in terms that 3D printing not only helps surgeons to understand acetabular fractures more intuitively, but also effectively reduces operation time, intraoperative blood loss, intraoperative fluoroscopy times, and postoperative complications. However, there were no significant differences in the excellent and good rate of Matta score for reduction and the excellent and good rate of hip function score at the end of follow-up.

Feasibility of Imaging-Based 3-Dimensional Models to Design Patient-Specific Osteosynthesis Plates and Drilling Guides

IMPORTANCE

In acetabular fracture surgery, achieving an optimal reconstruction of the articular surface decreases the risk of osteoarthritis and the subsequent need for total hip arthroplasty. However, no one-size-fits-all osteosynthesis plate is available owing to differences in fracture patterns and variations in pelvic anatomy. Currently, osteosynthesis plates need to be manually contoured intraoperatively, often resulting in inadequate reduction and fixation of the fractured segments.

OBJECTIVE

To determine the feasibility and accuracy of a novel concept of fast-track 3-dimensional (3-D) virtual surgical planning and patient-specific osteosynthesis for complex acetabular fracture surgery.

DESIGN, SETTING, AND PARTICIPANTS

This case series study examines the use of patient-specific osteosynthesis plates for patients needing operative treatment for displaced associated-type acetabular fractures at a tertiary university-affiliated referral center and level 1 trauma center between January 1, 2017, and December 31, 2018. Models were created in 3-D based on computed tomography (CT) data, fractures were virtually reduced, and implant positions were discussed in a multidisciplinary team of clinicians and engineers. Patient-specific osteosynthesis plates with drilling guides were designed, produced, sterilized and clinically applied within 4 days. Data were analyzed at the 1-year follow-up.

EXPOSURES

Development and clinical implementation of personalized fracture surgery.

MAIN OUTCOMES AND MEASURES

The primary outcome was the quality of the reduction as determined by the postoperative CT scan. The secondary outcomes were accuracy of the screw placement and clinical outcome using patient-reported outcome measures.

RESULTS

Ten patients with a median (range) age of 63 (46-79) years with an acetabular fracture were included. The median (interquartile range [IQR]) preoperative gap was 20 (15-22) mm, and the median (IQR) step-off was 5 (3-11) mm. Postoperatively, the median (IQR) gap was reduced to 3 (2-5) mm (P = .005), and the median (IQR) step-off was reduced to 0 (0-2) mm (P = .01), indicating good fracture reduction, indicating good fracture reduction. The mean difference between the preoperative and postoperative gap was 14.6 (95% CI, 10-19) mm, and the mean difference in step-off was 5.7 (95% CI, 2-9) mm. The median (IQR) difference in screw direction between the planning and actual surgery was only 7.1° (7°-8°). All patients retained their native hip and reported good physical functioning at follow-up.

CONCLUSIONS AND RELEVANCE

These findings suggest that 3-D virtual surgical planning, manufacturing, and clinical application of patient-specific osteosynthesis plates and drilling guides was feasible and yielded good clinical outcomes. Fast-track personalized surgical treatment could open a new era for the treatment of complex injuries.

Socioeconomic Factors Influencing Self-reported Outcomes After Posterior Wall Fractures of the Acetabulum: Lessons Learned From a Hispanic Population

Introduction:

Demographic and socioeconomic factors are important determinants that may affect patient self-reported outcomes after acetabular fracture surgery. Hispanics, as a minority group, have an increased tendency to suffer demographic and socioeconomic disparities. At the present time, there is scant information regarding their role among Hispanic patients with acetabular fractures. The aim of this study was to investigate whether demographic or socioeconomic factors would affect satisfaction and self-reported functional outcomes in Hispanic patients who endured open reduction and internal fixation (ORIF) of posterior wall fractures of the acetabulum.

Methods:

A cross-sectional study of 78 patients with posterior wall fracture of the acetabulum treated with ORIF from 2011 to 2017 was performed. Data from demographics (age, sex, and body mass index [BMI]) and socioeconomic factors (household income, highest educational level achieved, employment status, type of medical insurance, workers' compensation involvement, and injury-related litigation process) were obtained and compared with the Short Musculoskeletal Form Assessment-46 (SMFA-46) questionnaire using a multivariable logistic regression analysis.

Results:

Unemployment was the most significant variable associated with dissatisfaction among 15 of the 46 responses of the SMFA-46 (P < 0.048). Patients who had an overweight or obese BMI and had an age of 41 years or older exhibited significantly worse outcomes in 7 of the 46 questions (P < 0.049). Finally, women were less likely to be satisfied in 1 of the 46 questions (P = 0.028). No notable difference was observed in any of the SMFA-46 responses regarding insurance plan, educational level, workers' compensation involvement, and injury-related litigation process.

Discussion:

A strong association exists between dissatisfaction after ORIF of posterior wall fractures of the acetabulum and employment status, BMI, and age among the Hispanic population. Addressing socioeconomic factors can be critical to overcome dissatisfaction and improve functional status among Hispanic patients with acetabular fractures.

Epidemiology of pelvic and acetabular fractures in France

INTRODUCTION

Acetabular and pelvic fracture accounts for 1.5% of fractures in adults and 2-5% of fractures requiring hospital admission. Several national-level epidemiological studies have been conducted outside France, but French national data are not known. We therefore assessed all patients admitted for acetabular or pelvic fracture in France between 2006 and 2016. The study objectives were: 1) to determine incidence of acetabular and pelvic fracture, 2) to determine progression in incidence between 2006 and 2016, and 3) to determine progression in treatment.

HYPOTHESIS

Incidence of acetabular and pelvic fracture in France is increasing.

METHODS

The following data for the period 2006-2016 were collated from the French national health insurance (CPAM: Caisse Primaire d'Assurance Maladie) database: gender, age, type of treatment, and geographical distribution by administrative area (Département). Two-tailed Student tests were used for comparison of means for numerical variables between independent samples; linear regression was used to analyze correlations; and the Chi² test was used to compare percentages of categoric variables.

RESULTS

There were 32,614 acetabular and 164,694 pelvic fractures, with male predominance for the acetabulum and female predominance for the pelvis. Mean age at acetabular fracture was 66±22 years (range, 1-108 years), and 74±20 years (range, 1-112 years) for pelvic fracture. The rate of acetabular fracture increased to 3,301 in 2016 from 2,316 in 2006, with a strong increase in the rate of pelvic fracture, to 18,902 in 2016 from 10,806 in 2006. Incidence of acetabular fracture per 100,000 increased from 3.67 in 2006 to 4.95 in 2016, and from 17.06 to 23.18 in over-75 year-olds. Incidence of pelvic fracture per 100,000 increased from 17.1 to 28.33, and from 129.30 to 210.69 in over-75 year-olds. Linear regression predicts incidence per 100,000 of 5.9 for acetabular fracture and of 41 for pelvic fracture by 2030 in young subjects and 32 and 309 respectively in over-75 year-olds. Management was surgical for acetabular fracture in 12.31% of cases in 2006 and in 14.33% in 2016, and in 1.43% and 2.16% respectively for pelvic fracture.

DISCUSSION

The present data agree with previous reports, with strong increase in incidence of fracture in young and especially in elderly subjects. In elderly subjects, such fractures may require surgery.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

A new internal fixation technique for acetabular fractures involving the quadrilateral plate

BACKGROUND

The treatment of acetabular fracture involving the quadrilateral plate is a technical challenge, and the optimal management of the fracture remains controversial. We have designed a new implant (named acetabular fracture reduction internal fixator, AFRIF) for acetabular fractures involving the quadrilateral plate. This use of this new device was not investigated therefore we conducted a retrospective study aiming to determine whether the AFRIF can achieve satisfactory clinical and radiological outcomes for quadrilateral plate fracture.

HYPOTHESIS

The AFRIF for quadrilateral plate fracture is an acceptable option to treat acetabular fracture involving the quadrilateral plate.

MATERIALS AND METHODS

We performed a retrospective analysis of prospectively collected data on 24 patients (15 males and 9 females) with acute displaced quadrilateral plate fractures of the acetabulum who were treated by the AFRIF between August 2011 and May 2015. The mean age of the patients was 61.5±9.2 years (range, 31-82 years). All hips had protrusion of the femoral head, of these 5 hips with associated articular impaction of the medial roof. The type of fractures included anterior column in 4, anterior column+posterior hemitransverse in 3, associated both column in 11, T-shaped in 6 patients. The approaches included Limited Ilioinguinal (5 patients) and Limited Standard-Ilioinguinal combined with Kocher-Langenbeck (19 patients). Quality of reduction was evaluated and graded as anatomical (0mm to 1mm of displacement), imperfect (2mm to 3mm displacement) or poor (more than 3mm displacement) according to the residual displacement as defined by Matta. The final follow-up clinical outcome was classified as excellent (18 points), good (15-17 points), fair (13-14 points) or poor (<13 points) in terms to the modified Merle d'Aubigné-Postel score, and radiological outcomes evaluation were as excellent, good, fair, or poor based on Matta score.

RESULTS

The mean duration of follow-up was 45.7±13.0 months (range, 24-60 months). Average operative time and bleeding amount was 110.3±30.8min (range, 105-210min) and 950.6±348.6ml (range, 300-1500ml), respectively. There was anatomical reduction in 17 patients (17/24, 70.8%), imperfect in 5 patients (5/24, 20.8%), and poor in 2 patients (2/24, 8.3%). All of the quadrilateral plate fractures achieved anatomical except one imperfect reduction. No re-protrusion of the femoral head was observed at the final follow-up. The mean modified Merle d'Aubigné-Postel score was 16.9±2.0 points (range, 10-18 points), and 83.3% (20 of 24) have good or excellent radiological outcomes.

DISCUSSION

The findings suggest that the AFRIF for quadrilateral plate fractures may prevent protrusion of the femoral head and achieve good to excellent clinical and radiological outcomes.

LEVEL OF EVIDENCE

IV, retrospective study.

Posterior wall fractures associated with both-column acetabular fractures can be skilfully ignored

INTRODUCTION

Posterior wall fractures may be associated with both-column acetabular fractures. Considering the differences in the pattern of these fractures in contrast to isolated posterior wall fractures, it is currently unclear whether they can be ignored or need to be addressed surgically.

HYPOTHESIS

Stable posterior wall fractures can be skilfully ignored in patients with both-column acetabular fractures operated by an ilioinguinal approach.

MATERIAL AND METHODS

We retrospectively reviewed 49 consecutive patients who were treated for both-column acetabular fractures between the years 2009 and 2018. Considering the association of posterior wall fractures, we divided the cohort into two groups: Group 1 (n=29): absence of posterior wall fractures; and Group 2 (n=20): presence of posterior wall fractures, subsequently treated while skilfully ignoring stable posterior wall fracture according to our criteria. Intergroup comparison of radiologic and clinical outcomes and multiple linear regression for predictors of clinical outcomes were analysed.

RESULTS

No significant intergroup difference in quality of reduction, post-traumatic osteoarthritis grade, or clinical outcome was noted. Poor post-traumatic osteoarthritis grade and poor quality of reduction of both acetabular columns were significant predictors of clinical outcomes in patients with both-column acetabular fractures. Whether posterior wall fracture was associated and skilfully ignored was unrelated to clinical outcomes.

DISCUSSION

Posterior wall fractures associated with both-column acetabular fractures can be successfully ignored if the posterior wall fragment is adequately attached to the acetabulum through the labrocapsular complex of the hip joint, and the hip-joint-congruency in the presence of<2-mm step-off and 3-mm gap.

LEVEL OF PROOF

III, prognostic.

Clavicle fractures: Associated trauma and morbidity

BACKGROUND

Clavicle fractures are frequently associated with trauma to regions beyond the immediate zone of injury. In order to provide surgeons with information on injury prevalence to prevent delays in diagnosis and management, we describe the epidemiology of concomitant injuries in patients with clavicle fractures and identify differences between those with open and closed fractures. Methods:The Nationwide Inpatient Sample (NIS) 2001-2013 database was queried for adult patients discharged with a diagnosis of a clavicle fracture using ICD-9 codes. A "common" injury was defined as prevalence ≥4.0% in our study population. We analyzed data for injury locations associated with open vs. closed clavicle fractures with chi square and independent samples t-tests.

RESULTS

A total of 41,1612 patients were included in our study population. The majority of patients had closed clavicle fractures (98.2%). The most common concomitant fracture was that of the rib, followed by the spine. The most common non-vascular, non-nervous injury was a hemo/pneumothorax followed by a lung, bronchus, or diaphragm injury. Fractures of the humerus, rib, scapula, pelvis, tibia or fibula, and facial bones as well as concussion, pneumo/hemothorax, other pulmonary, and splenic injuries were more common in patients with open clavicle fractures. Patients with open clavicle fractures were, on average, 11.8 years younger than those with closed fractures.

CONCLUSION

There is a significant association between clavicle fractures and concussion, splenic, and thoracic injuries, as well as increased rate of complications with open fractures. Clinicians may use this information to perform risk assessments prevent delays in diagnosis.

High- Versus Low-Energy Acetabular Fracture Outcomes in the Geriatric Population

Introduction:

High-energy mechanisms of acetabular fracture in the geriatric population are becoming increasingly common as older adults remain active later in life. This study compared outcomes for high- versus low-energy acetabular fractures in older adults.

Materials and Methods:

We studied outcomes of 22 older adults with acetabular fracture who were treated at a level-I trauma center over a 4-year period. Fourteen patients were categorized as low-energy mechanism of injury, and 8 were identified as a high-energy mechanism. We analyzed patient demographics with univariate logistic regressions performed to assess differences in high- and low-energy group as well as patient characteristics compared with surgical outcomes.

Results:

Most high-energy mechanisms were caused by motor vehicle collision (n = 4, 50.0%), with most having posterior wall fractures (50.0%). Among patient characteristics, the mechanism of injury, hip dislocation, fracture types, and fracture gap had the largest differences between energy groups effect size (ES: 2.45, 1.43, 1.36, and 0.83, respectively). The high-energy group was more likely to require surgery (odds ratio [OR] = 2.80, 95% CI: 0.26-30.70), develop heterotopic bone (OR = 4.33, 95% CI: 0.33-57.65), develop arthritis (OR = 3.60, 95% CI: 0.45-28.56), and had longer time to surgery (mean = 4.8 days, standard deviation [SD] = 5.8 days) compared to low-energy group (mean = 2.5 days, SD = 2.3 days).

Discussion:

The results of this case series confirm previous findings that patients with high-energy acetabular fractures are predominantly male, younger, and have fewer comorbidities than those who sustained low-energy fractures. Our results demonstrate that the majority of the high-energy fracture patients also suffered a concurrent hip dislocation with posterior wall fracture and experienced a longer time to surgery than the low-energy group.

Conclusion:

Geriatric patients who sustained high-energy acetabular fractures tend to have higher overall rates of complications, including infection, traumatic arthritis, and heterotopic bone formation when compared with patients with a low-energy fracture mechanism.

Operative versus non-operative treatment of displaced acetabular fractures in elderly patients

BACKGROUND

Acetabular fracture treatments in elderly patients are not well codified.

PURPOSE

The aim of the study was to determine if, for active elderly patients, the clinical results after surgical treatment of displaced acetabular fractures are better than for non-operative treatment.

METHODS

All active patients over 60 years with a Parker score higher than 6, managed for displaced acetabular fracture between 2005 and 2014, were included in this single-center retrospective study. Clinical outcomes were compared according to the therapeutic option (operative or non-operative) and the fracture pattern (anterior fracture that requires open reduction and internal fixation or posterior fracture that requires total hip arthroplasty).

RESULTS

Among the 82 patients with Parker score higher than 6, 44 were treated non-operatively and 38 were operated. Forty-seven had anterior fracture (AF) and 35 had posterior fracture (PF). In the AF group, the autonomy scores were better for operative than non-operative patients (p < 0.05) with a PARKER score 7.8 (7-8) versus 5.4 (1-9); ADL score 5.7 (4-6) versus 4.4 (1-6) and IADL score 7.6 (6-8) versus 4.2 (0-8). In the PF group, the autonomy scores were better for operative than non-operative patients (p < 0.05) with a PARKER score 7.3 (4-9) versus 5.6 (2-9), ADL score 5.3 (2-6) versus 4.4 (1-6) and IADL score 5.6 (2-8) versus 4.1 (1-7). Regarding clinical outcomes, the HARRIS and PMA scores were better for operative patients (p < 0.05).

CONCLUSION

Surgical treatment in elderly patients with displaced acetabular fractures is associated with better clinical outcomes than non-operative treatment when the autonomy level is comparable.

Epidemiology of pelvic fractures in adult: Our experience at two tertiary care hospital in Dhaka, Bangladesh

PURPOSE

In Bangladesh the incidence of pelvic fracture is increasing day by day due to suboptimal roads and heavy traffic. However, there is no epidemiological study of these injuries in Bangladesh. Our aim was to study the epidemiology of patients admitted with pelvic fractures at two tertiary care hospital in Dhaka, Bangladesh.

METHODS

This was a prospective study carried out on trauma patients with pelvic fracture at two level 1 trauma care center of two tertiary care hospital in Dhaka, Bangladesh. The study period was from July 2015 to June 2019 (48 months). Patient's data including demography of patients, mechanism of injuries, fracture types, associated injuries, method of treatment, post-operative complications, length of hospital stay were recorded according to a unified protocol.

RESULTS

The study population was comprised of 696 patients, where 556 (79.88%) were male and 140 (20.12%) were female. Mean age was 37.75 years and road traffic accidents were the most common mode of injuries. Lateral compression fractures were the most common injuries and Urethral injuries were the most common associated injuries. Death was the outcome in 3.5% of the cases due to high energy trauma.

CONCLUSION

This study revealed that pelvic fractures were significantly more frequent in men. Most frequent cause was road traffic accident. The majority of these cases did not required surgery. Mortality was associated with high velocity trauma with severe injuries.

Epidemiological assessment of acetabular fractures in a level one trauma centre: A 7-Year observational study

PURPOSE

The present study was conducted to evaluate the epidemiological characteristics of the Acetabular fractures treated in a level one trauma centre of India. This study is one of the largest to provide first-hand information regarding the demography, fracture patterns, other associated injuries, and the hospital stay of acetabular fractures in India.

METHOD

Patients admitted with the diagnosis of acetabular fractures between January 2013 and November 2019 were retrospectively analyzed in terms of demographic data such as age and sex, mechanism of injury, other associated injuries, and the duration of hospital stay.

RESULTS

A total of 305 patients with 313 fractures of the acetabulum were included in the study. Among the 305 patients, 268 (87.8%) were male and 37 (12.1%) were female, with a declining male to female ratio over the years. The mean age was 37.1 ± 13.2 years (range 14-84 years). During the seven years, the mean age of presentation progressively increased. Linear regression showed an increase from 33 to 40 years from 2013 to 2019 (R2 = 0.027). Road traffic injuries were the most common mechanism of injury, contributing to about 77.4% of all cases. Associated injuries were seen in 62% of total cases with multiple system involvement in 26.6% of patients. The most frequent pattern in this epidemiological study was an isolated posterior wall fracture (21.4%) while the isolated anterior wall was the least frequent (0.95%).

CONCLUSION

Acetabular fractures are increasing in numbers and with increasing knowledge so is their surgical management in our country. It shall be prudent to establish an integrated electronic national trauma registry to maintain complete documentation in all institutions dealing with trauma management to ascertain the changing trends of acetabular fracture patterns in the country over time.

Arthroscopically assisted treatment for nonconcentric reduction of hip posterior dislocation caused by acetabular labrum rim fracture: Medium-term clinical and radiological outcomes

BACKGROUND

Nonconcentric reduction of hip posterior dislocation caused by the acetabular labrum rim fracture is rare. There has been very little study on the feasibility of arthroscopically treatment and medium and mid-term evaluation to this pathology. The objectives of the current study were: (1) Is the arthroscopically assisted technique feasible to this manage this injury? (2) What is the effectiveness of arthroscopic treatment for nonconcentric reduction of hip posterior dislocation caused by acetabular labrum rim fracture.

HYPOTHESIS

Arthroscopically assisted procedure is an alternative treatment modality for nonconcentric reduction of hip posterior dislocation caused by acetabular labrum rim fracture.

PATIENTS AND METHODS

Thirteen of 257 posterior hip dislocations who were admitted to our hospital from February 2008 to March 2017 were included: 9 males and 4 females, with an average age of 23.7 (15-36) years. All of them underwent hip posterior dislocation and nonconcentric reduction related to acetabular labrum rim fracture. All of them had arthroscopic reduction and fixation of the rim fracture. Visual Analogic Score (VAS) score, modified Harris score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and the last follow-up radiographs were analyzed respectively. Postoperative complication and the need for secondary operation were recorded during the process.

RESULTS

The incidence rate of this pathology was nearly 5%. Twelve out of 13 patients were followed up for an average of 42 (range, 26-68) months. At the final follow-up, VAS score was decreased from 5.2±0.9 (range, 4.0-6.1) preoperatively to 0.5±0.5 (range, 0.0-1.0) (p<0.0001), modified Harris score and WOMAC score were increased statistically significant from 32±8 (range, 28-40) and 30±5 (range, 25-35) to 94±5 (range, 89-99) and 95±4 (range, 91-99) respectively (p<0.0001). All patients have had completely concentric reduction and returned to activities of daily life. There was not any hip arthroscopic complication such as sciatic nerve injury and intra-abdominal fluid extravasation. Besides, there were no aseptic necrosis and revision case.

CONCLUSION

Arthroscopically assisted procedure is an alternative treatment modality for nonconcentric reduction of hip posterior dislocation caused by the acetabular labrum rim fracture without surgical dislocation procedure. Good clinical results can be achieved without any complications related to the surgical procedure.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Posterolateral clamp placement on the pelvic brim provides optimal reduction of transtectal acetabular fractures fixed through the anterior intrapelvic approach

PURPOSE

To determine the optimal position of reduction clamps applied to reduce transtectal transverse acetabular fractures approached through the anterior intrapelvic route.

METHODS

Transtectal transverse fractures were created in sawbone hemipelvis models. Fractures were reduced and held with a large pointed reduction clamp with one tine centered on the quadrilateral plate and the other placed in one of nine various positions on the pelvic brim accessible from the anterior intrapelvic (AIP) approach. Reduction was assessed by measuring maximum gapping and step-off at the joint surface.

RESULTS

The posterolateral pelvic brim clamp position provided the most accurate reduction with the smallest articular fracture gap (mean 1.09 ± 1.05 mm) and step-off (mean 0.87 ± 1.35 mm). This clamp position, compared with the other positions as a whole, also yielded the highest proportion of perfect reductions (0 mm maximum displacement) for both step-off (83% vs 34%; RR 2.4, 95% CI 1.7-3.2) and gap (88% vs 49%; RR 1.8, 95% CI 1.4 to 2.2).

CONCLUSIONS

When clamping transtectal fractures through the AIP approach, positioning the clamp posterolaterally on the pelvic brim appears to provide the best reduction in this fracture model.

A Survey of High- and Low-Energy Acetabular Fractures in Elderly Patients

Introduction:

Geriatric patients represent 14% of acetabular fractures and are the fastest growing subset of patients affected by this injury in the US. Treatment outcomes have been reported as inferior to those achieved in younger patients after high-energy (HE) acetabular trauma. This study aimed to compare detailed demographic characteristics and clinical outcomes in elderly patients (≥65 years of age) treated in a tertiary North American trauma center for acetabular fractures after both high- and low-energy mechanisms of injury.

Methods:

Patients (≥65 years of age) diagnosed with an acetabular fracture were identified over a 7-year period. Patient and injury characteristics were extracted from our institutional trauma database. Length of stay, intervention, operative details, disposition, complications, readmissions, and mortality were analyzed.

Results:

One hundred nine patients were identified for inclusion. Low-energy mechanisms (simple falls) were found in 64 (58.7%) and HE mechanisms in 45 (41.3%) patients. The HE cohort was younger (74.6 vs 80.7 years; P < .001), had a higher male predominance (76% vs 56%; P = .10), a lower Charlson comorbidity index (1.29 ± 1.49 vs 2.16 ± 1.76; P = .01), and a higher injury severity score (19.90 ± 15.33 vs 6.46 ± 3.57; P < .001). Fracture patterns, described according to the Letournel-Judet classification, were similar between the 2 groups. Thirty-day mortality was significantly higher in the HE group (26.7% vs 3.1%; P < .001); however, the 1-year mortality rates were not statistically different (31.1% vs 25.0%; P = .20).

Discussion:

Patients with acetabular fractures sustained due to HE accidents demonstrate significantly higher 30-day mortality rate than patients with low-energy fractures, but similar mortality 1 year after the injury, despite having a much lower mean age and fewer comorbidities.

Conclusion:

Medical efforts made during initial hospital admission may have the biggest impact on survivorship following acetabular fracture.

Surgical Repair of Acetabular Fracture Using Unidirectional Porous β-Tricalcium Phosphate

We report a case of an acetabular fracture treated using a unidirectional porous β-tricalcium phosphate artificial bone (Affinos®) to surgically repair bone defects. An 82-year-old man sustained an acetabular fracture on the left side and presented with shock on arrival along with impaired vital signs and systolic blood pressure. Upon stabilization, we performed an open reduction and internal fixation. However, there were significant bone defects, which were then fixed using Affinos® (both blocks and granules), an artificial β-tricalcium phosphate bone with a porosity of 57% (pore size: 25–300 μm), characterized by a novel unidirectional porous structure. By 18 months postoperatively, the patient was able to perform stair climbing and absorption and bone fusion around the artificial bone were observed. Affinos® has a frost-like structure, which endows it with good tissue-invasive properties because of the capillary effect. Moreover, it has excellent osteoconduction capability. In this case, both Affinos® blocks and granules showed good affinity, absorption, and bone substitution. Further prospective studies are required to confirm our findings.

The Relevance of the Judet and Letournel Acetabular Fracture Classification System in the Modern Era: A Review

The Judet and Letournel acetabular fracture classification system, based on the idea of bicolumnar support of the acetabulum, was first described in a landmark article published in the 1960s. It has stood the test of time and continues to be the preferred method for describing acetabular fractures for the majority of orthopaedic trauma surgeons. Still, there have been attempts to modify or replace Letournel system since its introduction for a variety of reasons, chief among them a perceived inability of the classification system to account for a number of transitional fracture patterns and injury modifiers that may affect surgical decision making and patient outcomes. In this review, we present the literature related to the Judet and Letournel acetabular fracture classification system, over 50 years after its first formal description. We summarize its strengths, weaknesses, and its place in our current understanding of acetabular fractures and their recommended management.

A growing problem: cycling referrals to the National Centre for Pelvic and Acetabular Fracture Management in Ireland

BACKGROUND

Popularity in cycling continues to grow. In Ireland, in the last 5 years, 42% more people now use it to travel to work. This has been mirrored by a rise in cycling-related trauma and deaths. The popularity amongst men has led to the term middle-aged men in Lycra (MAMIL) being coined.

AIMS

The purpose of our study was to quantify cycling-related pelvic and acetabular fracture referrals in Ireland and determine injury patterns, cost and functional outcomes following these injuries.

METHODS

A retrospective cohort study was conducted of all referrals to our institution, the National Centre for Pelvis and Acetabular Fracture Management, in 2016 and 2017. Demographic, mechanism of injury, concomitant trauma and treatment data were analysed. Patients were contacted to assess return to work, sport and quality of life (EQ-5D-3L).

RESULTS

Cycling injury referrals increased by 90% between 2016 and 2017 with a greater number of cycling than motorbike injury referrals. Twenty-nine patients sustained a pelvic and acetabular (PA) injury while cycling. The mean patient age was 51.7 years of which 86.2% were male with 41% suffering a concomitant injury. Fourteen patients (48.3%) required surgery of which 60% have returned to cycling. Mean cost of treatment was €11,757. The median EQVAS was 80.

CONCLUSIONS

The rise in popularity of cycling has been mirrored by an increase in PA injuries and deaths. These injuries are associated with significant costs to the patient, hospital and society. Greater investment in safety and awareness is needed to protect this vulnerable group.

Outcomes of acetabular fractures in the elderly: a five year retrospective study of twenty seven patients with primary total hip replacement

PURPOSES

Open reduction and internal fixation (ORIF) in osteoporotic acetabular fractures is quite difficult with high risk of implant failure. Total hip arthroplasty (THA) may be an effective option for treating acetabular fractures in appropriately selected patients, with immediate full weightbearing. The aim of the study was to evaluate the functional outcomes of primary THA for acetabular fractures in elderly patients.

METHODS

Between 2010 and 2015, 27 elderly patients operated for acetabular fractures by primary THA were included. The surgical technique associated plate stabilization of both acetabular columns with THA using an acetabular reinforcement cross-plate. Mean age was 68.5 years (57-84) and mean ASA was 2 (1-3). The mean follow-up was four years.

RESULTS

The mean Harris score was 70.4 ± 23 (24-90), and the mean Postel-Merle Aubigné (PMA) score was 14.3 ± 4 (7-18). For 17 patients with rank of pre-operative Devane 4, the post-operative rank was unchanged (p < 0.05). Twenty patients (74%) were satisfied by the surgical treatment. Twenty post-operative complications (74%) were found. Two patients died during follow-up (7%).

CONCLUSIONS

Primary THA for acetabular fracture in the elderly population might be a good therapeutic option that allows return to the previous daily life activity. Three patients (11%) became bedridden, and four patient's skiers (15%) returned to skiing. However, this surgery is difficult and selection of elderly patients, i.e., with acetabular fractures who are expected to get a poor result with ORIF, i.e., fracture patterns with posterior wall lesion and marginal impaction, for primary THA in an experienced centre provides satisfactory clinical results.

Complex fractures of the acetabulum: Should the enlarged iliofemoral approach be abandoned? Results at 20 years' follow-up

INTRODUCTION

Among the various options for internal fixation of acetabular fractures, the enlarged iliofemoral approach is less often used, being more invasive, although providing greater exposure enabling control of all components in complex fractures. Even so, the impact of its invasiveness has not been confirmed, and long-term results are not known. We therefore performed a retrospective study, aiming: to assess long-term functional outcome, and; to assess associated morbidity.

HYPOTHESIS

The enlarged iliofemoral approach allows precise reduction, with favorable long-term outcome.

MATERIAL AND METHODS

Between 1992 and 1997, 15 patients were operated on for complex acetabular fracture by a single surgeon using an enlarged iliofemoral approach. Two patients were excluded due to lack of follow-up data, leaving 13 patients for analysis: 3 simple transverse fractures, 4 transverse+posterior wall fractures, 4 anterior column+posterior hemi-transverse fractures, one T-shaped fracture and one 2-column fracture. There were 4 cases of posterior dislocation of the hip, and 8 of intrapelvic protrusion. Surgical morbidity was assessed in terms of operative time, number of packed red blood cell transfusions, iatrogenic lesions or postoperative complications, rehabilitation time, and hospital stay. Functional assessment at follow-up used the WOMAC index and Harris score; radiologic assessment used the Kellgren-Lawrence score for osteoarthritis and Brooker score for ossification.

RESULTS

Reduction was in all cases anatomic. There were no intra- or post-operative complications. Median number of packed red blood cell transfusions was 5 [range, 3-10]. Median operative time was 4hours [3-6]. Median hospital stay was 6 weeks [6-8], to allow systematic traction with early postoperative mobilization. Weight-bearing was resumed at a median 8 weeks [8-12]. At a median 22 years' follow-up [20-24], median Harris score was 83.5 [63-92] and median WOMAC index 24.5 [1-52]. All patients showed Brooker 1 or 2 ectopic ossification and moderate osteoarthritis. Two underwent subsequent arthroplasty (at 1 and 11 years after the index procedure).

DISCUSSION

The enlarged iliofemoral approach allowed anatomic reduction of acetabular fracture. It provided very good long-term results, without excessive morbidity.

LEVEL OF EVIDENCE

IV, retrospective non-controlled study.

Computer-assisted surgery in acetabular fractures: Virtual reduction of acetabular fracture using the first patient-specific biomechanical model simulator

Preoperative planning for the management of acetabular fracture is founded on geometric models allowing virtual repositioning of the bone fragments, but not taking account of soft tissue and the realities of the surgical procedure. The present technical note reports results using the first simulator to be based on a patient-specific biomechanical model, simulating the action of forces on the fragments and also the interactions between soft issue and bone: muscles, capsules, ligaments, and bone contacts. In all 14 cases, biomechanical simulation faithfully reproduced the intraoperative behavior of the various bone fragments and reduction quality. On Matta's criteria, anatomic reduction was achieved in 12 of the 14 patients (86%; 0.25mm±0.45 [range: 0-1]) and in the 12 corresponding simulations (86%; 0.42mm±0.51 [range: 0-1]). Mean semi-automatic segmentation time was 156min±37.9 [range: 120-180]. Mean simulation time was 23min±9 [range: 16-38]. The model needs larger-scale prospective validation, but offers a new tool suitable for teaching purposes and for assessment of surgical results in acetabular fracture.

LEVEL OF EVIDENCE

IV: retrospective study.

Computer assisted surgery in preoperative planning of acetabular fracture surgery: state of the art

INTRODUCTION

The development of imaging modalities and computer technology provides a new approach in acetabular surgery.

AREAS COVERED

This review describes the role of computer-assisted surgery (CAS) in understanding of the fracture patterns, in the virtual preoperative planning of the surgery and in the use of custom-made plates in acetabular fractures with or without 3D printing technologies. A Pubmed internet research of the English literature of the last 20 years was carried out about studies concerning computer-assisted surgery in acetabular fractures. The several steps for CAS in acetabular fracture surgery are presented and commented by the main author regarding to his personal experience.

EXPERT COMMENTARY

Computer-assisted surgery in acetabular fractures is still initial experiences with promising results. Patient-specific biomechanical models considering soft tissues should be developed to allow a more realistic planning.