Management of anteromedially displaced acetabular fractures using a collinear reduction clamp through modified ilioinguinal approach

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.

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 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.

Supra-ilioinguinal versus modified Stoppa approach in the treatment of acetabular fractures: reduction quality and early clinical results of a retrospective study

Background

To compare the efficacy of the operative techniques, complications, reduction quality and hip functional recovery by using the supra-ilioinguinal approach and the modified Stoppa approach for the management of acetabular fractures.

Methods

A consecutive cohort of 60 patients from September 2014 to October 2017 with displaced acetabular fractures involving the quadrilateral plate were treated operatively with supra-ilioinguinal approach (group A) and modified Stoppa approach (group B), respectively. There were 36 patients in group A and 24 patients in group B. The surgical details, complications, radiographic and clinical results were recorded. The quality of reduction was assessed by measuring the residual step and gap displacement of postoperative CT with a standardized digital method.

Results

The complications, reduction quality (gaps and steps) and hip function recovery had no significant statistical difference in approaches. The mean operative time was shorter and the mean intraoperative haemorrhage was less in group A. There were statistical differences in the operative time (P = 0.025) and intraoperative haemorrhage (P = 0.003) between the supra-ilioinguinal approach and the modified Stoppa approach.

Conclusion

Compared to the modified Stoppa approach, the supra-ilioinguinal approach provides a closer visualization to the quadrilateral plate, the operative time was shorter and the intraoperative haemorrhage was clearly less. It is at least equal to or could be a better choice to deal with complicated acetabular fractures especially involving the quadrilateral plate and the anterior one third of the iliac bone.

Comparison of three different reduction methods of the ankle mortise in unstable syndesmotic injuries

In order to achieve a clinically satisfying result and to prevent posttraumatic osteoarthritis in the treatment of unstable syndesmotic injuries, anatomically correct reduction is crucial. The objective of the study was to investigate three different reduction methods of the ankle mortise in unstable syndesmotic injuries. In a specimen model with 38 uninjured fresh-frozen lower legs, a complete syndesmotic dissection was performed. The ankle mortise was reduced with either a collinear reduction clamp, a conventional reduction forceps or manually with crossing K-wires. The reduction clamps and the K-wires were placed in a 0°-angle to the leg axis. The clamps were positioned on the posterolateral ridge of the fibula 20 mm proximal to the ankle joint line. A cone beam computed tomography was performed after dissection and after each reduction. Tibio-fibular distances and angles were determined. Despite significant differences in terms of overcompression (0.09–0.33 mm; p = 0.000–0.063) and the slight external rotation (0.29–0.47°; p = 0.014–0.07), the results show a satisfying reduction of the ankle mortise. There were no considerable differences between the reduction methods. It can therefore be concluded that the ankle mortise can be reduced with any of the methods used, but that the positioning and the contact pressure must be considered.