Treatment of acetabular fractures with quadrilateral plate injury - a comparison of two commonly used methods

Experimental study on the biomechanical stability of complex acetabular fractures in the quadrilateral area: application of a dynamic anterior titanium-plate screw system

BACKGROUND AND OBJECTIVE

Complex acetabular fractures involving quadrilateral areas are more challenging to treat during surgery. To date, there has been no ideal internal fixation for these acetabular fractures. The purpose of this study was to evaluate the biomechanical stability of complex acetabular fractures using a dynamic anterior titanium-plate screw system of the quadrilateral area (DAPSQ) by simulating the standing and sitting positions of pelvic specimens.

MATERIALS AND METHODS

Eight formal in-preserved cadaveric pelvises aged 30-50 years were selected as the research objects. First, one hip of the normal pelvises was randomly used as the control model (group B) for measurement, and then one hip of the pelvises was randomly selected to make the fracture model in the 8 intact pelvises as the experimental model (group A) for measurement. In group A, acetabular both-column fractures in the quadrilateral area were established, and the fractures were fixed by DAPSQ. The biomechanical testing machine was used to load (simulated physiological load) from 400 N to 700 N at a 1 mm/min speed for 30 s in the vertical direction when the specimens were measured at random in simulated standing or sitting positions in groups. The horizontal displacement and longitudinal displacement of the acetabular fractures in the quadrilateral area were measured in both the standing and sitting simulations.

RESULTS

As the load increased, no dislocation or internal fixation breakage occurred during the measurements. In the standing position, the horizontal displacement of the quadrilateral area fractures in group A and group B appeared to be less than 1 mm with loads ranging from 400 N to 700 N, and there was no significant difference between group A and group B (p > 0.05). The longitudinal displacement appeared to be greater than 1 mm with a load of 700 mm in group A (700 N, 2 cases), and the difference was significant between group A and group B (p < 0.05). In the sitting position, the horizontal and longitudinal displacements of the quadrilateral areas were within 0.5 mm in group A and group B, and there was no significant difference between group A and group B (p > 0.05).

CONCLUSION

For complex acetabular fractures in the quadrilateral area, DAPSQ fixation may provide early sitting stability, but it is inappropriate for patients to stand too early.

Clinical and radiographic results of internal fixation of quadrilateral plate fractures of acetabulum

INTRODUCTION

Quadrilateral plate (QLP) is a relatively thin bony structure located below the pelvic brim proximal to the hip joint, so management of its fractures is challenging.

OBJECTIVES

Evaluation of the functional and radiological outcomes of internal fixation of quadrilateral plate acetabular fractures; comparison of two methods of fracture fixation.

PATIENTS AND METHODS

A prospective multicentric study including 30 patients who underwent open reduction and internal fixation of QLP fractures through modified Stoppa approach. Patients were divided into two groups according to the method of fixation (anatomical QLP plate vs suprapectineal and infrapectineal plates). Post-operative quality of reduction was evaluated using Matta score. Radiographical assessment according Matta's grading criteria and clinical outcome assessment using the Harris Hip Score (HHS) were repeated at follow-up and at one year to assess displacement.

RESULTS

Mean age of patients was 34.9 ± 12.1 years. After one year follow-up, clinically mean HHS was 88. ± 5.74. Radiologically post-operative reduction quality was anatomical in 21 (70%) patients, satisfactory in eight (26.7%) patients and unsatisfactory in one (3.3%) patient. Matta's grading at the last follow-up was excellent in 21 (70%) patients, good in six (20%), fair in two (6.7%) patients and poor in one (3.3%) patient. No significant difference was recorded between the two groups in terms of radiographical and clinical results and rate of complications.

CONCLUSION

Accurate reduction of quadrilateral plate fracture with secure fixation through modified Stoppa approach provides good and reproducible outcomes with few complications regardless the type of the implant.

Use of calcaneal locking plate in surgical treatment of quadrilateral plate fractures of the acetabulum

PURPOSE

Specialized devices for fixation of the acetabulum quadrilateral plate (QP) fractures may not be readily available in resource-constrained settings. In this article, we aim to explore the use of a 3.5-mm locking calcaneal plate in fixation of QP fractures.

METHODS

Twenty-eight patients with QP fractures underwent surgery using the modified Stoppa approach. Follow-up at 12 months assessed fracture healing and functional outcomes using the Majeed pelvic outcome score. Descriptive statistics summarized patient demographics and fracture characteristics. Analysis of variance (ANOVA) and exact logistic regression explored associations between factors (age, AO/OTA classification, gender, and time to surgery) and Majeed scores.

RESULTS

The mean age of patients was 42.71 years, with the majority being male (64.29%). All patients achieved bony union. Post-traumatic arthritis developed in three patients, while two patients experienced post-operative fracture redisplacement. Evaluation using the Majeed pelvic outcome score revealed generally favorable outcomes, with 32.14% achieving excellent, 39.29% good, 21.43% fair, and 7.14% poor outcome. Only an older age was associated with a worse outcome score (excellent/good versus fair/poor, odds ratio: 0.87, 95% confidence interval: 0.77, 0.96).

CONCLUSION

Surgical management of quadrilateral plate fractures using 3.5-mm locking calcaneal plates demonstrates promising outcomes, particularly in resource-constrained settings, where specialized devices may be lacking.

Percutaneous osteosynthesis of acetabular fractures with quadrilateral plate involvement using an infra-pectineal plate through a new paramedial approach: Description of the technique using cadaveric specimens

Percutaneous osteosynthesis of acetabular fractures with quadrilateral plate involvement using an infra-pectineal plate through a new paramedial approach using cadaveric specimens.

BACKGROUND

Intrapelvic approaches and infrapectineal plates have been used since the mid-nineties to solve Quadrilateral Plate osteosynthesis, with some problems in applying screws in the correct direction and difficulty in fracture reduction. We describe a minimally invasive paramedial approach and new ways to fix infrapectineal plates using one-step osteosynthesis (reduction and fixation).

METHODS

Four transverse and four posterior hemitransverse acetabular fractures were reproduced using four fresh frozen cadavers. Acetabular osteosynthesis was performed using the paramedial approach. Sequential lasting time and reduction/stability quality were measured using analysis of variance (ANOVA) with Bonferroni Correction as the statistical method, registering iatrogenic injuries.

RESULTS

Osteosynthesis was performed on seven acetabulae using infrapectineal horizontal plates for transverse fractures and vertical plates for posterior hemitransverse fractures. The duration of incision was 3:08 min and osteosynthesis was 55:12 min, with a total of 58:29 min. Median fracture displacement of 13.25 mm turned to a median of 0.01 mm once fracture osteosynthesis was performed with a p = 0.017. The peritoneum was injured twice and good osteosynthesis stability was observed.

CONCLUSION

The paramedial approach is safe with direct access to key anatomical structures for acetabular osteosynthesis. Infrapectineal with reverse fixation plate osteosynthesis provides an excellent reduction rate and good stability once the implants act against displacement forces, making it possible to direct them freely. Further clinical and biomechanical trials are required to confirm our findings. We believe that there was an improvement of up to 60% in the result quality for some cases; however, this technique must be compared with other techniques. Evidence Level IV (Experimental Trial).

Ilioinguinal versus modified Stoppa approach for open reduction and internal fixation of displaced acetabular fractures: a systematic review and meta-analysis of 717 patients across ten studies

BACKGROUND

Acetabulum fracture is one of the most challenging fractures to manage and operate for orthopaedic surgeons; anatomical reduction of fractures and reconstruction of the joint is of utmost importance. These factors in turn are dependent on the appropriate surgical approach used to improve the clinical outcomes and reduce associated complications. Hence, this meta-analysis aims to compare the outcomes of ilioinguinal versus modified Stoppa approach for open reduction and internal fixation (ORIF) of displaced acetabular fractures.

METHODS

Medline (PubMed), Embase, Scopus, and Cochrane Library databases were searched from their inception to 10th of June 2021 for both randomized clinical trials (RCTs) and or non-randomized studies comparing the outcomes of ilioinguinal approach and modified Stoppa approach for the ORIF of acetabular fractures. The estimates of treatment effects were described by mean difference (MD) for continuous variables and odds ratio (OR) for dichotomous variables with corresponding 95% confidence (95% CI) intervals. The risk of bias was assessed by MINORS tool for the non-randomized, and the Cochrane Collaboration's risk of bias tool for RCTs.

RESULT

A total of ten studies (717 patients), three RCTs and seven retrospective studies, were included. Modified Stoppa approach showed shorter mean duration of surgery (MD 47.13, 95% CI: 27.30-66.96), lesser number of overall complications (OR 2.14, 95% CI: 1.46-3.13), less intraoperative blood loss (MD 259.65, 95% CI: 152.66-366.64), and lower rates of infection (OR 2.17, 95% CI: 1.14-4.15). However, ilioinguinal approach showed a better quality of fracture reduction (OR 0.59, 95% CI: 0.42-0.82). Results were equivocal in terms of vascular injuries (OR 1.88 (95% CI: 0.86-4.09), nerve injuries (OR 1.77, 95% CI: 0.99-3.17), heterotopic ossification (OR1.74, 95% CI: 0.63-4.82), and clinical outcome (OR 0.81, 95% CI: 0.45-1.47) between the two groups.

CONCLUSION

Modified Stoppa approach carries a lesser duration of surgery, lesser intraoperative blood loss, fewer overall complications, and lesser postoperative infection rates compared to ilioinguinal approach. Although a better anatomical reduction is achieved by ilioinguinal approach, however, this does not translate into better clinic functional outcomes which remain comparable between the two approaches. So overall, modified Stoppa approach seems a better alternative for managing these fractures.

Three-dimensional morphological analysis of quadrilateral plate fragments in associated both-column acetabular fractures

OBJECTIVE

To investigate whether the fracture morphology of quadrilateral plate (QP) fragments is associated with the anterior and posterior columns in associated both-column (ABC) fractures.

MATERIALS AND METHODS

Three-dimensional computed tomography data of 100 ABC fractures treated at our hospital from August 2016 to August 2019 were retrospectively analyzed using Mimics and 3-matic software. The distribution of fracture lines was described using the fracture mapping technique.

RESULTS

One fragment presented on the QP was confirmed in 88% of the patients. The QP fragments' fracture lines were divided into the anterior oblique (AO), superior posterior oblique (SPO), and mid-posterior oblique (MPO) lines, occurring in 100, 86, and 8 cases, respectively. AO lines were distributed along the arcuate line. SPO lines were continuations of the AO lines, which were distributed to the posterior column from the greater sciatic notch to the lesser sciatic notch. MPO lines were involved in the QP's central area. A simple fracture was found at the proximal AO and SPO lines in 80% and 86% of all displaced fractures, respectively. AO lines distal to the superior rim of the acetabula were confirmed to be comminuted fractures in 32% of all cases.

CONCLUSIONS

In ABC fractures, there was only one QP fragment in nearly 90% of all cases. The QP fractures were mainly present in the QP's peripheral area. More than 80% of the fracture patterns on the cephalic side of the QP were simple. The reduction and internal fixation of QP fractures in ABC fractures should be in the cephalic region.