Classification Of Acetabular Fractures Research Articles

Utility of 3D printed models as adjunct in acetabular fracture teaching for Orthopaedic trainees

ObjectiveTo evaluate the use of 3-D printed models as compared to didactic lectures in the teaching of acetabular fractures for Orthopaedic trainees.MethodsThis was a randomised prospective study conducted in a tertiary hospital setting which consisted of 16 Orthopaedic residents. Ten different cases of acetabular fracture patterns were identified and printed as 3-D models. The baseline knowledge of orthopaedic residents regarding acetabular fracture classification and surgical approach was determined by an x-ray based pre-test. Trainees were then randomly assigned into two groups. Group I received only lectures. Group II were additionally provided with 3-D printed models during the lecture. Participants were then assessed for comprehension and retention of teaching.ResultsSixteen trainees participated in the trial. Both Group 1 and 2 improved post teaching with a mean score of 2.5 and 1.9 to 4.4 and 6 out of 10 respectively. The post test score for fracture classification and surgical approach were significantly higher for 3-D model group (p < 0.05). Trainees felt that the physical characteristics of the 3-D models were a good representation of acetabular fracture configuration, and should be used routinely for teaching and surgical planning.Conclusion3-D printed model of real clinical cases have significant educational impact compared to lecture-based learning towards improving young trainees’ understanding of complex acetabular fractures.

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

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

Classification of acetabular fractures: how to apply and relevance today

The acetabulum is considered as a complex three-dimensional structure with intricate nomenclature describing its anatomy, becoming even further intimidating when fractured. The dominant classification system for acetabular fractures (AFxs) remains the one Letournel introduced 40 years ago. The main features of the different types of this classification system are presented, its recognized limitations, the published alternative systems, but also a simple algorithm which allows its successful use even by less experienced clinicians. The great importance of being effective in using the Letournel classification system derives from its strong association with the anatomic characteristics of the different AFxs and the understanding of the principles of reconstruction of this demanding type of orthopaedic trauma.

Хирургические доступы при лечении пациентов со свежими переломами вертлужной впадины

Abstract. Introduction According to the overwhelming majority of Russian and foreign authors, orthopedic traumatologists have been striving to improve the results of surgical treatment of acetabular (AC) fractures over the past decades. First of all, this is due to an increase in the number and severity of this injury, persisting complications and dissatisfaction of researchers with their own results of surgical treatment. Purpose Study of the rationale used by traumatologists for certain surgical approaches in the treatment of acute acetabular fractures. Materials and methods Literature sources were searched for information in the systems and databases Pubmed, Embase, Scopus, Medline, Cochran Library, eLibrary, Wiley Online Library using the keywords: acetabular fractures, surgical treatment, acetabular approach, open reduction and fixation of acetabular fractures, duration and blood loss, hip arthroplasty. Results The incidence of AC fractures, according to different authors, ranges from 2 to 23.4 %. The cause of this injury is road traffic accidents in up to 83 % of all cases. A significant increase in the number of AC fractures was noted. AC fractures in the vast majority of cases are classified according to AO/ASIF. Displaced AC fractures and multiplanar fractures are subject to surgical treatment. Open reduction and internal fixation still remain the standard treatment for AC fractures. The choice of the surgical approach is carried out more often taking into account the classification of AC fractures, and the type of fracture dictates the choice of approach to the acetabulum. It was found that the authors are forced to use surgical approaches taking into account the fractures of the AC columns. Discussion Adherence of traumatologists to the standards regarding indications for the choice of surgical approaches for complex AC fractures was noted. Surgical approaches for the treatment of two-column acetabular fractures are still often extended and traumatic, prolonged and accompanied by blood loss. Conclusion In the surgical treatment of pelvic and AC fractures, most authors adhere to standards in the choice of approach and fixation of columns and AC fragments. There is unanimity in the recognition of the trauma and "expansion" of the approaches used, accompanied by blood loss reaching up to 2000 ml and more, and the duration of the operation is on average 3 hours 50 minutes. For the surgical treatment of acute AC fractures, the researchers used both classical and modified anterior and posterior surgical approaches with the obligatory consideration of the classification of AC fractures. The rationale for choosing an operative approach, as a rule, was the determination of the type of AC fracture according to the AO/ASIF classification. The most effective approach in the surgical treatment of AC fractures is the combined anterior and posterior approach.

A New Algorithm for Classifying Acetabular Fracture Patterns on Three-dimensional Computed Tomography Reconstructions Markedly Improves Residents' Ability to Correctly Classify Fractures.

CT and three-dimensional (3D) CT reconstructions have been shown to improve the understanding of acetabular fractures. With the increased availability of 3D pelvic CT reconstructions, our goal for this study was to develop an algorithm to aid residents in the classification of acetabular fractures. We hypothesized that the use of a stepwise algorithm will markedly enhance the trainees' ability to correctly identify acetabular fracture patterns. This was a multicenter study that included 33 residents. Residents reviewed 15 sets of 3D reconstructions of the 10 acetabular fracture patterns. Residents completed the first round, and the results were collected electronically. Three weeks later, they were asked to classify the fractures a second time with the use of the algorithm. The number of correct responses from the two sessions was analyzed to determine if the algorithm improved residents' ability to correctly classify fracture patterns. Thirty-three residents classified 15 fractures which yielded 495 unique responses. Residents correctly classified 52.5% (260/495) of fractures without the algorithm, which significantly increased to 77.5% (384/495) (P = 0.001) with the algorithm. When stratified by year in residency, all residents were able to correctly classify markedly more fractures with the algorithm. Overall, we believe this method is a reproducible diagnostic tool that will assist residents in classifying acetabular fractures. We were able to demonstrate that with the use of this algorithm, residents' ability to correctly classify acetabular fractures is markedly enhanced, regardless of year in training. This algorithm will be a useful adjunct to assist and advance trainees' education and understanding of a complex topic.

Is "Transcolumnar" a better Terminology than "Transverse" in Judet-Letournel Classification of Acetabular Fractures?

Acetabular fractures are among the most complex and challenging injuries for orthopaedic surgeons. The choice of surgical treatment in acetabular fracture is important for optimal outcomes. It requires an understanding of the precise outline of the fracture by appropriate classification because it is important for decision making. For this purpose, the classification proposed by Judet and Letournel in 1963 remains the gold standard despite its shortcoming, which are attributed to the inclusion of multiple criteria including anatomical, directional and geometrical. This complex classification remains challenging especially to lesser experienced surgeons. In this article, a new method for classification of acetabulum fractures is proposed. It places posterior column with posterior wall fractures to simple fractures instead of complex fractures in Judet and Letournel classification. More importantly the proposed new classification renames “transverse fracture” as “transcolumnar fracture” to better represent anatomical structure rather than morphology. It is expected that by coining the new term “transcolumnar ”it will be easy to understand different types of acetabular fractures. Especially the confusion between “transverse” and “both column fractures” would not be a concern in future.

Interobserver and intraobserver agreement for Letournel acetabular fracture classification system using 3-dimensional printed solid models.

BACKGROUNDAcetabular fractures pose diagnostic and surgical challenges. They are classified using the Judet-Letournel system, which is based solely on X-ray. However, computed tomography (CT) imaging is now more widely utilized in diagnosing these injuries. The emergence of 3-dimensional (3-D) printing technology in varying orthopedic fields has provided surgeons a solid model that improves their spatial understanding of complex fractures and ability to plan pre-operatively.AIMTo evaluate the reliability of the Judet-Letournel classification system of acetabular fractures, when using either CT imaging or 3-D printed models.METHODSSeven patients with acetabular fractures underwent pelvic CT imaging, which was then used to create solid, 3-D printed models. Eighteen orthopaedic trauma surgeons responded to questionnaires regarding fracture classification and preferred surgical approach. The same questionnaire was completed using only CT imaging, and two weeks later, using only 3-D printed models. The inter- and intra-observer agreement rates were then analyzed.RESULTSInter-observer agreement rates based on CT imaging or 3-D printed models were moderate for fracture classification: κ = 0.44, κ = 0.55, respectively (P < 0.001) and fair for preferred surgical approach: κ = 0.34, κ = 0.29, respectively (P < 0.005). Intra-observer agreement rates for fracture classification and preferred surgical approach comparing CT imaging or 3-D printed models were moderate: κ = 0.48, κ = 0.41, respectively. No significant difference in intra-observer agreement was detected when comparing orthopedic pelvic specialists to general orthopedic traumatologists.CONCLUSIONThe Judet-Letournel classification demonstrated only moderate rates of agreement. The use of 3-D printed models increased the inter-observer agreement rates with respect to fracture classification, but decreased it with respect to the preferred surgical approach. This study highlights the role of 3-D printed models in acetabular fractures by improving spatial understanding of these complex injuries, thus providing more reliable fracture diagnoses and alternative viewpoints for pre-operative planning.

Advantages of Modified Stoppa Approach in Mangement of Acetabular Fractures

This study presents our experience of internal fixation of the acetabular fractures and pelvic fractures using a newly modified Stoppa approach, which provides closer visualization to the entire anterior column, quadrilateral surface and the pelvic brim portion of the posterior column, and permits stable internal fixation for the acetabular fracture patterns with main anterior displacement and the anterior and lateral parts of the pelvis. The present study was a prospective clinical study including 10 patients with acetabular fractures who were treated operatively using modified Stoppa approach . The classification of acetabular fractures described by Letournel and Judet. All operative data was recorded Patients were followed-up for 12 months after the operation. The maximum displacement of the bony fragment was measured in the unit of mm by using PACS, Marosis mview ver. 5.4 Our result shows the incidence of perioperative complication. Two patients developed DVT and two patients developed obturator nerve palsy. Our result shows the radiological outcomes of the included patients. The mean CT gap was 1.685 ±0.27mm. Eighty percent of the patients had anatomical Matta class. Our result shows the Merle D‟Aubigne-Postel score of the included patients. Eighty percent of the patients had excellent score. The incidence of MVO after PPCI may be lowered by the addition of manual TA (6,24). The results of the present study show that the additional intracoronary administration of a high dose of adenosine may further improve STR up to 70%. Future larger studies with clinical endpoints are warranted to confirm the benefit of intracoronary administration of a high dose of adenosine in addition to glycoprotein IIb/ IIIa antagonist administration and TA in the setting of PPCI or rescue PCI.

Evaluation of Judet view radiographs accuracy in classification of acetabular fractures compared with three-dimensional computerized tomographic scan: a retrospective study

BackgroundIn the current diagnostic procedure, generally, both plain radiographs and 3D-CT scans are used for the diagnosis of acetabular fractures. There is no consensus regarding the value of a three-dimensional computerized tomographic (3D-CT) scan alone in the classification of acetabular fractures. In this study, we compared the accuracy of 3D-CT scan and plain radiography through the evaluation of their agreement with the intraoperative surgeon’s classification.MethodIn a retrospective study, patients who were referred to our center with an acetabular fracture and underwent surgical treatment were included. The classification of acetabular fractures was performed once using Judet view plain radiographs and once using a 3D-CT scan by the corresponding one Experienced musculoskeletal radiologist one independent trauma fellowship-trained orthopaedic who routinely treat acetabular fractures and based on Letournel and Judet classification (17 and 23 years of experience respectively). Cohen’s kappa value was used for the assessment agreement between the two imaging modalities, as well as between the imaging modalities and intraoperative classification.ResultsMedical files of 152 patients with acetabular fracture were retrospectively reviewed. A kappa value of 0.236 was obtained as the agreement level between radiographs and intraoperative findings (p < 0.001). A kappa value of 0.943 was obtained as the agreement level between 3D-CT and intraoperative classification (p < 0.001). An agreement level of 0.264 was found between the Judet radiographs and 3D-CT scans (p < 0.001).Conclusions3D-CT scans are reliable enough in the classification of acetabular fractures, and plain radiographs could be omitted to avoid radiation exposure as well as to reduce the cost for patients who sustain acetabular fractures.

Efficacy of total hip arthroplasty after operatively treated acetabular fracture.

We evaluated the clinical and radiological outcomes of patients following total hip arthroplasty (THA) for acetabular fracture. This was a retrospective cohort study in a single center. The medical records of patients who underwent THA from March 2002 to March 2017 were reviewed. Inclusion criteria were THA and a history of open reduction and internal fixation of acetabular fractures. Thirty-seven patients with a mean age of 56.2years were enrolled. The Harris hip score (HHS), acetabular fracture classification, time interval between acetabular fracture and THA, cause of THA, surgical approach, implant type, complications, radiographic results, and Kaplan-Meier survival curves were analyzed. All patients were followed up for an average of 6.6years. The mean preoperative HHS of 42.5 had improved to 83.5 at the final follow-up (p < 0.05). There were 29 cases of post-traumatic arthritis, 6 cases of avascular necrosis, and 4 cases of non-union. The average interval from injury to THA was 58months (range 4-336months). The re-admission rate was 18.9%. Patients who underwent conversion to THA due to post-traumatic arthritis combined with non-union acetabular fracture developed clinical failure more frequently than patients with post-traumatic arthritis (p = 0.037). At 12years, 83.4% of patients were free from revision of femoral and acetabular components. THA secondary to an operatively treated acetabular fracture provides good symptomatic relief, but shows relatively inferior survival rates, and clinical failure was related to post-traumatic arthritis with acetabular non-union.

Acetabular fractures in the elderly (≥ 60 years old): a propos of 33 cases

Acetabular fractures in the elderly are serious fractures because they affect a deep, load-bearing and at first difficult surgical joint, all complicated by an osteoporotic tissue condition. We conducted a retrospective descriptive study over 10 years (January 2010 to January 2020, including 33 patients aged ≥ 60 years with acetabular fractures treated at the Orthopedics and Traumatology Department B4 of CHU Hassan II Fes. The aim was to study the types of fractures and to evaluate their treatment as well as the functional result obtained in order to compare them with those of the literature. We collected the data using an exploitation sheet and their analysis was facilitated by the EPI info7 statistical analysis software. The average age of our patients was 65.5 years, with a clear male predominance. Road Traffic Accidents represented the main etiology (72.7%), and the left side was the most affected 54.5%. The para-clinical assessment, based on the Anteroposterior iliac and obturator radiological views and confronted with the CT scan made it possible to pose the diagnosis of the fracture, to establish the type according to the Judet and Letournel classification of acetabular fractures, and to evaluate the displacement and articular congruence according to the Duquennoy and Coll criteria as well as those of Matta. Elementary fractures were the most frequent at 54.5%. We opted for orthopedic treatment in 72.7% of the cases with none weight bearing in 62.5%; whereas the surgical treatment was carried out in 27.3% with the use of the special acetabular plate in 66.7% of the operated cases. The Kocher-Langenbeck posterior approach was the most used (66.7%). The vertical congruence between the femoral head and the roof of the acetabulum after reduction was satisfactory in 27.3% of the cases and the horizontal congruence between the femoral head and the entire acetabulum in 18.2% of the cases. In our series, we noted as a complication 12 cases of post-traumatic osteoarthritis, ie 36.3%. The results according to the Postel Merle d´Aubigne score at an average follow-up of 62 months were satisfactory (excellent, very good and good) in 27.3% of the cases and unsatisfactory (fair, poor and bad) in 72.7% cases. The surgical management of fractures of the acetabulum in elderly and osteoporotic patients remains subject to controversy and is not entirely satisfactory. Would not primary arthroplasty combined with open reduction internal fixation constitute a better management approach in old people?

Comparison of clinical and radiological outcomes after posterior acetabular fractures in patients younger and older than 40 years old

Aim: This study aimed to evaluate and compare the clinical and radiological outcomes of patients aged >40 years and ≤40 years old, who underwent open reduction internal fixation for posterior fracture and/or fracture dislocation of the acetabulum.Material and Methods: A total of 52 patients who underwent surgical treatment for posterior acetabular fracture and/or fracture dislocation between June 2006 and October 2013 were included in this study. The patients were divided into the following 2 groups: group I, patients aged 40 years (n = 27; mean age, 53.3; mean follow-up period, 36.8 months). The Judet–Letournel classification system was used in the radiological classification of acetabular fractures. Clinical and radiological evaluations were performed using the modified Merle D’Aubigne evaluation score and the criteria developed by Matta, respectively. In addition, radiological evaluation for heterotopic ossification was performed according to the Brooker scoring system.Results: No significant difference in the quality of reduction and clinical and radiological findings was found between the two groups (p>0.05). The modified Merle D’Aubigne clinical outcome distribution and the distribution of Matta radiological results in groups I and II did not differ significantly (p>0.05 and p>0.05, respectively). Moreover, no significant difference in the development of postoperative heterotopic ossification was observed between the groups (p>0.05). Conclusion: Clinical and radiological outcomes are not significantly different between patients younger and those older than 40 years. Nevertheless, the clinical outcome scores are better in patients aged ≤40 years.

Evaluation of credibility and repeatability of modified acetabular fracture classification system

The Letournel-Judet classification system for acetabular fractures is widely used, but there are still some shortcomings, such as incomplete classification and confusion of classification concepts, which cannot effectively guide the treatment. Professor Hou Zhiyong proposed and elaborated an improved acetabular fracture classification system based on the concept of three columns of acetabulum. However, the credibility and repeatability of the classification still lacked validation from clinical data. In this regard, the author included 463 patients with relatively complete imaging data admitted to Third Hospital of Hebei Medical University and Honghui Hospital affiliated to Xi'an Jiaotong University Medical College in the past five years. Four trauma orthopedists classified the patients according to the modified classification method of acetabular fracture. After two months, the original sequence of imaging data was disrupted and re-classified by the same trauma orthopedists. The consistency of the classification was evaluated by Kappa test and compared with Letournel-Judet classification. The results showed that credibility and repeatability of the modified classification were higher than Letournel-Judet classification, suggesting the feasibility of clinical application. Key words: Hip fractures; Acetabulum; Modified acetabular fracture classification

Direct posterior approach for the treatment of posterior acetabular fractures

Objective To explore surgical technique and clinical results of the direct posterior approach (DPA) for acetabular fractures involving posterior column, posterior wall, or posterior column and wall. Methods From January 2016 to June 2017, data of 10 cases (7 males, 3 females, an average age of 37 years, ranging from 17 to 54 years) with posterior acetabular fractures treated by the DPA were retrospectively analyzed. Fractures were caused by traffic accident in 6 cases and by falling in 4 cases. According to Letournel-Judet classification of acetabular fractures, there were 6 cases of posterior acetabular wall fractures, 4 cases of posterior wall fractures involving posterior column. A straight skin incision was made from the middle of the line between the posterior margin of the tip of the femoral greater trochanter and the posterior superior iliac spine, to the posterior margin of the femoral greater trochanter. The gluteus maximus muscle was cleaved longitudinally. A view of the area from hip capsule to the superior margin of the greater sciatic foramen was obtained by entering along the interspace of the gluteus medius and pyriformis muscle, and the superior gluteal neurovascular bundle was protected. Acetabular posterior column and posterior wall fractures were reduced and fixed under direct vision. The fracture reduction, fracture healing, femoral head necrosis, sciatic nerve injury, superior gluteal neurovascular injury and heterotopic ossification were evaluated by the postoperative X-ray and CT examination. The function of hip joint was assessed by the Merle d’Aubigne-Posteal score modified by Matta. Results The average operative incision length was 9.6 cm (range, 8-11 cm). The average operation time was 50 min (range, 35-80 min). The average blood loss was 310 ml (range, 200-440 ml). The time of follow-up was 12-30 months. All the patients were healed within 8-12 weeks without any complications such as superior gluteal nerve injury, superior gluteal vessel injury, or sciatic nerve injury. One case of acetabular posterior wall and posterior column fracture with posterior dislocation of hip joint, suffered from femoral head necrosis at the 9th months after surgery, which was treated by total hip arthroplasty and was recovered one year after surgery. In one case of actebular posterior wall and posterior column fracture, heterotopic ossification occurred 3 month after operation, without any special treatment and the hip joint activity was not affected at the follow-up of 15 months after surgery. During the 12-month follow-up after surgery, the Merle d’Aubigne-Postel score modified by Matta was 13-18, among which there were excellent in 6 cases, good in 2, acceptable in 2, with an overall excellent and good rate of 80% (8/10). Conclusion The direct posterior approach for posterior acetabular fractures can obtain satisfactory clinical results. The advantages of the DPA include decreasing trauma, shortening operation time, reduing blood loss and decreasing risks of iatrogenic injury to the gluteus medius muscle, the external rotators, the arteriae circumflexa femoris medialis and sciatic nerves as well as reducing and fixing the fractures under direct vision. Thus, the DPA is a relatively safe surgical approach for acetabular posterior wall/column fracture. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal

Foreword.

This JOT supplement publication is the second in our series in tribute to the achievements of a great orthopaedic fracture surgeon. In this supplement, we posthumously honor a man who was an iconic and transcendent figure in orthopaedic surgery—Emile Letournel (Fig. 1). He is best known for his work in acetabular and pelvic fracture care, having co-authored the groundbreaking English language journal article establishing the first functional and comprehensive acetabular fracture classification system,1 further refining this system (as shown in our “classic article” republication2) and writing the definitive, “Gold Standard” text on overall acetabular fracture care.3 However, his body of work was much more wide-ranging.FIGURE 1.: Copyright 2018. Eric E. Johnson, MD.Professor Letournel actually was a general orthopaedic surgeon, actively involved in patient care encompassing the full scope of orthopaedic surgery. Furthermore, his academic publications, although mostly in the French literature, were similarly comprehensive. In addition, he was an avid and exceptional educator. He organized his own seminal instructional courses in acetabular and pelvic fracture care and his prosections were the highlight of any course. A complete gentleman, he always made himself available to participate in the follow-on courses organized by others and was very open to new ideas. Teaching excellence was one of his goals no matter what the venue. Those who were privileged to spend time with Letournel on his medical service at the Centre Médico-Chirurgical de la Porte de Choisy in Paris, France for training, whether for a week or 2 or for a full fellowship (as was the case for each of the guest editors), were assured of having the experience of their professional lives: from the espresso bar on the top floor of the hospital, to the operating room to assist the master surgeon at work, to the clinics and finally the wards. Who else could have his cigar at the scrub sink – and where else could you see it (Fig. 2)! A consummate host, Letournel took pride in taking care of his visitors well beyond the operating theater. There was nothing like Christmas dinner in Charleville (Fig. 3).FIGURE 2.: Copyright 2018. Berton R. Moed, MD.FIGURE 3.: Copyright 2018. Berton R. Moed, MD.Emile Letournel was a mentor to the contributing authors of this supplement, and it is our honor to have been chosen to coordinate this fitting tribute. Unfortunately, he died unexpectedly in 1994 while still very active both as a surgeon and educator. We are pleased to be able to include a testimonial by his close friend, Eric Johnson.

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.

Obturator ring fracture detection using anteroposterior view x-ray

Patients with acetabular trauma require a treatment plan based on proper recognition and classification of acetabular fractures, which depends on analyzing the status of several landmarks of the pelvis, including the obturator ring. With the aim of developing a tool for computer-aided diagnosis and classification of acetabular fractures, this paper addresses the problem of detecting disruptions of the obturator ring. In our study, anteroposterior view x-ray images are used. A simple approach is first developed, then augmented with machine learning algorithms, namely Support Vector Machines and Neural Networks. Results show that an accuracy of 94% could be reached.

Mid-term results of displaced acetabulum fractures surgically treated using anterior intra-pelvic approach (modified Stoppa).

This study aims to evaluate the radiological and clinical mid-term results of the patients with displaced acetabular fractures surgically treated with open reduction and internal fixation using an anterior intra-pelvic approach (AIP). In this study, we retrospectively reviewed 12 patients with displaced acetabular fractures treated surgically via the AIP approach. Patients were analyzed for Letournel's acetabular fracture classification, associated injuries, time to surgery, additional surgical procedures needed, perioperative and postoperative complications, radiologic and functional results. Of the 12 patients, the male/female ratio was 1/2; the mean age was 40.5±16.2 (16-64) years. The mean follow-up time was 59.8±32.2 (12-124) months. Seven patients had both column fractures, three patients had anterior column + posterior hemitransverse fractures, one patient had transverse + posterior wall and one patient had anterior column fracture. The mean time to surgery was 6.6±4.4 (2-16) days. The mean intraoperative blood transfusion was 830 (300-2000) ml. Intra-operative and post-operative complications were noted in eight patients. The mean Merle d'Aubigné and Postel score was 14.5±2.7 (10-18). Six patients with an anatomical reduction of the fracture showed excellent/good functional and radiologic outcomes. Three patients with a non-anatomic reduction developed post-traumatic arthrosis that was treated with total hip arthroplasty. AIP approach provides a satisfactory exposure for the surgical treatment of displaced anterior wall/column and both column acetabular fractures. Clinical outcome is directly related to the reduction quality. Patients with poor reduction are most likely to develop mid-term complications, such as hip joint arthrosis.

A New, Easy, Fast, and Reliable Method to Correctly Classify Acetabular Fractures According to the Letournel System.

Background:Accurate classification of acetabular fractures remains difficult. To aid in the classification of acetabular fractures and to aid in teaching, our department developed a diagnostic algorithm that involves the use of 1 standardized 3-dimensional reconstruction of a computed tomography (CT) scan (an exopelvic view without the femoral head) with 8 anatomical landmarks. The algorithm was integrated into a smartphone application (app). The main objective of this study was to test the efficacy of this algorithm and smartphone app.Methods:Fourteen reviewers (3 experts, 3 fellows, 3 residents, and 5 novice reviewers) evaluated a set of 35 CT scans of acetabular fractures in 2 phases. During the first phase, the scans (including axial 2-dimensional views and 3-dimensional (3D) multiplanar reconstruction views) were assessed by each reviewer twice, with an interval of 4 weeks between the readings to decrease recall bias. During that phase, the reviewers were provided with a diagram of the Letournel classification system with no guidelines for interpretation. During the second phase, performed 4 weeks after the first phase, 1 standardized 3D reconstruction (an exopelvic view without the femoral head) was reviewed twice, with an interval of 4 weeks between the readings. During that phase, the reviewers used the smartphone app. The primary outcome was the accuracy of classification. Interobserver reliability, reading time, and time needed for accurate classification were noted.Results:The accuracy of fracture classification was 64.5% when the standard method of analysis was used and 83.4% when the app was used (p < 0.001). Improvement was noted in all groups, with the expert group showing the least improvement (88.6% to 97.2%, p = 0.04) and the novice group showing the most improvement (42.0% to 75.5%, p < 0.001). Furthermore, use of the app greatly increased the accuracy of classification of complex fractures. The average reading time was 71.8 minutes when the standard method was used and 37.4 minutes when the app was used. The interobserver reliability improved in all groups to an excellent reliability (interclass correlation coefficient [ICC] > 0.79).Conclusions:The Letournel classification system is difficult to understand and to learn but remains the only system guiding the surgical strategy for acetabular fractures. The impact of diagnostic algorithms is debatable. The most important finding of the present study is the high accuracy for inexperienced groups when the app was used. Another important finding is the high reliability of this method for the diagnosis of complex acetabular fractures.

Standardized three dimensional computerised tomography scanner reconstructions increase the accuracy of acetabular fracture classification.

Evaluate the role of four standardized 3D reconstruction views in the accurate diagnosis of acetabular fractures. Thirty-five acetabular fracture cases were selected from a tertiary centre database. Fourteen reviewers with different experience level evaluated this set of images which were provided in axial 2D views and multiplanar reconstruction (MPR) without 3D views in the first two readings then the standardized 3D views were added for the subsequent two readings. The primary outcome was the accuracy of diagnosis while inter-observer reliability and reading time as well as time needed for accurate diagnosis were evaluated. Accuracy of classification was 56.7% using the 2D and 73% using the described 3D (p < 0.001). Improvement was noted in all groups even though the expert group showed the least improvement (6.7% (p = 0.04)) and the least experience group showed the most improvement (35.7% (p < 0.001)). Average time of interpretation was 96 minutes for the 2D sets and 47 minutes for the 3D sets. Finally, the adding of the four standardized views increased the inter-observer reliability in all groups compared to the standard 2D sets with MPR. Acetabular fracture diagnosis according to Letournel classification is difficult and depends greatly on the experience of the reader. The described set of 3D images yields better accuracy and renders the diagnosis more repeatable and faster. We recommend the use of these images in classifying acetabular fractures.