Judet Classification Research Articles

Estudo da reprodutibilidade e compreensão da classificação de Judet e Letournel

ObjectiveTo evaluate the effectiveness of the method of radiographic interpretation of acetabular fractures, according to the classification of Judet and Letournel, used by a group of residents of Orthopedics at a university hospital.MethodsWe selected ten orthopedic residents, who were divided into two groups; one group received training in a methodology for the classification of acetabular fractures, which involves transposing the radiographic images to a graphic two-dimensional representation. We classified fifty cases of acetabular fracture on two separate occasions, and determined the intraobserver and interobserver agreement.ResultThe success rate was 16.2% (10-26%) for the trained group and 22.8% (10-36%) for the untrained group. The mean kappa coefficients for interobserver and intraobserver agreement in the trained group were 0.08 and 0.12, respectively, and for the untrained group, 0.14 and 0.29.ConclusionTraining in the method of radiographic interpretation of acetabular fractures was not effective for assisting in the classification of acetabular fractures. Level of evidence I, Testing of previously developed diagnostic criteria on consecutive patients (with universally applied reference "gold" standard).

A shape-memory alloy internal fixator for treatment of acetabular fractures involving weight-bearing area

Objective To assess the mid-term results of acetabular three-dimensional memory fixation system (ATMFS) used to reconstruct weight-bearing area of the acetabulum. Methods From August 2003 to February 2009, totally 28 consecutive cases of unilateral severe fracture of the weight-bearing area of the posterior acetabular wall were treated with open reduction and ATMFS in our department. They were 19 males and 9 females, with a mean age of 39. 2 years (range, 18 to 70 years). Four fractures were old and 24 fresh. According to the Letournel & Judet classification system, there were 17 posterior wall fractures, 5 posterior column fractures, 5 transverse fractures, and one T-shaped fracture. According to the Zhang Chun-cai's classification system, the 28 cases all belonged to middle column-wall fracture, of which 19 were type Am1, 6 type Am2 and 3 type Am3. A modified hip posterolateral approach was adopted for all the patients. Results The 28 patients were followed up from 6 to 30 months (average, 8. 5 months). None of the patients lost reduction after surgery, and there was no case of implant failure. By Matta's criteria, 25 cases achieved anatomical reduction (89. 3% ) and 3 satisfactory reduction (10. 7% ) . All the patients achieved bony union in an average time of 12. 7 weeks after operation (from 11. 1 to 15. 0 weeks) . At the final follow-up, according to D' Aubigne & Postal's criteria, 92. 9% of the patients were rated as excellent or good.Conclusions ATMFS, as a wise biomechanical method to treat fractures involving weight-bearing area of the acetabulum, ensures stability of the hip joint, consistent compressive stress which promotes fracture union,and convenience of local grafting and reconstruction. It is an effective internal fixator for treatment of acetabular fractures involving weight-bearing area. Key words: Acetabulum; Fractures; Internal fixator

The Use of an Algorithm for Classifying Acetabular Fractures: A Role for Resident Education?

The Letournel and Judet classification system is commonly used for classifying acetabular fractures. However, for orthopaedic surgeons with less experience with these fractures, correct classification can be more difficult. A stepwise approach has been suggested to enhance the inexperienced observer's ability to properly classify acetabular fractures, but it is unclear whether this actually improves one's ability. We asked (1) whether the use of a step-by-step algorithm improves residents' ability to classify acetabular fractures, (2) whether resident experience influenced ability to correctly classify acetabular fractures, and (3) which acetabular fractures were the most difficult to classify? Forty-six residents reviewed 15 sets of plain radiographs of 10 acetabular fracture patterns. Residents used the Letournel and Judet classification with only a diagram for reference. Three weeks later they were asked to classify the fractures a second time with the use of the algorithm. We then compared the number of correct responses from the two sessions and determined whether resident experience and use of the algorithm influenced correct classification. We found an improvement in the number of correctly classified fractures between the first (348/690 [50%]) and second (409/690 [59%]) sessions. Thirty-two of 46 participants improved their score with the use of the algorithm. There was a tendency for participants with more residency training to correctly classify the fractures. The algorithm provided modest improvement to the residents' ability to classify acetabular fractures. This or other such algorithms could provide residents with a basic tool to better evaluate standard radiographs and classify acetabular fractures.

Evaluation of Severely Displaced Radial Neck Fractures in Children Treated With Elastic Stable Intramedullary Nailing

We performed a retrospective case study of 28 consecutive severely displaced radial neck fractures (Judet types III and IV) in children treated with elastic stable intramedullary nailing using the Metaizeau technique. We reviewed all preoperative radiographs and classified the injuries according to Judet. All patients were asked to return for later assessment. They underwent physical examination; radiographs were taken; and they were asked for subjective assessment. An evaluation of clinical results was performed using the Mayo Elbow Performance Score (MEPS). According to Judet classification there were 13 type III and 15 type IV fractures. Using the MEPS, excellent results were achieved in 23 cases (82%) and good results in 5 cases (18%). The average MEPS was 97 points. Five patients complained of mild pain. Three malunions were observed. Elastic stable intramedullary nailing is a minimally invasive technique, allowing stable fixation and providing excellent to good outcomes with a low complication rate. We performed a retrospective level 4 study of case series.

The value of specific radiological features in the classification of acetabular fractures

Specific radiological features identified by Brandser and Marsh were selected for the analysis of acetabular fractures according to the classification of Letournel and Judet. The method employs a binary approach that requires the observer to allocate each radiological feature to one of two groups. The inter- and intra-observer variances were assessed. The presence of articular displacement, marginal impaction, incongruity, intra-articular fragments and osteochondral injuries to the femoral head were analysed by a similar method. These factors were termed 'modifiers' and are generally considered when planning operative intervention and, critically, they may influence prognosis. Six observers independently assessed 30 sets of plain radiographs and CT scans on two separate occasions, 12 weeks apart. They were asked to determine the presence or absence of specific radiological features. This simple binary approach to classification yields an inter- and intra-observer agreement which ranges from moderate to near-perfect (kappa = 0.49 to 0.88 and kappa = 0.57 to 0.88, respectively). A similar approach to the modifiers yields only slight to fair inter-observer agreement (kappa = 0.20 to 0.34) and slight to moderate intra-observer agreement (kappa = 0 to 0.55).

Fractures of the neck of the radius in children. Early experience with intramedullary pinning.

The treatment of fractures of the neck of the radius in children is difficult, particularly if the angulation of the fracture exceeds 60 degrees. Since 1994 we have used closed reduction and stabilisation with an intramedullary Kirschner wire in patients with grade-IV fractures according to the classification of Judet et al. In a retrospective analysis of a two-year period (1994 to 1996), 324 children with fractures of the elbow were treated in our department. Of these, 29 (9%) had a fracture of the neck of the radius; six were grade-IV injuries (1.9%). Five of the latter had an excellent postoperative result with normal movement of the elbow and forearm. One patient with a poor result had a concomitant dislocation of the elbow. Our results suggest that closed reduction and intramedullary pinning of grade-IV fractures allows adequate stabilisation while healing occurs.

Fractures of the neck of the radius in children

The treatment of fractures of the neck of the radius in children is difficult, particularly if the angulation of the fracture exceeds 60°. Since 1994 we have used closed reduction and stabilisation with an intramedullary Kirschner wire in patients with grade-IV fractures according to the classification of Judet et al. In a retrospective analysis of a two-year period (1994 to 1996), 324 children with fractures of the elbow were treated in our department. Of these, 29 (9%) had a fracture of the neck of the radius; six were grade-IV injuries (1.9%). Five of the latter had an excellent postoperative result with normal movement of the elbow and forearm. One patient with a poor result had a concomitant dislocation of the elbow. Our results suggest that closed reduction and intramedullary pinning of grade-IV fractures allows adequate stabilisation while healing occurs.

Evaluation of Letournel and Judet classification of acetabular fracture with plain radiographs and three-dimensional computerized tomographic scan.

Letournal and Judet classification of acetabular fracture is widely used. The classification is based on the identification of fracture lines on plain radiographs. Three-dimensional CT scan was claimed to give a better view of the fracture line. Our study showed that intraobserver reproducibility and interobserver reliability were almost the same when classification was done by using plain radiographs and 3D-CT scan. And 3D-CT scan did not increase either the interobserver reliability or the intraobserver reproducibility in classifying the fracture.

Long term results of surgical therapy in acetabular fractures

Objectives: This study was designed to evaluate long term results and to determine prognostic factors in patients who underwent surgery for acetabular fractures. Methods: Of three hundred and thirty-two patients who underwent surgery for acetabular fractures between January 1970 and January 1998, 240 patients (186 males, 54 females; mean age 17 years; range 15-81 years) with adequate follow-up data were included. The mean period between the traumatic event and the last follow-up examination was 11.2 years (range 2-26 years). According to the classification of Letournel and Judet, 163 fractures (68%) were simple and 77 (32%) were of compound type. Central, posterior, and anterior dislocations occurred in 45.8%, 38.4%, and 15.8% of fractures, respectively. Results: At the last follow-up examination, excellent, good, fair, and poor functional results were obtained in 96 (40%), 96 (40%), 12 (5%), and 36 (15%) patients, respectively. Radiologic results were excellent in 45%, good in 21.7%, fair in 18.3%, and poor in 15%. Statistical analyses revealed that significant prognostic factors included mean period between the trauma and operation (p=0.05), damage to the femoral head (p=0.01), and the quality of anatomic reduction (p=0.009). Conclusion: We obtained satisfactory results in 192 of 240 hips (80%) by surgical therapy, aiming an excellent anatomic reduction in order to prevent late secondary osteoarthrosis. Similar results are reported in the literature by experienced surgical teams after long follow-up periods. Both in our series and in some other in the literature, no statistical significance between clinical and radiologic results have been found.

Acetabular Fractures

Sixty patients with acetabular fractures were treated surgically. All fractures were a result of high energy trauma, most with significant associated injuries. Fifty-three of the patients were followed up for at least 2 years. Clinical outcome was analyzed clinically using the Harris hip score and radiographically. In 41 (77.4%) of the patients, the surgical procedure was judged successful (Harris hip score greater than 80 points). Three factors were found to be statistically significant predictors of such an outcome: patient age younger than 40 years; simple fractures based on the classification of Letournel and Judet; and absence of damage to the femoral head. Possible influential factors that were not found to be statistically significant in this population included additional injuries, immediate complications, quality of reduction, heterotopic ossification, ipsilateral femoral fracture, and sciatic nerve damage. Open reduction and internal fixation of the displaced acetabular fracture, although a demanding procedure, can result in a satisfactory clinical outcome given a consistent approach with a dedicated team.

Open reduction and internal fixation of acetabular fractures.

Between 1982 and 1995, 84 patients with displaced acetabular fractures underwent open reduction and internal fixation in our institution. The mean follow-up was 5.5 years with a minimum of 2 years. There were 33 simple and 51 complex fractures according to the classification of Judet and Letournels. Reduction after operation was anatomical in 49% of the patients, satisfactory in 24%, and unsatisfactory in 27%. Using Merle d'Aubigné's scale, the clinical results were excellent in 39% of the patients, good in 29%, fair in 8%, and poor in 24%. Factors of statistical significance associated with a poor clinical outcome were T-shaped fractures, unsatisfactory reduction (> 3 mm residual displacement), age > 40 years and development of avascular necrosis. Acetabular surgery is demanding, and a high rate of complications can be expected. Trauma centres should designate a group of surgeons who will consistently treat these fractures in order to obtain more experience and better results.

Injury classification and surgical approach in hip dislocations and fractures

During the last few decades, traumatic injuries of the hip joint have significantly increased in number, and traffic accidents have also increased. Depending on the speed, direction of the forces and the position of the femur at the moment of impact, different patterns of injury occur. Basically, they are classified as hip dislocations, dislocation fractures and acetabular fractures. These injuries have in common a high rate of concomitant lesions. Several classification systems have been developed for these injuries. Commonly, Stewart and Milford's or Levin's classification is used for dislocations and dislocation fractures. For acetabular fractures, Judet and Letournel's classification and its newer version developed by Helfet (AO classification) are generally accepted. Fractures of the femoral head, though included in these classifications, are typically described by separate classifications like the one presented in 1957 by Pipkin. The multitude of injuries occurring in the hip joint requires vast knowledge of various operative approaches. No single approach exists that would permit the treatment of all injuries in an ideal fashion. Approaches are either considered limited (Kocher-Langenbeck, ilioinguinal iliofemoral) when they permit access only to a restricted segment of the joint, or extended (extended iliofemoral, Maryland, Ruedi) when they allow all-round visualization of the hip joint. The choice of the best approach for an individual patient depends on the type of injury and also on patient variables like age, preexisting disease, and concomitant injuries. The decision is further influenced by the timing of surgery, the kind of fracture stabilization intended and by complications typically seen with certain approaches. The indication for extended procedures is only seen in patients with complex injury patterns involving both the anterior and the posterior column or in delayed cases undergoing surgery more than 3 weeks after trauma. Extended approaches permit excellent visualization of the fracture, but the extent of the soft tissue trauma is reflected in a high rate of postoperative complications. After a phase in which extended procedures were favored, recently a trend towards more limited approaches can be recognized because of their lower complication rate. This is facilitated by modern fracture-reduction methods using indirect techniques.

Fractures of the Acetabulum

The results were reviewed for 259 patients who had open reduction and internal fixation of 262 displaced acetabular fractures within twenty-one days after the injury. Two hundred and fifty-five hips were followed for a mean of six years (range, two to fourteen years) after the injury; the remaining seven, which clearly had a poor result, were followed for less than two years. According to the classification of Letournel and Judet, associated fracture types accounted for 208 (79 per cent) of the fractures, with both-column fractures being the most common type (ninety-two hips; 35 per cent). Two hundred and fifty-eight hips were operated on with a single operative approach (Kocher-Langenbeck, ilioinguinal, or extended iliofemoral). The four remaining hips were operated on with a Kocher-Langenbeck as well as an ilioinguinal approach. The reduction was graded as anatomical in 185 hips (71 per cent). The rate of anatomical reduction decreased with increases in the complexity of the fracture, the age of the patient, and the interval between the injury and the reduction. The over-all clinical result was excellent for 104 hips (40 per cent), good for ninety-five (36 per cent), fair for twenty-one (8 per cent), and poor for forty-two (16 per cent). The clinical result was related closely to the radiographic result. The clinical result was adversely affected by associated injuries of the femoral head, an older age of the patient, and operative complications. It was positively affected by an anatomical reduction and postoperative congruity between the femoral head and the acetabular roof. Osteonecrosis of the femoral head was noted in eight hips (3 per cent), and progressive wear of the femoral head was seen in thirteen (5 per cent). Subsequent operations included a total replacement of seventeen hips (6 per cent), an arthrodesis in four (2 per cent), and excision of ectopic bone in twelve (5 per cent). These findings indicate that in many patients who have a complex acetabular fracture the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved. An increase in the rate of anatomical reduction and a decrease in the rate of operative complications should be the goals of surgeons who treat these fractures.

The Judet quadricepsplasty

Five patients with posttravmatic knee extansion contractures were followed for 33.6 (19-51) months after Judet quadricepsplasty. The average age of the patients was 36.2 years (26-50). At the final follow-up average knee flexion was 99° (45-120°) degrees. None of our patients showed neither extension lag nor wound problem. There were three excellent (60%), one good (20%), one poor (20%) results according to the Judet classification. The patients who had poor result had tibia fracture during the manipulation at the surgery and active range of motion was from 0 to 45 degrees. We are in the opinion that the judet quadricepsplasty is an effective and confidental technique in the treatment of limited knee flexion due to posttravmatic extension contractures.