Letournel Classification Research Articles

Doctor, When Should I Start Walking? Revisiting Postoperative Rehabilitation and Weight-Bearing Protocols in Operatively Treated Acetabular Fractures: A Systematic Review and Meta-Analysis.

Background and Objectives: Management of acetabular fractures is aimed at anatomically reducing and fixing all displaced or unstable fractures, as the accuracy of fracture reduction has been demonstrated to strongly correlate with clinical outcomes. However, there is a noticeable gap in the literature concerning the perioperative and postoperative care of patients with acetabular fractures, which ultimately can be potential risk factors for adverse outcomes and permanent disabilities. This study aimed to systematically review the available literature regarding rehabilitation practices, including weight-bearing protocols, across time points in surgically treated acetabular fracture patients and correlate these practices with functional outcomes. Methods: We systematically reviewed the Medline and PubMed databases and the Cochrane Central Register of Controlled Trials in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were studies with adult patients (19+ years), publications from the last 10 years, articles focusing on rehabilitation or mentioning any aspect related to rehabilitation (such as weight-bearing or muscle training), and describing the surgical management of acute, isolated acetabulum fractures. Specific information was collected, including the fracture classification, time to surgery, surgical approach, surgical time, blood loss, fixation strategy, quality of reduction, postoperative rehabilitation protocol, complication rate, type(s) of complication, and outcome measurement(s). The choice(s) of surgical approach, surgical time, blood loss, and fixation strategy were stratified based on the fracture classification. The complication rate and type(s) of complication were calculated for all studies. Fractures were classified based on the Letournel classification. Results: A total of 494 articles were identified from the initial search, of which 22 (1025 patients) were included in the final review. The most common rehabilitation protocol favored isometric quadriceps and abductor strengthening exercises starting on the first postoperative day, with passive hip movement at 1-3 days postoperatively and active hip movement ranging from the first postoperative day to 4 weeks postoperatively. Partial weight-bearing with a walker or a pair of crutches was permitted from 1 to 12 weeks after surgery, and full weight-bearing was allowed depending on the patient's general condition and fracture healing state (generally at the end of 3 months). In only three studies did the patients start bearing weight in the early postoperative period (≤1 week). Meta-regression analysis was not performed due to the discrepancy between studies that reported a weight-bearing protocol ≤1 week and >1 week postoperatively. Conclusions: Our study suggests that an accelerated postoperative rehabilitation protocol, including early permissive weight-bearing, does not appear to increase the risk of loss of reduction or the rate of complications after surgical treatment of acetabular fractures. However, a proper meta-analysis was not possible, and the heterogeneity of the included studies did not allow us to conclude anything about the potential biomechanical and clinical benefits nor the negative effects related to this rehabilitation regimen in terms of functional results. There is an inconsistent use of PROMs for objectively calculating the effect size of the accelerated protocol compared with restricted weight-bearing regimes. We pose the need for higher-level evidence to proof our hypothesis.

Unclassified acetabular fractures: Do they really exist?

PurposeAlthough 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.MethodsThis 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.ResultsIn 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.ConclusionSeveral 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.

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.

ASSESSMENT OF INTEROBSERVER RELIABILITY FOR THE LETOURNEL AND JUDET CLASSIFICATION.

The Judet and Letournel classification is the most widely used classification system for acetabular fractures. Some complex fractures couldn't be classified according to this classification. The main purpose of this study was to evaluate the reliability of the Letournel and Judet classification system for acetabular fractures. 10 acetabular fractures were analyzed among 17 orthopedic surgeons. The surgeons were asked to classify the fractures according to the Judet and Letournel classification. Their experience, the number of surgeries, and the incision type that the surgeon uses for the anterior part of the acetabulum were recorded. The overall interobserver agreement for the Letournel classification was found to be poor, with a Kappa value of 0.287. The Kappa value for interobserver agreement was 0.224 for plain radiographs, 0.293 for 2D-CT, and 0.321 for 3D-CT scans. There was no significant difference between the incision types used by the surgeons. The highest reliability was determined among the surgeons who operate on 10-20 acetabular fractures per year, with a Kappa value of 0.309. This results revealed that the Judet and Letournel Judet classification is not sufficient to classify acetabular fractures because of unclassified fractures and the complex algorithm of the system. Level of Evidence III; Comparative Retrospective Study.

Clinical and Radiological Outcomes of Patients With Anterior Acetabulum Fractures Treated by the Modified Stoppa Approach.

Introduction Acetabular fractures are intra-articular fractures involving the lower extremity's weight-bearing dome. These fractures require an anatomical reduction of the fracture fragments. This aim can be accomplished by the selection of an appropriate surgical approach. This study aimed to analyze the clinical and radiological outcomes of patients with fractures in the anterior part of the acetabulum who were treated by the modified Stoppa approach. Methods This prospective observational study was conducted from April 2022 to September 2023. The inclusion criteria were: (i) age between 18 and 70 years, (ii) displaced acetabular fracture (displacement > 3 mm), (iii) within three weeks of trauma (iv) acetabular fractures with involvement of anterior column. Exclusion criteria included: (i) patients with visceral injuries requiring colostomy, (ii) pathological fracture, (iii) open fractures of the acetabulum, and (iv) neglected fracture (more than three weeks). Intraoperative data regarding surgical time, amount of blood loss, and incidence of intraoperative complications were recorded. In the postoperative period, anteroposterior X-ray and Judet views of the pelvis X-ray were obtained. Matta criteria were used to judge the quality of Fracture reduction and fixation. All the patients to be included in this study had undergone a minimum follow-up duration of six months. At the last follow-up, an assessment of the functional outcome of the affected hip by Merle d'Aubigné Hip Score and Harris Hip Score was done. Results Twenty-four patients were included in the study. The mean patient age was 36.08±11.65 years. Eighteen patients were male (75%) and six patients were female in this study. All acetabular fractures were due to high-energy trauma: road traffic accidents in 22 cases (91%) and fall from height in two cases (9%). According to Judet & Letournel's classification, there were 13 T-type fractures, five transverse fractures, and six associated both column fractures. The mean duration of surgery was 152.08 ±29.19 minutes, and the mean intraoperative blood loss was 277.08±85.95 ml. Intraoperatively one unit of blood transfusion was done in most cases. There were intraoperative complications of rent in the external iliac vein in two patients. Postoperative X-rays showed anatomical reduction in 17 cases, imperfect reduction in five cases, and poor reduction in two cases. Functional outcome of the hip by Merle d'Aubigné Hip Score was very good in 15, good in four, fair in three, and poor in two patients. Similar functional outcomes were obtained with the Harris Hip Score. Conclusion The results of the current study demonstrated that the modified Stoppa approach allows good visualization of the pelvic brim, quadrilateral surface, and posterior column. Lesser experienced orthopedic surgeons should utilize this approach to get good radiological and functional outcomes.

Antegrade Posterior Column Acetabulum Fracture Screw Fixation via Posterior Approach: A Biomechanical Comparative Study.

Background and Objectives: Minimally invasive surgeries for acetabulum fracture fixation are gaining popularity due to their known advantages versus open reduction and internal fixation. Antegrade or retrograde screw fixation along the long axis of the posterior column of the acetabulum is increasingly applied in surgical practice. While there is sufficient justification in the literature for the application of the anterior approach, there is a deficit of reports related to the posterior approach. The aim of this study was to evaluate the biomechanical competence of posterior column acetabulum fracture fixation through antegrade screw placement using either a standard cannulated screw or a cannulated compression headless screw (CCHS) via posterior approach. Materials and Methods: Eight composite pelvises were used, and a posterior column acetabulum fracture according to the Letournel Classification was simulated on both their left and right sides via an osteotomy. The sixteen hemi-pelvic specimens were assigned to two groups (n = 8) for either posterior column standard screw (group PCSS) or posterior column CCHS (group PCCH) fixation. Biomechanical testing was performed by applying steadily increased cyclic load until failure. Interfragmentary movements were investigated by means of motion tracking. Results: Initial stiffness demonstrated significantly higher values in PCCH (163.1 ± 14.9 N/mm) versus PCSS (133.1 ± 27.5 N/mm), p = 0.024. Similarly, cycles and load at failure were significantly higher in PCCH (7176.7 ± 2057.0 and 917.7 ± 205.7 N) versus PCSS (3661.8 ± 1664.5 and 566.2 ± 166.5 N), p = 0.002. Conclusion: From a biomechanical perspective, CCHS fixation demonstrates superior stability and could be a valuable alternative option to the standard cannulated screw fixation of posterior column acetabulum fractures, thus increasing the confidence in postoperative full weight bearing for both the patient and treating surgeon. Whether uneventful immediate postoperative full weight bearing can be achieved with CCHS fixation should primarily be investigated in further human cadaveric studies with a larger sample size.

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

PurposeThe 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.MethodsTwelve 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.ResultsInitial 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.ConclusionStandard 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.

Total Hip Arthroplasty with Cemented Dual Mobility Cup into a Fully Porous Multihole Cup with Variable Angle Locking Screws for Acetabular Fractures in the Frail Elderly.

The purpose was to examine the clinical and radiological outcomes after surgical treatment of acetabular fractures with total hip arthroplasty with a dual mobility cup cemented into a porous multihole cup in the population of frail elderly patients. A retrospective review of 16 patients who underwent surgery (mean age, 76.7 years) with a mean follow-up period of 36.9 months was conducted. Following surgery, patients underwent postoperative follow-up at six weeks, three, six, and 12 months and clinical and radiological examinations were performed. Classification of fractures was based on the Letournel classification. Following surgery, all patients were allowed weight-bearing as tolerated immediately postoperative. Fourteen patients showed maintenance of preoperative mobility status at one year. The mean Harris hip score was 64.8 (range, 34.7-82.8) and 80.0 (range, 60.8-93.8) at three months and one year, respectively. The mortality rate was 12.5% at one year (2/16). Complications included heterotopic ossification (2/16), deep venous thrombosis (1/16), heamatoma (1/16), and femoral revision due to a Vancouver B2 fracture (1/16). No case of deep infection, dislocation, or implant loosening was reported. Total hip arthroplasty using a dual mobility cup cemented into a porous multihole cup with locking screws resulted in a stable construct with a capacity for immediate weight-bearing as tolerated with rapid relief of pain. The findings of this study suggest that this procedure can be regarded as a safe method that has shown promising clinical and radiological outcomes for treatment of patients with medical frailty.

Spring Plates as a Valid Additional Fixation in Comminuted Posterior Wall Acetabular Fractures: A Retrospective Multicenter Study.

The posterior wall fracture is the most frequent pattern of acetabular fractures. Many techniques of fixation have been described in the literature and involve plates, screws, or a combination of both. This study aims to investigate the clinical and radiological outcomes of spring plates in the treatment of comminuted posterior wall acetabular fractures. (2) Methods: A retrospective multicenter (four level I trauma centers) observational study was performed. Patients with a comminuted posterior wall acetabular fracture treated with a spring plate (DePuy Synthes, West Chester, PA) were included. Diagnosis was made according to the Judet and Letournel classification. Diagnosis was confirmed with plain radiographs in an antero-posterior view and Judet views, iliac and obturator oblique views, and thin-slice CT with multiplanar reconstructions. (3) Results: Forty-six patients (34 males and 12 females) with a mean age of 51.7 years (range 19-73) were included. The most common mechanism of injury was motor vehicle accident (34 cases). In all cases, spring plates were placed under an overlapping reconstruction plate. The mean follow-up was 33.4 months (range 24-48). The mean period without weight-bearing was 4.9 weeks (range 4-7), and full weight-bearing was allowed at an average of 8.2 weeks (range 7-11) after surgery. (4) Conclusions: According to the present data, spring plates can be considered a viable additional fixation of the posterior wall acetabular fractures.

Short-term effectiveness of reconstruction plate internal fixation via improved Stoppa approach combined with iliac fossa approach and Kocher-Langenbeck approach for complex acetabular fractures

To investigate the short-term effectiveness of reconstruction plate internal fixation via improved Stoppa approach combined with iliac fossa approach and Kocher-Langenbeck approach for complex acetabular fractures. Between January 2015 and January 2020, 30 patients with complex acetabular fractures were treated with reconstruction plate internal fixation via improved Stoppa approach combined with iliac fossa approach and Kocher-Langenbeck approach. There were 20 males and 10 females with an average age of 52.1 years (range, 25-71 years). The cause of injury included traffic accident in 17 cases and falling from height in 13 cases. Among them, 14 cases were left acetabular fractures and 16 cases were right acetabular fractures. According to Letournel classification, there were 16 cases of double column fractures, 2 cases of transverse fracture with posterior wall fracture, 4 cases of anterior column and posterior hemi-transverse fractures, 8 cases of T-shaped fracture. The displacement distance of fracture ranged from 6 to 30 mm (mean, 11.6 mm). The time from injury to operation was 6-14 days (mean, 8.7 days). The operation time was 2.0-4.5 hours (mean, 3.0 hours). The intraoperative blood loss was 200-800 mL (mean, 450.0 mL). All patients were treated with autologous blood transfusion during operation. All incisions healed by first intention after operation, and no infection occurred. All patients were followed up 12-15 months (mean, 13.4 months). The drainage tube was removed at 2-3 days after operation. After extubation, X-ray film and three-dimensional CT were performed to recheck the fracture reduction. According to Matta score system, 20 cases were excellent, 5 were good, and 5 were poor, the excellent and good rate was 83.3%. All fractures healed with the healing time of 16-25 weeks (mean, 17.7 weeks). According to Merle d'Aubigne-Postel score system, the hip function at 1 year after operation was rated as excellent in 18 cases, good in 6 cases, and fair in 6 cases, and the excellent and good rate was 80.0%. Two cases suffered from sciatic nerve injury due to traction during operation, 7 cases had heterotopic ossification, 2 cases had traumatic hip arthritis, and no other complications occurred. For complex acetabular fractures, the reconstruction plate internal fixation via improved Stoppa approach combined with iliac fossa approach and Kocher-Langenbeck approach can obtain good short-term effectiveness with good reduction and hip joint function, and less complications.

Clinical Outcomes of the Modified Stoppa Combined with Iliac Fossa Approach for Complex Acetabular Fractures: A Medium- and Long-term Retrospective Study.

ObjectiveThe modified Stoppa combined with iliac fossa approach has gained increasing popularity. Although early clinical outcomes have been satisfactory, extensive long‐term clinical outcomes are relatively scarce. The purpose of this study was to evaluate the medium‐ and long‐term outcomes of this approach for complex acetabular fractures.MethodsThis was a retrospective study involving 57 patients with complex acetabular fractures from January 2009 to January 2016. All fractures were treated with the modified Stoppa combined with iliac fossa approach. Follow‐up was at least 5 years. Primary outcome measures, including quality of reduction and clinical outcomes, were recorded by an independent observer. Secondary outcome measures included time to surgery, surgical time, intraoperative blood loss, and perioperative complications.ResultsFifty‐seven patients (range, 18–80 years) included 46 males and 11 females. There were 32 cases on the left side and 25 cases on the right side. The most common associated injury was pulmonary contusion. According to the Judet–Letournel classification, there were 27 both‐column fractures, 16 anterior column with posterior hemitransverse fractures and 14 T‐type fractures. The average time from injury to surgery was 7.3 days. The average intraoperative blood loss and transfusion were 750.9 ml and 564.3 ml, respectively. All fractures healed within 6 months after surgery. The average follow‐up time was 7.7 years, and there was no loss of follow‐up. The quality of reduction was graded as anatomical in 23 cases (40.4%), imperfect in 22 cases (38.6%), and poor in 12 cases (21.0%). According to grading system of Merle d’ Aubigne and Postel, clinical outcomes at 1 year follow‐up were excellent in 17 cases (29.8%), good in 25 cases (43.9%), fair in four cases (7.0%), and poor in 11 cases (19.3%). The excellent and good rate was 73.7% and the difference was not statistically significant compared with the clinical outcomes at the last follow‐up. Intraoperative complications included four cases of obturator nerve injury and two cases of vascular injury. Postoperative complications included one case of wound delayed healing, two cases of deep vein thrombosis, two cases of avascular necrosis of femoral head, three cases of heterotopic ossification and five cases of post‐traumatic arthritis. Only one of these patients underwent reoperation for femoral head necrosis.ConclusionsThe modified Stoppa combined with iliac fossa approach can achieve satisfactory reduction quality and hip function. It might be a valuable alternative to the ilioinguinal approach for the surgical management of acetabular fractures.

Koksartrozlu Kalçada Gelişen Kompleks Asetabuler Kırığın Tedavisinde Erken ve Geç Dönem Artroplasti Sonuçlarinin Değerlendirilmesi

Purpose: We aimed to compare the clinical results of patients who underwent early and late hip arthroplasty due to complex acetabulum fracture with coxarthrosis and investigate the factors affecting the clinical results. Method: Patients who were operated on for acetabular fractures between 2005 and 2017 were retrospectively analysed. Patients with complex fractures according to the Letournel Classification and arthrosis according to the Kellgren-Lawrence radiological criteria were included in the study. Patients were divided in to two groups, post-fracture early period (group 1) and late period (group 2), based on when they underwent arthroplasty. Both groups were compared in terms of Harris hip score, Visual Analogue Scale (VAS), age, arthrosis, operation time, and time to return to daily life. Result: It was determined that 20 of the patients included in the study underwent arthroplasty in the early period and 21 in the late period. The mean average Harris score was 71.60 (± 13.5) in those who underwent early arthroplasty and 61.23 (± 2.6) in those who underwent late arthroplasty (p = 0.002). The average VAS score was 1.7 (1–3) in those who underwent early arthroplasty and 2.6 (1–5) in those who underwent late arthroplasty (p= 0.102) Conclusion: Early arthroplasty is a safer option with better functional results and lower complication rates than late arthroplasty in patients with complex acetabular fractures with coxarthrosis. In patients with complex acetabular fractures with coxarthrosis, early arthroplasty should be preferred when the surgeon is not sure about early or late arthroplasty. Keywords: Acetabular fracture, coxarthrosis, total hip replacement.

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.

Treatment of Two-column Acetabular Fractures by Double Extrapelvic Approach: Three Clinical Cases.

Fractures of two columns of the acetabulum according to the Letournel classification are among the most common in frequency, indication and surgical complexity. These are mainly the result of lateral compression mechanisms and are characterized by originating a disconnected acetabulum from the axial skeleton. Its surgical treatment may include: isolated anterior or posterior approach; combined, at the same surgical time or not; or broad approaches. The authors present another surgical option with association of the Kocher-Langenbeck pathway with the iliac crest approach simultaneously and in the same positioning (lateral decubitus) based on the first three clinical cases performed and their clinical and imaging results. In addition to the presentation of the cases, a description of the three characteristic fragments of this type of acetabular fractures, the approach pathway, and the reduction sequence performed are made. From the results obtained and the associated advantages, the authors believe that the addition of the iliac crest approach to the Kocher-Langenbeck pathway may be a very attractive option to consider in the surgical treatment of properly selected fractures of two columns of the acetabula.

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.

Complications and outcomes in 69 consecutive patients with floating hip

BackgroundFloating hip is a rare and potentially serious injury. The objective of this study was to evaluate our management strategy for patients with floating hip. HypothesisA standardized strategy with specialised multidisciplinary management is associated with a low mortality rate. MethodsConsecutive patients who had surgery to treat floating hip between January 2010 and December 2019 were included in this single-centre retrospective study. Epidemiological, clinical, and radiological data were collected and analysed. Patients were managed according to a standardised strategy adapted to the haemodynamic status and type of floating hip (type A, femoral and pelvic ring fractures; type B, femoral and acetabular fractures; and type C, femoral, acetabular, and pelvic ring fractures). The clinical outcome at last follow-up was determined by a telephone interview, based on the Majeed and Oxford scores, sports resumption, and work resumption. To assess the radiological outcomes, we applied Matta's criteria for the acetabulum and Tornetta's criteria for the pelvic ring. ResultsWe included 69 patients with a mean age of 38.5 years. Among them, 39 (57%) had haemodynamic instability requiring embolisation (n=15, 22%) or multiple blood transfusions (n=24, 35%). Type A injuries predominated (n=57, 83%). The need for multiple blood transfusions was significantly associated with type C floating hip, underlining the risk of heavy bleeding with this injury. Two (3%) patients died. When management was complete, the reduction was anatomical or satisfactory for 76% (13/17) of the acetabula according to Matta's criteria (maximum residual displacement <3mm) and for 85% (56/66) of the pelvic rings according to Tornetta's criteria (maximum residual displacement <10mm). One or more complications occurred in 45 (65%) patients. After a mean follow-up of 5 years, the mean Oxford Hip Score in patients with acetabular fractures was 35.5 and the mean Majeed score in patients with pelvic ring fractures was 71.5. Only 30% of patients were able to resume physical activities at the former level and to return to their former professional activities. ConclusionType C floating hip, which combines fractures of the pelvic ring and acetabulum, carries a high risk of bleeding. Special attention should be directed to the reduction of pelvic ring fractures, to avoid malunion. Acetabular fractures that are complex in the Letournel classification carry a risk of imperfect reduction. The results of this study confirm the severity of these rare injuries and the need for specialised multidisciplinary management according to a standardised strategy that is appropriate for the haemodynamic status and type of floating hip (A, B, or C). Level of evidenceIV; retrospective study.

Teaching Letournel classification

Background The aim of Letournel classification was to identify accurately the pathological anatomy of the fractured acetabulum. For orthopedic residents, this classification system is somewhat cumbersome. An important objective is to facilitate the understanding of this classification system among the junior residents. The aim of this study was to compare two educational tools, namely the systematic analysis of the plain films and the 3D computed tomography (CT) scans in improving the diagnostic performance of orthopedic residents. Patients and methods Twenty x-rays set for acetabular fractures, including A/P, iliac, and obturator view, were selected from our hospital database. These sets were prepared in a quiz form. Thirty residents were asked to diagnose the given fracture using x-rays only. Then, the residents were randomly allocated to two groups. Group I was asked to repeat the same quiz with the addition of 3D CT-reformatted images (A/P and obliques). Group II was asked to analyze the same x-rays using an algorithm. Data collected included the training period of the resident, the answers in pre- and post-tests together with the subjective assessment of how difficult each diagnosis was. Results While the two groups showed a significant and similar improvement in reaching the right diagnosis, using the algorithm was significantly easier. Conclusion Compared with the advanced imaging technology, plain x-ray film if analyzed systemically is an easier way to understand Letournel classification when educating junior orthopedic residents.

Comparison of the functional and radiological results of the conservatively and surgically treated displaced acetabulum fractured patients.

The purpose of the study was to compare the functional and radiological results of the conservatively and surgically treated displaced acetabular fractured patients. The study included 61 patients with a displaced acetabulum fracture over the age of 18, who have been treated con-servatively or surgically for acetabular fractures, between 2000 and 2014. Patients were divided into two groups according to their treatment type. Group 1 consisted of conservatively treated 31 between 2000 and 2010 patients and Group 2 consisted of surgically treated 30 patients between 2010 and 2014. The fractures were classified according to Judet and Letournel classification. Clinical evaluation of the patients was conducted according to Modified Merle D'Aubigne Score, SF-36, and Harris Hip Score. Radiological evaluation was evaluated according to Matta's Radiological Evaluation Criteria. Kolmogorov-Smirnov, t-test, Mann-Whitney U-test, and two Wilcoxon paired sample tests were used for statistical analysis. The significance limit was chosen as p<0.05. The mean follow-up time was 10 years for the conservative group and 5.5 years for the surgery group. There was no statistically significant difference in functional scores between both groups (p>0.05), Matta's radiological staging score was significantly higher in the operated group (p=0.023). Radiological scores are not directly correlated with the functional capacity. We obtained good radiological and functional scores in the surgical group, operative treatment should be considered when absolute indications are there. The outcome of conservatively managed fractures is not bleak. We think that there is an alternative to surgical treatment in displaced acetabular fractures and that similar functional results can be obtained in selected cases.

Therapeutic Effect of Acetabular Fractures Using the Pararectus Approach Combined with 3D Printing Technique.

ObjectiveTo explore the clinical efficacy of pararectus approach combined with 3D printing technique for the surgical treatment of partial acetabular fractures.MethodsWe retrospectively evaluated 33 (20 males and 13 females) patients with acetabular fractures in the period of June 2017 to December 2018. According to Judet and Letournel classification: 11 cases were of anterior column fracture, 10 cases were of double column fracture, seven fractures were of the anterior column with posterior half transverse, three fractures were of transverse fracture, and two cases were of “T” fracture. For all cases, 3D printing is used to print the acetabular model. Pre‐bent reconstruction plates from the model were placed to fixate fractures via the pararectus approach.ResultsThirty‐three patients (mean age 48 years; range, 35–63 years), included 20 men and 13 women, were treated successfully with open reduction and internal fixation by the pararectus approach. Surgery duration was 203 min on average (range: 135–245 min), and intra‐operative bleeding was 1030 mL on average (range: 450–1400 mL). All patients were followed‐up for 12–18 months (average,14 months); two patients (6.0%) developed postoperative ossifying myositis, and there are no obvious symptoms at present; one patient (3.0%) developed postoperative wound infection, and the wound completely improved by secretion culture, enhanced dressing, and effective antibiotics; all the acetabular fractures united after 12 to 16 weeks (average,13 weeks). According to the modified Merle d'Aubigne and Postel scoring system to assess the hip function: excellent in 22 cases (66.7%), good in seven cases (21.2%), and fair in four cases (12.1%).ConclusionsIn the treatment of partial acetabular fractures, the pararectus approach combined with 3D printing technique can achieve effective reduction and fixation, decrease intraoperative hemorrhage, shorten operation time, and the internal fixation position can be properly adjusted during the operation by looking directly at the model.

Double column acetabular fractures fixation using a novel dynamic anterior plate-screw system: A biomechanical analysis

BackgroundAccording to the classification of Judet and Letournel, all double column acetabular fractures will certainly involve the disruption of the quadrilateral plate (QLP). Accurate reduction and reliable fixation of QLP is the key to obtain a normal congruent hip joint and avoid postoperative arthritis. The aims of this study were to assess the biomechanical properties of a novel dynamic anterior plate-screw system (named DAPSQ) and to compare its biomechanical stability with buttress-plate construct. MethodsDouble column acetabular fractures involving the QLP were created on cadaveric pelvic specimens and subsequently stabilized with (1) a pre-contoured side-specific DAPSQ titanium plate and 4 quadrilateral screws (Group A) or a 12-hole suprapectineal pelvic reconstruction plate combined with a 9-hole 1/3 tube buttress plate (Group B). These constructs were mechanically loaded on ZwickZ 100 testing machine. Construct stiffness and displacement amounts of the two fixation methods in the condition of dynamic axial loading conditions were measured. ResultsAs the axial loading force increased from 200 N to 800 N, the longitudinal displacement of each pelvic specimen increased linearly and Group B was found to have significantly higher displacement than Group A (p<0.05). In the 600 N physiological loading, the construct stiffness values of Groups A and B were 139.4 ± 37.4 N/mm and 101±18.3 N/mm, respectively. Group A is 27% stiffer than Group B(p<0.05). ConclusionsIn this in vitro biomechanical study, DAPSQ plate and quadrilateral screws fixation of a double column acetabular fracture involving the QLP resulted in a better fixation construct than the traditional suprapectineal pelvic reconstruction plate and 1/3 tube buttress plate fixation.