Quadrilateral Plate Fractures Research Articles

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

Quadrilateral plate (QLP) is a relatively thin bony structure located below the pelvic brim proximal to the hip joint, so management of its fractures is challenging. Evaluation of the functional and radiological outcomes of internal fixation of quadrilateral plate acetabular fractures; comparison of two methods of fracture fixation. A prospective multicentric study including 30 patients who underwent open reduction and internal fixation of QLP fractures through modified Stoppa approach. Patients were divided into two groups according to the method of fixation (anatomical QLP plate vs suprapectineal and infrapectineal plates). Post-operative quality of reduction was evaluated using Matta score. Radiographical assessment according Matta's grading criteria and clinical outcome assessment using the Harris Hip Score (HHS) were repeated at follow-up and at one year to assess displacement. Mean age of patients was 34.9 ± 12.1years. After one year follow-up, clinically mean HHS was 88. ± 5.74. Radiologically post-operative reduction quality was anatomical in 21 (70%) patients, satisfactory in eight (26.7%) patients and unsatisfactory in one (3.3%) patient. Matta's grading at the last follow-up was excellent in 21 (70%) patients, good in six (20%), fair in two (6.7%) patients and poor in one (3.3%) patient. No significant difference was recorded between the two groups in terms of radiographical and clinical results and rate of complications. Accurate reduction of quadrilateral plate fracture with secure fixation through modified Stoppa approach provides good and reproducible outcomes with few complications regardless the type of the implant.

Use of calcaneal locking plate in surgical treatment of quadrilateral plate fractures of theacetabulum.

Specialized devices for fixation of the acetabulumquadrilateral plate (QP) fractures may not be readily available in resource-constrained settings. In this article, we aim to explore the use of a 3.5-mm locking calcaneal plate in fixation of QP fractures. Twenty-eight patients with QP fractures underwent surgery using the modified Stoppa approach. Follow-up at 12months assessed fracture healing and functional outcomes using the Majeed pelvic outcome score. Descriptive statistics summarized patient demographics and fracture characteristics. Analysis of variance (ANOVA) and exact logistic regression explored associations between factors (age, AO/OTA classification, gender, and time to surgery) and Majeed scores. The mean age of patients was 42.71years, with the majority being male (64.29%). All patients achieved bony union. Post-traumatic arthritis developed in three patients, while two patients experienced post-operative fracture redisplacement. Evaluation using the Majeed pelvic outcome score revealed generally favorable outcomes, with 32.14% achieving excellent, 39.29% good, 21.43% fair, and 7.14% poor outcome. Only an older age was associated with a worse outcome score (excellent/good versusfair/poor,odds ratio: 0.87, 95% confidence interval: 0.77, 0.96). Surgical management of quadrilateral plate fractures using 3.5-mm locking calcaneal plates demonstrates promising outcomes, particularly in resource-constrained settings, where specialized devices may be lacking.

Quadrilateral plate classification program of acetabular fractures based on three-column classification: a three-dimensional fracture mapping study

BackgroundA new classification system for acetabular fractures has been proposed in recent years, which is called the 3-column classification. However, this system does not provide information regarding quadrilateral plate fractures. To address this issue, we utilized three-dimensional (3D) fracture line mapping and heat map to analyze the link between the 3-column classification and quadrilateral plate fractures.MethodsWe collected CT scan data from 177 patients who had been diagnosed with acetabular fractures. Additionally, we utilized a CT scan of a healthy adult to generate a standard acetabular model. We utilized the collected CT data of the fracture to create a 3D model and subsequently reduced it. We then matched each acetabular fracture model with the standard acetabular model and mapped all of the fracture lines to the standard model. 3D fracture lines and heat maps were created by overlapping all fracture lines. Fracture characteristics were then summarized using these maps.ResultsThis study analyzed a total of 221 acetabular fractures. The most frequently observed fracture type, based on the three-column classification, was A1.2, which corresponds to fractures of the anterior column. In contrast, the least common type of fracture was A4, which represents fractures of the central wall. It was noted that quadrilateral plate fractures were frequently observed in fractures classified as type B and C according to the three-column classification.ConclusionsAmong the three-column classification, the QLP fractures are commonly observed in type B and C. It is important to carefully identify these fractures during the diagnostic process. Therefore, based on the three-column classification, we have amalgamated quadrilateral plate fractures and formulated a classification program for acetabular fractures.

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.

Functional, radiological, and quality of life outcome of unstable acetabular fracture with quadrilateral plate involvement at a tertiary care center in Jakarta, Indonesia.

Unstable acetabular fracture remains a complex fracture that requires technically demanding surgery for orthopedic surgeons. Quadrilateral plate (QP) fractures of the acetabulum are a challenging group of acetabular fractures to manage. However, the literature regarding the management of these injuries are limited. The QP is a relatively thin medial wall of the acetabulum and intra-articular; thus, anatomical reduction and stable fixation are required for satisfactory outcome. This study aims to determine the functional, radiological, and quality of life outcome of unstable acetabular fracture with QP involvement. This was a retrospective cohort study conducted at Cipto Mangunkusumo General Hospital during the period of 2010-2020. Patients with unstable acetabular fractures with and without QP involvement were included in this study. They were followed up postoperatively at 1, 6, and 12months. Functional outcome was assessed using the Harris Hip Score (HHS), Merle D'Aubigne, and Oxford Hip Score (OHS); while radiology outcome was assessed using Matta Outcome Grading; and quality of life was assessed using the SF-36. This study involved 53 subjects with a median age was 29 (18-75) years of age. Twenty-eight (52.8%) subjects had unstable acetabular fracture with QP involvement. Twenty-five (47.2%) subjects had unstable acetabular fracture without QP involvement. Twenty-five (47.2%) subjects were fixed using quadrilateral hook plate, 3 (5.7%) with infrapectineal plate, 10 (18.8%) with posterior column plate, and 15 (28.3%) with suprapectineal plate. The median intraoperative bleeding in those with unstable acetabular fracture with QP involvement was 600 (300-4000) ml, which was higher than those without QP involvement (400 [100-1700]ml). Those with QP involvement achieved anatomical reduction in 20 (71.4%) subjects. Whereas, the subjects without QP involvement achieved anatomical reduction 23 patients (92%). Subjects with QP involvement had significantly lower functional, radiological, and quality of life outcomes compared to those without quadrilateral plate involvement based on Harris Hip Score (p = 0.046), Merle D'Aubigne (0.001), Oxford Hip Score (0.001), Matta Outcome Grading (0.004), and SF-36 (0.001). Patients with quadrilateral hook plate showed no significant functional, and radiological outcome difference compared to patients with infrapectineal plate based on Harris Hip Score (p = 0.582), Merle D'Aubigne (0.698), Oxford Hip Score (1.000), and Matta Outcome Grading (1.000). In addition, we also found no significant functional, radiological, and quality of life outcome difference between posterior column plate and suprapectineal plate group based on Harris Hip Score (p = 0.200), Merle D'Aubigne (0.643), Oxford Hip Score (0.316), Matta Outcome Grading (1.000), and SF-36 (0.600). Patients with unstable acetabular fracture with quadrilateral plate involvement subject had significantly lower functional, radiological, and quality of life outcomes compared to those without quadrilateral plate involvement. Both quadrilateral hook and infrapectineal plates demonstrated non-significant functional and radiological outcomes difference. Posterior column plate also resulted in the same functional, radiological, and quality of life outcome compared with suprapectineal fixation.

Is the Direct Fixation of Displaced Quadrilateral Plates in Acetabular Fractures Necessary?

Quadrilateral plate fractures represent a heterogeneous group of acetabular fractures. Accurate reduction is required to prevent post-traumatic arthritis. The purpose of this study is to determine the reduction effect of the direct fixation of quadrilateral plates in acetabular fractures, and to evaluate the strength of direct fixation compared to indirect fixation. Between 2005 and 2021, 49 patients underwent surgery for open reduction and internal fixation in acetabular fractures with severely displaced quadrilateral plates. Twenty-nine patients comprised the indirect fixation group, and twenty patients comprised the direct fixation group. In a comparison of primary outcome between two groups, 10 out of 29 indirect-group patients and 1 out of 20 direct-group patients developed post-traumatic osteoarthritis, wherein the difference between the two groups is statistically significant. In the assessment of postoperative Matta's radiological reduction status, 19 out of 20 patients in the direct group had achieved anatomical and congruent reduction. The treatment using a direct reduction and internal fixation improved the reduction quality of articular displacement and offered a better survivorship of the affected hip joint.

Inclined angles of acetabular quadrilateral plate: digital measurement and clinical application of the new anatomical concept

PurposeMatta scoring standard is one of the most frequently used postoperative imaging evaluations for acetabular fracture reduction, but has obvious shortcomings. This study, for the first time, proposed the concept of inclined angles of acetabular quadrilateral plate. The purpose of this study was to investigate the normal range of the inclined angles in adults by digital measurement and explore the feasibility of using them to evaluate the reduction quality of acetabular quadrilateral fractures after surgery.MethodsFirstly, the pelvic CT three-dimensional reconstruction data of 40 healthy adults including 20 males and 20 females were collected. The normal range of the anterior, middle, and posterior inclined angles were measured via Mimics software. Secondly, a modified Matta criteria that combined the classic Matta criteria and evaluation criteria of the inclined angles was proposed. And we classified modified Matta criteria into three grades including excellent, good and poor. Finally, a total of 125 cases with quadrilateral plate fractures was included and the postoperative CT data were analyzed by using both the classic Matta criteria and our modified Matta criteria. Then, the accuracy and consistency of both criteria to evaluate postoperative hip function was investigated.ResultsThe average anterior inclined angle: male (97.11° ± 2.59°), female (90.63° ± 2.09°); middle inclined angle: male (105.57° ± 1.93°), female (100.64° ± 2.46°); and posterior inclined angle: male (112.62° ± 2.54), female (106.37° ± 2.53°). Whether in males or in females, the anterior, middle, and posterior inclined angles showed a progressively increasing trend. All the three inclined angles in males were all significantly larger than those in females (p < 0.05). Among 125 cases with quadrilateral plate fractures, 101 cases (80.8%) were graded as excellent, 18 cases (14.4%) as good, and 6 cases (4.8%) as poor according to the classic Matta criteria. While based on modified Matta criteria, there were excellent in 37 cases (29.6%), good in 76 cases (60.8%), and poor in 12 cases (9.6%). According to the Harris hip score system, the functional outcomes were excellent in 59 cases (47.2%), good in 26 cases (20.8%), fair in 24 cases (19.2%), and poor in 16 cases (12.8%). Our results showed that among the cases evaluated as excellent according to the classic Matta criteria and modified Matta criteria, the excellent-to-good rates of hip function were 70.3% and 78.4%, respectively. And among the cases evaluated as poor according to the modified Matta criteria, the fair-to-poor rate of hip function was 75%, while this value was 50% for classic Matta criteria. Both differences were statistically significant (p < 0.05).ConclusionInclined angles of the quadrilateral plate could be used to assess the quality of fracture reduction and provide a basis for evaluating the rotational displacement of fracture blocks in the quadrilateral plate, which compensates the shortage of classic Matta criteria.

A new classification for quadrilateral plate fracture of acetabulum

BackgroundRecently, quadrilateral plate (QLP) fractures of acetabulum have attracted increasing attention. However, evidence for the appropriate classification of QLP fractures is still lacking, making it difficult to understand and manage these fractures. This study aimed to introduce a new classification for QLP fractures and evaluate its reproducibility. MethodsA series of 1101 consecutive patients with acetabular fractures from 8 level-I trauma centers were enrolled in this study. All patients underwent preoperative radiograph and computed tomography imaging. QLP fractures were identified and classified using the new and Judet-Letournel classification system. The inter- and intra-observer reliabilities (kappa coefficients, κ) of these two systems were investigated by 4 observers. Furthermore, surgical approaches and fixation methods for each fracture type are described. ResultsIn total, 243 (243/1101, 22%) patients with QLP fractures were identified and included in this analysis. The mean κ value of the intra-observer reliability was 0.84 (range, 0.763−0.919) for the new classification, indicating excellent agreement, and the inter-observer reliability was 0.762 (range, 0.625−0.876), indicating substantial agreement. The values were 0.649 (range, 0.523−0.708) and 0.584 (0.497−0.646), respectively, according to the Judet-Letournel classification. Six cases (6/243, 2.5%) could not be classified using the Judet-Letournel classification. The selection of surgical approaches and fixation methods depends on the fracture type; however, an anterior intra-pelvic approach and buttressing fixation using the plate or screw are preferred for QLP fractures. ConclusionThis study presents a new classification for QLP fractures, showing higher intra- and inter-observer reliabilities than those obtained using the Judet-Letournel classification. This allowed us to obtain an in-depth and comprehensive understanding of QLP fractures. Additionally, the new classification might guide further studies on surgical strategies for QLP fractures. Level of EvidenceLevel II

Результаты хирургического лечения пациентов с переломами вертлужной впадины и квадрилатеральной поверхности

Background Open reduction and internal fixation (ORIF) remain the standard method of treating acetabular fractures. Many authors report poor results in quadrilateral plate fractures of the acetabulum with the use of ORIF. The objective was to evaluate outcomes of quadrilateral plate fractures of the acetabulum. Material and methods Surgical outcomes of 55 patients with quadrilateral plate fractures of the acetabulum were retrospectively reviewed between 2009 and 2019. Early postoperative results were followed up in 55 patients. Surgical treatment was provided for 32 (58.2 %) control patients with acetabular fractures and 23 patients (41.8 %) with quadrilateral plate fractures of the acetabulum in the main group. Long-term results were explored in 45 patients aged 18 to 60 years with acetabular fractures (control group, n = 24) and in combination with quadrilateral plate involvement (main group, n = 21). Results Surgical interventions were performed by one team consisting of the same specialists. Surgical outcomes in oth clinical groups were evaluated according to 11 criteria. Discussion The results of surgical treatment of acetabular fractures and quadrilateral plate involvement were associated with the negative impact of quadrilateral plate involvement on the duration and volume of blood loss, intraoperative and late complications and dynamics in the development of post-traumatic hip arthrosis. The results obtained were comparable with the data of the itation sources. Conclusion A comparative analysis of the outcomes suggested a negative impact of quadrilateral plate involvement on the results of surgical treatment and an objective necessity to rank quadrilateral plate fractures of the acetabulum as a risk factor for adverse outcomes with ORIF.

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

To investigate whether the fracture morphology of quadrilateral plate (QP) fragments is associated with the anterior and posterior columns in associated both-column (ABC) fractures. Three-dimensional computed tomography data of 100 ABC fractures treated at our hospital from August 2016 to August 2019 were retrospectively analyzed using Mimics and 3-matic software. The distribution of fracture lines was described using the fracture mapping technique. One fragment presented on the QP was confirmed in 88% of the patients. The QP fragments' fracture lines were divided into the anterior oblique (AO), superior posterior oblique (SPO), and mid-posterior oblique (MPO) lines, occurring in 100, 86, and 8 cases, respectively. AO lines were distributed along the arcuate line. SPO lines were continuations of the AO lines, which were distributed to the posterior column from the greater sciatic notch to the lesser sciatic notch. MPO lines were involved in the QP's central area. A simple fracture was found at the proximal AO and SPO lines in 80% and 86% of all displaced fractures, respectively. AO lines distal to the superior rim of the acetabula were confirmed to be comminuted fractures in 32% of all cases. In ABC fractures, there was only one QP fragment in nearly 90% of all cases. The QP fractures were mainly present in the QP's peripheral area. More than 80% of the fracture patterns on the cephalic side of the QP were simple. The reduction and internal fixation of QP fractures in ABC fractures should be in the cephalic region.

Fast-Track-Protocol for Optimization of Presurgical Planning in Acute Surgical Treatment of Acetabular Quadrilateral Plate Fractures Using 3D Printing Technology and Pre-Contoured Reconstruction Plates

Background. Preoperative planning and 3D printing can be used to treat pelvic bone fractures using pre-contoured surgical plates, in particular complex, comminuted fractures involving the acetabulum and quadrilateral plate. The aim of the study was to develop a Fast-Track-Protocol (fast track methodology) for creating 3D anatomical models, that could be used to shape surgical plates, using open-source software and budget 3D printers. Such a ‘low-budget’ approach would allow a hospital-based multidisciplinary team to carry out pre-surgical planning and treat complex pelvic fractures using 3D technology. Methods. The study included 5 patients with comminuted pelvic fractures. For each patient, CT (computed tomography) data were converted into two 3D models of the pelvis-injured side and mirrored model of the contralateral, uninjured hemipelvis. These models were 3D printed and used as templates to shape surgical plates. Results. A Fast-Track-Protocol was established and used to successfully treat 5 patients with complex, comminuted fractures of the pelvis. Conclusion. Using the Fast-Track-Protocol it was possible to prepare 3D printed models and patient-specific pre-contoured plates within 2 days of hospital admittance. Such an approach resulted in better surgical technique and shorter operative times, while incurring relatively low costs.

Fixation of acetabular fractures with quadrilateral plate involvement using intrapelvic reduction and buttress plate via modified stoppa approach: A clinico-radiological and functional outcome evaluation

Acetabular fractures with quadrilateral plate involvement form a heterogeneous group of fractures which are not specifically defined by any current classification system. Surgical treatment of these fractures poses a challenge to Orthopaedic surgeons. The aim of this study was to evaluate the efficacy, safety and outcomes of the fixation technique by using IRBP for acetabular fractures with quadrilateral plate involvement via single modified Stoppa approach.A total of 30 patients with acetabular quadrilateral plate fracture, selected between January 2016 to June 2019, were managed by IRBP via modified Stoppa approach. This was a prospective study and all patients were followed up to a minimum of 2 years. The primary outcome measures were reduction quality and functional outcome which were evaluated according to Matta’s radiological criteria and modified Merle d’Aubigné and Postel score respectively. Secondary outcomes were intra-operative conditions such as operative time and blood loss and post-operative complications.Anatomic reduction was obtained in 22 (73.3%), Imperfect in 6 (20%), and Poor in 2 (6.7%) cases. The modified Merle d’Aubigné and Postel score outcomes were Excellent to Good in 25 (83.3%) patients, Fair in 3 (10%), and Poor in 2 (6.7%) with the mean score being 16.07 ± 2.68. 21 (70%) patients did not have any complications. None of the cases had quadrilateral screws entering the hip joint.The use of IRBP system is an effective and safe choice for acetabular fractures with quadrilateral plate involvement done via modified Stoppa approach as it has low rate of complications, addresses multiple fractures of acetabulum through a single approach and provides good functional and radiological outcomes over long term.

Quadrilateral plate fractures of the acetabulum: Classification, approach, implant therapy and related research progress.

The quadrilateral plate (QP) is an essential structure of the inner wall of the acetabulum, an important weight-bearing joint of the human body, which is often involved in acetabular fractures. The operative exposure, reduction and fixation of QP fractures have always been the difficulties in orthopedics due to the special morphological structure and anatomical features of the QP. Fortunately, there have been many effective methods and instruments developed for QP exposure, reduction and fixation by virtue of the combined efforts of numerous orthopedists. At the same time, each method presents with its own advantages and disadvantages, resulting in different prognoses. It is necessary to have a thorough understanding of the anatomy, radiology and fixation techniques of the QP in terms of patient prognosis optimization. In this paper, the anatomical features, definition and classification of QP, operative approach selection, implant internal fixation methods and efficacy were reviewed.

Role of combined brim and spring plates in the treatment of acetabular fractures involving quadrilateral plates: a retrospective study of early results

Background: Quadrilateral plate (QP) fractures constitute an intrapelvic component of acetabular fractures and are challenging for surgical fixation. Inability to reduce and buttress QP leads to poor functional outcome. The hypothesis was that use of combined brim and spring plates for fixation of fractures that involved QP would maintain reduction and improve functional outcomes of those patients. Methods: This was a retrospective case series study of 44 patients with acetabular fractures that involved QPs that were fixed by combined brim and spring plates between March 2015 and January 2020 in the orthopaedic surgery department in Suez Canal University Hospitals. All patients were operated by the same surgical team. A minimum of 12 mo of postoperative follow-up was planned for each. Statistical analysis was done using SPSS software (version 17 for Windows, Chicago, Illinois). Results: The mean patient age was about 40.4 yr. The associated dislocations were present in ten patients (22.7%). Anterior column and posterior hemitransverse fractures were in about 50% of patients. Average operative time was about 146 min. Average intraoperative blood loss was about 583 mL. No patients developed avascular necrosis of the femoral head, heterotopic ossification, or implant failure. Two patients had postoperative obturator nerve injury. Quadrilateral component reduction was anatomical in 28 hips (63.6%). At 1-year follow-up, final clinical scores were excellent in 15 hips (34.1%) and good in 18 hips (40.9%). Conclusions: Combined brim and spring plates can maintain anatomical reduction of QP fractures and give good clinical results with less operative time and fewer complications than other methods mentioned in the literature. Level of Evidence: Level IV.

Traitement des fractures de l’acetabulum atteignant la lame quadrilatère : comparaison des voies ilio-inguinales et de Stoppa

BackgroundAcetabular fractures with quadrilateral plate (QLP) involvement have traditionally been treated by buttress plates applied through an Ilio-inguinal approach. Recently, many surgeons prefer the application of infra-pectineal plates through the modified Stoppa approach for this purpose. Whether one method can be preferred over the other is a matter of investigation. HypothesisThe research question was whether an infra pectineal plate applied through the modified Stoppa approach for acetabular fractures with QLP involvement would result in an equivalent or better outcome than a buttress plate applied through an ilioinguinal approach. Patients and methodsThis was a retrospective study of patients with QLP fractures operated by either of the two methods and who had completed at least one year follow up. Demographic and surgical details and the radiological and clinical outcomes at the last follow-up visit were obtained from patient records. ResultsForty one patients were treated with a buttress plate applied through an ilioinguinal approach (group A), and 49 patients were treated with an infra-pectineal plate by the modified Stoppa approach (group B). Duration of surgery and intra-operative blood loss was significantly less in group B patients. Radiological and clinical outcomes were better in group B patients than group A patients. Implant loosening was more frequent in group A patients. Injury to the obturator vessels were more common in group B patients. ConclusionWith a comparatively lesser surgical duration and blood loss, better clinical and radiological outcomes at least one year after the surgery, an infra-pectineal plate applied through the modified Stoppa approach can be considered the preferred treatment for most acetabular fractures with QLP involvement. Level of evidenceIII.

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

BackgroundAcetabular fractures with quadrilateral plate (QLP) involvement have traditionally been treated by buttress plates applied through an Ilio-inguinal approach. Recently, many surgeons prefer the application of infra-pectineal plates through the modified Stoppa approach for this purpose. Whether one method can be preferred over the other is a matter of investigation. HypothesisThe research question was whether an infra pectineal plate applied through the modified Stoppa approach for acetabular fractures with QLP involvement would result in an equivalent or better outcome than a buttress plate applied through an ilioinguinal approach. Patients and MethodsThis was a retrospective study of patients with QLP fractures operated by either of the two methods and who had completed at least one year follow up. Demographic and surgical details and the radiological and clinical outcomes at the last follow-up visit were obtained from patient records. ResultsA total of 41 patients were treated with a buttress plate applied through an ilioinguinal approach (group A), and 49 patients were treated with an infra-pectineal plate by the modified Stoppa approach (group B). Duration of surgery and intra-operative blood loss was significantly less in group B patients. Radiological and clinical outcomes were better in group B patients than group A patients. Implant loosening was more frequent in group A patients. Injury to the obturator vessels were more common in group B patients. ConclusionWith a comparatively lesser surgical duration and blood loss, better clinical and radiological outcomes at least one year after the surgery, an infra-pectineal plate applied through the modified Stoppa approach can be considered the preferred treatment for most acetabular fractures with QLP involvement. Level of evidenceIII.

Open reduction and internal fixation of quadrilateral plate fractures in the elderly: association between initial fracture pattern and outcomes

BackgroundAcetabular fractures with medial displacement of the quadrilateral plate (QLP) are common in the elderly. The presence of QLP fractures greatly increase the surgical difficulty of acetabular fractures. This study aims to evaluate the clinical radiological outcomes of open reduction and internal fixation (ORIF) in QLP fractures in elderly patients and to investigate factors potentially affecting the result.MethodsWe conducted a retrospective study. A series of 37 consecutive patients with acetabular fracture involving the QLP aged 60 years and older who received ORIF between January 2010 and May 2019 were included. QLP fractures were classified according to Walid’s classification system. Radiological outcomes were evaluated using Matta criteria and functional outcomes were assessed using the modified Merle d’Aubigné score. The relationships between Walid’s classification and radiological or functional outcomes were analyzed.ResultsAccording to Walid’s classification, 18, 13, 6 were classified as QLP1, QLP2 and QLP3, respectively. The average follow-up was 35.5 ± 10.7 months. We obtained anatomic reduction in 48.6 % (18/37) of cases, imperfect reduction in 40.5 % (15/37) of cases, and poor reduction in 10.8 % (4/37) of cases. Excellent-good functional scores were found in 83.7 % (modified Merle d’Aubigné). There were no cases of screw entering the hip, pull-out and loosening or implant failure during the follow-up. Walid’s classification was positively correlated with radiological outcomes of reduction (r = 0.661; P < 0.001), and functional outcomes (r = 0.478; P = 0.003). Unsatisfactory reduction was demonstrated a correlation with the development of post-traumatic arthritis (r =-0.410; P = 0.012).ConclusionsORIF may be suggested for quadrilateral plate fractures in the elderly. Walid’s classification system is associated with the reduction quality and functional recovery.

The Quadrilateral Plate in Acetabular Fracture Surgery: What Is It and When Should It Be Addressed?

The quadrilateral plate (QP) is the relatively flat surface of bone in the true pelvis lying directly medial to the acetabulum. This surface is frequently involved in acetabular fractures. Elderly individuals, in particular, commonly sustain anterior column fractures with incomplete or complete posterior hemitransverse fracture lines with associated QP comminution. If QP fracture lines propagate through the superior weight-bearing surface of the acetabulum, the femoral head may displace medially, leading to poor outcomes if not addressed. Fortunately, the collective work of many orthopaedic surgeons has resulted in numerous effective methods for approaching, reducing, and stabilizing the QP and the diverse family of fractures which affect it. A thorough understanding of the QP, its anatomy, radiology, and techniques for fixation, is required to optimize patient outcomes.

Management of quadrilateral plate fractures: An up to date

Acetabular fractures are result of mostly high velocity injury with an incidence of 3/100,000/year. However in elderly patent low energy trauma also result in acetabulum fracture due to osteoporosis. Most of acetabular fracture commonly combined with quadrilateral plate fractures. Till date there is no standard classification system for quadrilateral plate fracture of acetabulum is published which can be utilized for accurately studying the fracture pattern and planning for the surgical approach with management. Initially acetabulum fracture was managed conservatively with traction for at least 6 weeks which results in aggravation of secondary symptoms such as pressure sore, DVT, post traumatic arthritis, loss of muscle strength and endurance. Aim of acetabulum fracture fixation are to allow early mobilization, restoring joint congruity, pain relive and reducing the risk of post traumatic arthritis. An internet search of MEDLINE and PMC using the search term 'acetabular fracture', 'quadrilateral plate fracture' and central hip dislocation in English language was performed on 1st march 2021. Papers specific with quadrilateral plate fracture were only included in the study and we found variety of technique available for displaced quadrilateral plate fractures, such as cerclage wire-plate composite, pelvic brim long screws, various combinations of spring plates (T-shaped plate, L-shaped plate, infrapectineal plate, H-plate, and multidirectional titanium fixator. In this review article we studied different treatment modalities and techniques used over several decades for management of quadrilateral fracture with their outcome.

Does use of a quadrilateral surface plate improve outcome in elderly acetabular fractures?

BackgroundAcetabular fractures in the elderly frequently involve segmental quadrilateral plate injury, yet no consensus exists on how to best control the femoral head medial displacement. Quadrilateral surface plates (QSP) were developed to help buttress these challenging fractures. The study aims to 1) Determine the prevalence of segmental quadrilateral plate fractures (SQPF) in elderly patients; and 2) Assess if utilization of a QSP is associated with improved acetabulum fracture reduction and outcome. MethodsThis was a retrospective study conducted at a level-1 trauma centre. . All patients over 60-years that sustained an acetabular fracture between 2007 and 2019 were reviewed. Pre-operative pelvic radiographs and CT imaging were reviewed for 96 patients, to assess for SQPF. From the 96 patients reviewed, over one third of patients (n = 40, 41.6%) sustained a SQPF. Patients that had an acute-THA (n = 7) were excluded as were patients that underwent an ORIF but did not have a QSP or an anterior column buttress plate (n = 3). The remaining 30 formed the study’s cohort. We assessed the ability to achieve and maintain reduction in this elderly population, and compared outcomes using traditional anterior column buttress plates (ilioingual or intra-pelvic approach) versus an intra-pelvic pre-contoured buttress suprapectineal plate (QSP). Outcome measures included: fracture reduction using the Matta classification (desirable: anatomical/imperfect and poor), re-operations, conversion to THA and Oxford Hip Score (OHS) (for the preserved hips). ResultsTen patients had an ORIF with utilization of a QSP (QSP-group), and 20 had an ORIF but did not have the QSP (non-QSP-group). There was no difference in patient demographics between groups. Fracture patterns were also similar (p = 0.6). Postoperative fracture reduction was desirable (anatomical/imperfect) in 17 patients and poor in 13. Improved ability to achieve a desirable reduction was seen in the QSP-group (p = 0.02). Conversion to THA was significantly lower in patients that had a desirable fracture reduction (appropriate: 3/17; poor: 7/13). No patients in the QSP-group have required a THA to-date, compared to 10/20 patients in the non-QSP-group (p = 0.01). The mean time to THA was 1.6 ± 2.1 year. There was no difference in OHS between the two groups (34.4 ± 10.3). ConclusionElderly acetabulum fractures have a high incidence (approaching 40%) of segmental QPF. Desirable (anatomical/imperfect) fracture reduction was associated with improved outcome. The use of a QSP was associated with improved ability to achieve an appropriate reduction. A QSP should be considered as they are both reliable and reproducible with a significantly improved fracture reduction and lower conversion to THA.