Transverse Acetabular Fractures Research Articles

The added value of intraoperative CT scanner and screw navigation in displaced posterior wall acetabular fracture with articular impaction

Posterior wall with transverse acetabular fractures represents the most common type of acetabular fractures and is generally associated with poorer outcomes. This is caused by improper visualization of the fragments leading to imperfect reductions. Navigation in pelvic and acetabular trauma is reserved nowadays to non-displaced or mildly displaced fractures. To add to that, perioperative control of reduction is difficult using the conventional X-ray. The described 3D imaging method allowed proper reduction control. On the other hand, screw navigation of acetabular screws enabled better control of screw position as well as screw placement in otherwise inaccessible zones. In conclusion, peroperative 3D imaging and screw navigation optimize fracture reduction promoting better radiological and functional results.

Finite element analysis of the stability of transverse acetabular fractures in standing and sitting positions by different fixation options

BackgroundTreatment of a transverse acetabular fracture type is possible from an anterior approach, a posterior approach or both. Different fixation methods have been described but whether one is superior to the other is still under debate. The aim of the current study was to test the different fixation alternatives of stabilization of transverse acetabular fractures under two basic physiological loading conditions: standing and sitting utilizing a finite element model. Material and methodsA transtectal transverse fracture model was fixed in five different alternatives: an anterior column plate; a posterior column plate; an anterior column plate combined with a posterior column screw; a posterior column plate combined with an anterior column screw; and a posterior column plate and an anterior column plate. In these models, a load of 400N was applied at standing and sitting positions and the displacements were analyzed by using three-dimensional finite element stress analysis method. ResultsIn the model simulating standing human position, overall motion at the posterior column was minimum when two columns were plated (0.071mm). The second best fixation was posterior column plate with an anterior column screw (0.077mm). Overall motion at the anterior column was minimum by posterior column plate with an anterior column screw (0.0326mm). The plating of two columns was associated with motion of (0.0333mm).In the model that simulates sitting position, the motion at the posterior column was minimum when two columns were plated (0.0478mm), and (0.0517mm) when a posterior column plate with an anterior column screw was used. Overall motion in the anterior column was minimum when posterior column plate with an anterior column screw (0.0198mm) was used, whereas the motion was (0.0203mm) when plating of both columns was examined. ConclusionPosterior column plating combined with an anterior column screw has quite comparable results to a both column plating in transverse fractures, suggesting that two column fixations might be unnecessary. This method is also very superior to anterior column plating combined with a posterior column screw in that type of fractures.

RESEARCH ON TRANSVERSE ACETABULAR FRACTURE FIXATION USING DIFFERENT PLATE ATTACHMENT METHODS / GŪŽDUOBĖS SKERSINIO LŪŽIO FIKSAVIMO SKIRTINGAI IŠDĖSTYTOMIS PLOKŠTELĖMIS TYRIMAS

The article deals with the problem of transverse acetabular fracture fixation using different plate attachment methods. A 3D model of pelvis and hip joint structure was created and the design of three different fixation plates using SolidWorks was made. The plates were fixed at distances of 10, 20 and 30 mm from the acetabulum. The model was meshed into finite elements, a static external load of 2500 N was added and the analysis of stress distribution in plates and fracture displacement was performed. The obtained results showed that fracture displacement was quite similar in all fixation methods. However, the maximal stress in the nearest from the acetabulum plate was higher than yield strength. Thus, this placement is not eligible. The plate fixed at a distance of 30 mm from the acetabulum appeared the most suitable because of the smallest and symmetrical stress distribution in the plate. Straipsnyje išnagrinėta gūžduobės skersinio lūžio fiksavimo skirtingai išdėstytomis plokštelėmis problema. Taikant kompiuterinį trimatį dubenkaulio modelį ir SolidWorks programų paketą, suprojektuotos 3 lūžiui fiksuoti reikalingos plokštelės, prie dubenkaulio tvirtinamos skirtingose vietose. Modelis suskirstytas į baigtinius elementus, pridėta statinė išorinė apkrova ir atlikta plokštelių įtempių bei lūžio vietos poslinkių analizė. Atsižvelgiant į gautus rezultatus, nustatytas tinkamiausias plokštelės tvirtinimo būdas.

Erratum to: Are Quadrilateral Surface Buttress Plates Comparable to Traditional Forms of Transverse Acetabular Fracture Fixation?

Erratum to: Are Quadrilateral Surface Buttress Plates Comparable to Traditional Forms of Transverse Acetabular Fracture Fixation?

Trauma

The October 2014 Trauma Roundup360looks at: proximal humeral fractures in children; quadrilateral surface plates in transverse acetabular fractures; sleep deprivation and poor outcomes in trauma; bipolar hemiarthroplasty; skeletal traction; forefoot fractures; telemedicine in trauma; ketamine infusion for orthopaedic injuries; and improved functional outcomes seen with trauma networks.

Acetabular Fractures in the Elderly Treated With a Primary Burch–Schneider Reinforcement Ring, Autologous Bone Graft, and a Total Hip Arthroplasty

To investigate the clinical and radiologic outcomes in elderly patients suffering from an acetabular fracture operated with an acute primary acetabular reinforcement ring, autologous bone graft, and a total hip arthroplasty (THA). Prospective cohort study. Tertiary care university hospital. Fifteen elderly patients (7 women) with a mean age of 76 years and a displaced acetabular fracture after a low-energy trauma were included. The fractures involved the anterior column, but no patients with associated both column fractures were included. All the patients were able to walk independently before the fracture occurred. Primary operation with a Burch-Schneider reinforcement ring, autologous bone graft, and a THA. The patients were reviewed at 4, 12, 24, and 48 months after the fracture occurred. The outcome assessments included complications, reoperations, activity of daily living function, functional scores (Harris hip score and short musculoskeletal function assessment), health-related quality of life [EuroQol (EQ-5D) index score], and radiologic evaluation. There were no prosthetic dislocations, periprosthetic fractures, deep infections, or other adverse events. There were no radiologic signs of loosening of the reinforcement ring or the prosthesis components at any of the follow up sessions, and the autologous bone graft was well incorporated in all the patients at the final follow-up. At 48 months, the mean Harris hip score was 88, the mean short musculoskeletal function assessment dysfunction score was 30, the bother score was 25, and the mean EQ-5D index score was 0.65. All the patients were able to walk independently at the final follow-up. Treatment of displaced anterior column, anterior column posterior hemitransverse and transverse acetabular fractures in elderly patients using a primary reinforcement ring, autologous bone graft, and a THA seems to be a safe option with good functional and radiologic outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of Autologous Plasma, Ascorbic Acid and Glucose Local Infusions on Pelvic Fracture Healing in Experiment

The efficacy of reparative osteogenesis stimulation by local infusion of autologous plasma in combination with ascorbic acid and glucose solutions was experimentally demonstrated in ani- mals (dogs) using the models of transverse acetabular ( n =20) and iliac shaft fracture ( n= 6). Either intraarticular or intraosseous solution infusions via injection system with automatic drug pump were performed from 2nd to 5th day after transverse osteotomy, reposition and stable external fixation. Fixator was dismounted on 21st postoperative day. In control series of experiment (intraarticular and intraosseous infusion of saline) fibrocartilagenous junction was formed and bone deformity due to secondary bone fragments displacement was noted after device removal. In experimental series primary pelvic bone fragments consolidation was observed in 14 days after operation and no displacement of fragments occurred after external fixation device removal.

Effect of Autologous Plasma, Ascorbic Acid and Glucose Local Infusions on Pelvic Fracture Healing in Experiment

The efficacy of reparative osteogenesis stimulation by local infusion of autologous plasma in combination with ascorbic acid and glucose solutions was experimentally demonstrated in ani- mals (dogs) using the models of transverse acetabular ( n =20) and iliac shaft fracture ( n= 6). Either intraarticular or intraosseous solution infusions via injection system with automatic drug pump were performed from 2nd to 5th day after transverse osteotomy, reposition and stable external fixation. Fixator was dismounted on 21st postoperative day. In control series of experiment (intraarticular and intraosseous infusion of saline) fibrocartilagenous junction was formed and bone deformity due to secondary bone fragments displacement was noted after device removal. In experimental series primary pelvic bone fragments consolidation was observed in 14 days after operation and no displacement of fragments occurred after external fixation device removal.

Minimal invasive para-rectus approach for limited open reduction and percutaneous fixation of displaced acetabular fractures

IntroductionMinimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss and complications of extensive approaches. Closed reduction and percutaneous lag screw fixation can be done in minimally displaced acetabular fractures. Open reduction is indicated, if there is wide displacement. In this study, we report the use of a mini-open anterior approach to manipulate and reduce anteriorly displaced transverse acetabular fractures combined with percutaneous lag screw fixation. MethodsThis report included eight patients. All had anterior displaced simple transverse acetabular fractures. An oblique mini-incision was made above and medial to the mid-inguinal point, and lateral to the lateral border of rectus abdominis muscle. The external abdominal oblique aponeurosis was incised along its fibres. The arched fibres of internal abdominal oblique were displaced medially above the inguinal ligament to expose and incise the fascia transversalis. Care was taken to avoid injury of ilioinguinal nerve, inferior epigastric vessels, and spermatic cord. The external iliac vessels were palpated and protected laterally. A blunt long bone impactor was introduced through this small incision to manipulate and reduce the fracture under fluoroscopic control. Fluoroscopic guided percutaneous lag screw fixation was done in all patients. ResultsThe average time to operation was 4 days. Average blood loss was 110mL. Operative time averaged 95min. Maximum fracture displacement averaged 10mm preoperatively and 1.3mm postoperatively. According to Matta score, anatomical reduction of the fracture was achieved in five patients and imperfect in three. Follow up averaged 27 months. Wound healing occurred without complications and fracture union was achieved without secondary displacement in all patients. Average time to fracture healing was 14 weeks. According to the modified Merle d’Aubigné score, functional outcome was good to excellent in all patients. Discussion and conclusionLimited open reduction can solve the problem of fracture reduction, which is the main concern in minimal invasive fixation of acetabular fractures. It may help the inclusion of displaced acetabular fractures for percutaneous lag screw fixation. This mini-para-rectus approach has the advantages of minimal soft tissue dissection with the possible anatomical reduction of simple transverse displaced acetabular fractures.

Ganglion Cyst Associated with a Displaced Transverse Acetabular Fracture: A Case Report

Summary Open reduction and internal fixation is the standard of care in the treatment of displaced fractures of the acetabulum. Displacement in the anterior column is usually addressed with direct reduction through a traditional or limited ilioinguinal approach. This case report describes a patient with a displaced transverse posterior wall acetabular fracture with a soft tissue mass near the anterior hip joint noted during an ilioinguinal exposure. Surgical exploration through the middle window of an ilioinguinal approach revealed an apparent ganglion cyst arising from the anterior extent of the displaced transverse fracture. Excision was performed and pathology confirmed a ganglion cyst. To our knowledge, this is the first report of a ganglion cyst of the hip joint associated with acetabular fracture and surgeons should be aware of this pathology when treating acetabular fractures and review soft tissue windows of preoperative computed tomography scans for soft tissue abnormalities of the inguinal canal.

MODELING OF HIGH PRECISION POSITIONING SYSTEM / DIDELIO TIKSLUMO PADĖTIES NUSTATYMO SISTEMOS MODELIAVIMAS

This paper presents the modeling of a flexure-based precisionpositioning system for micro-positioning uses. The positioningsystem is featured with monolithic architecture, flexure-basedjoints and ultra fine adjustment screws. Its workspace has beenevaluated via analytical approaches. Reduction mechanism isoptimally designed. The mathematical model of the positioningsystem has been derived, which is verified by resorting to finiteelement analysis (FEA). The established analytical and (FEA)models are helpful for a reliable architecture optimization andperformance improvement of the positioning system. Santrauka Straipsnyje pristatomas didelio tikslumo centravimo ir niveliavimo padėties nustatymo sistemos su besideformuojančiais mechanizmais kūrimas ir modeliavimas. Padėties nustatymo sistema optimizuota Solidworks Simulation programiniu paketu. Centravimo platformų poslinkiams apskaičiuoti sudarytas matematinis modelis, kurio patikimumas buvo patikrintas taikant baigtinių elementų metodą. Sudaryto matematinio modelio ir rezultatų, gautų pritaikius baigtinių elementų metodą, skirtumai buvo mažesni nei 10 %. Pasiūlyta modeliavimo metodika gali būti taikoma kuriant padėties nustatymo sistemas su besideformuojančiais mechanizmais.

F2.1 Finite element analysis of the stability of transverse acetabular fractures in standing and sitting positions by different fixation options

F2.1 Finite element analysis of the stability of transverse acetabular fractures in standing and sitting positions by different fixation options

Transgluteal Posterior Column Screw Stabilization for Fractures of the Acetabulum

The traditional exposure of high posterior column or transverse acetabular fractures can pose a challenge for lag screw stabilization. The authors describe an adjunctive percutaneous transgluteal lag screw technique for the internal fixation of the high posterior column. In the senior author's experience, this technique has been helpful to achieve the optimal trajectory for a stable perpendicular lag screw to maintain an anatomical reduction. In our experience, this technique has been used in conjunction with the standard Kocher-Langenbeck exposure and posterior column plating techniques.

Propensity for Hip Dislocation in Gait Loading Versus Sit-to-Stand Maneuvers

Current recommendations relating to the treatment of acetabular fractures are based on studies that evaluate the loading patterns associated with normal gait despite the fact that the forces on the acetabulum are significantly greater during sit-to-stand activities. We hypothesize that this increased force will lead to greater instability when an acetabular fracture occurs, and our goal was to compare cadaveric hip stability during single-leg-stance (SLS) and sit-to-stand (STS) maneuvers using a transverse acetabular fracture model. Seven fresh-frozen cadaveric hemipelvic specimens with proximal femurs were dissected of all soft tissues. Transverse acetabular osteotomies were created in 5-mm increments from distal to proximal. The roof arc angle and decrease of articular surface area were measured after each osteotomy, and the specimens were tested in SLS and STS. A 1200-N load was applied and visible dislocation was recorded for each loading orientation. The average roof arc angle needed to dislocate in the SLS position was 46.1° in the anteroposterior, 71.9° in the iliac oblique, and 25.2° in the obturator oblique views compared with 90.9° in anteroposterior, 101.4° in iliac oblique, and 67.3° in obturator oblique views for the STS orientation (P < 0.003 for all radiographic views). The decrease in articular surface area needed to dislocate the hip was significantly less for the STS group (10.9%) than the SLS group (36.4%) (P = 0.003). There is significantly greater hip instability seen with STS loading of a transverse acetabular model than with simple SLS loading. This would suggest that some fractures previously deemed stable may show significant instability during common activities of daily living, and reassessment of nonoperative treatment may be indicated.

End-stage Posttraumatic Osteoarthritis Treated With THA in Osteogenesis Imperfecta

Osteogenesis imperfecta is an incurable genetic disorder manifested with altered bone quality that predisposes patients to a multitude of fractures throughout their lives, including acetabular fractures. The management of acetabular fractures in patients with osteogenesis imperfecta remains a challenging clinical problem, with a paucity of literature supporting treatments and their outcomes. Limited reports in the literature validate the use of total hip arthroplasty (THA) in patients with osteogenesis imperfecta, and they describe the adult population only.This article describes a case of delayed diagnosis of a transverse acetabular fracture and femoral head impaction fracture that led to posttraumatic end-stage hip osteoarthritis in a 16-year-old boy with osteogenesis imperfecta (Sillence Type I) that was sustained after minimal trauma. Clinical examination 3 months postinjury revealed a significant pelvic obliquity, severe pain with hip range of motion, and limited hip range of motion. Imaging studies revealed a complete loss of articular cartilage and significant joint effusion.The patient underwent THA. No postoperative complications occurred. Two-year follow-up showed an excellent clinical result. The patient's hip was pain free, and he was able to walk with no limp.The authors are unaware of any reported cases of children with osteogenesis imperfecta undergoing THA. Based on the reported literature and the authors' experience, THA can be a reliable surgical option for patients with osteogenesis imperfecta.

Biomechanical Analysis of Acetabular Revision Constructs: Is Pelvic Discontinuity Best Treated With Bicolumnar or Traditional Unicolumnar Fixation?

Pelvic discontinuity in revision total hip arthroplasty presents problems with component fixation and union. A construct was proposed based on bicolumnar fixation for transverse acetabular fractures. Each of 3 reconstructions was performed on 6 composite hemipelvises: (1) a cup-cage construct, (2) a posterior column plate construct, and (3) a bicolumnar construct (no. 2 plus an antegrade 4.5-mm anterior column screw). Bone-cup interface motions were measured, whereas cyclical loads were applied in both walking and descending stair simulations. The bicolumnar construct provided the most stable construct. Descending stair mode yielded more significant differences between constructs. The bicolumnar construct provided improved component stability. Placing an antegrade anterior column screw through a posterior approach is a novel method of providing anterior column support in this setting.

Quality of Radiographic Reduction and Perioperative Complications for Transverse Acetabular Fractures Treated by the Kocher-Langenbeck Approach: Prone Versus Lateral Position

Quality of Radiographic Reduction and Perioperative Complications for Transverse Acetabular Fractures Treated by the Kocher-Langenbeck Approach: Prone Versus Lateral Position

Quality of Radiographic Reduction and Perioperative Complications for Transverse Acetabular Fractures Treated by the Kocher-Langenbeck Approach: Prone Versus Lateral Position

To compare radiographic reduction, intraoperative factors, and perioperative complications for transversely oriented acetabular fractures treated by the Kocher-Langenbeck approach with the patient in either the prone or lateral position. Retrospective study. Two regional referral trauma centers. Sixty-six skeletally mature individuals with transversely oriented acetabular fractures treated operatively through the Kocher-Langenbeck approach in either the prone or lateral position. Operative fixation of an acute transverse acetabular fracture through the Kocher-Langenbeck approach. This study primarily assessed the radiographic reduction of two similar consecutive cohorts of patients surgically treated for transversely oriented acetabular fractures using the Kocher-Langenbeck approach with the patient positioned in either the lateral or prone position. Secondary outcome measures included operative time, estimated blood loss, and perioperative complications. Thirty-three transversely oriented acetabular fractures were reduced and stabilized with the patient in the lateral position, whereas 33 fractures were treated with the patient in the prone position. Demographic and injury variables as well as surgical time and estimated blood loss were similar between the two groups. Two postoperative infections occurred in each group, and one incomplete iatrogenic sciatic nerve palsy was recognized in the lateral group. The mean maximum fracture residual displacement measured on postoperative radiographs was 2.1 mm (range, 0-7 mm) in the lateral group compared with 1.3 mm (range, 0-7 mm) in the prone group (P = 0.08). The quality of reduction according to Matta's criteria was graded in prone positioned patients as anatomic in 20 patients (61%), imperfect in 11 patients (33%), and poor in two patients (6%), whereas lateral-positioned patients were graded as anatomic in 14 patients (42%), imperfect in 13 patients (40%), and poor in six (18%) patients (P = 0.21). This study demonstrated a trend toward higher radiographic residual fracture displacement in patients with transversely oriented acetabular fractures reduced and stabilized through the Kocher-Langenbeck approach in the lateral position compared with those positioned prone. However, no significant differences were observed in operative time, estimated blood loss, or perioperative complications between the two groups.

Single column locking plate fixation is inadequate in two column acetabular fractures. A biomechanical analysis

BackgroundThe objective of this study was to determine whether one can achieve stable fixation of a two column (transverse) acetabular fracture by only fixing a single column with a locking plate and unicortical locking screws. We hypothesized that a locking plate applied to the anterior column of a transverse acetabular fracture would create a construct that is more rigid than a non-locking plate, and that this construct would be biomechanically comparable to two column fixation.MethodsUsing urethane foam models of the pelvis, we simulated transverse acetabular fractures and stabilized them with 1) an anterior column plate with bicortical screws, 2) an anterior locking plate with unicortical screws, 3) an anterior plate and posterior column lag screw, and 4) a posterior plate with an anterior column lag screw. These constructs were mechanically loaded on a servohydraulic material testing machine. Construct stiffness and fracture displacement were measured.Result and DiscussionWe found that two column fixation is 54% stiffer than a single column fixation with a conventional plate with bicortical screws. There was no significant difference between fixation with an anterior column locking plate with unicortical screws and an anterior plate with posterior column lag screw. We detected a non-significant trend towards more stiffness for the anterior locking plate compared to the anterior non-locking plate.ConclusionIn conclusion, a locking plate construct of the anterior column provides less stability than a traditional both column construct with posterior plate and anterior column lag screw. However, the locking construct offers greater strength than a non-locking, bicortical construct, which in addition often requires extensive contouring and its application is oftentimes accompanied by the risk of neurovascular damage.

Results after surgical treatment of transtectal transverse acetabular fractures

To retrospectively evaluate the results of operative treatment of transtectal transverse fractures of the acetabulum. From May 1990 to July 2006, 40 patients with displaced transtectal transverse fracture of the acetabulum were treated surgically. A mean postoperative follow-up of 88.6 months' (range, 16-121 months) was achieved in 37 patients. Final clinical results were evaluated by a modified Merle d'Aubigné and Postel grading system. Postoperative radiographic results were evaluated by the Matta criteria. Fracture and radiographic variables were analyzed to identify possible associations with clinical outcome. Fracture reduction was graded as anatomic in 31 patients, imperfect in 4 and unsatisfactory in 2. Two hips were diagnosed to have subtle instability by postoperative radiography. The clinical outcome was graded as excellent in 16 patients, good in 14, fair in 4 and poor in 3. The radiographic result was graded as excellent in 14 patients, good in 15, fair in 4 and poor in 4. There was a strong association between the final clinical and radiographic outcomes. Variables identified as risk factors for unsatisfactory results included residual displacement greater than 2 mm, comminuted fracture of the weight bearing dome, postoperative subtle hip instability and damage to the cartilage of the femoral head. The uncomplicated radiographic appearance of transtectal transverse fracture belies its complexity. Comminuted fracture of the weight bearing dome, unsatisfactory fracture reduction, subtle hip instability and damage to the cartilage of the femoral head are risk factors for the clinical outcome of transtectal transverse fracture of the acetabulum.