Treatment Of Complex Acetabular Fractures Research Articles

Use of Dual Mobility Cups Reduce Dislocation Risk After Internal Fixation for Acetabular Fracture Concomitant With Total Hip Arthroplasty in Patients Who are Over 60 Years Old

Treatment of complex acetabular fractures in patients over 60 remains challenging. Functional treatments for these fractures have yielded disappointing outcomes. Internal fixation may fail facing this porotic bone, and postoperative non weight bearing may expose the patient to decubitus complications. Our hypothesis was that use of a dual mobility cup (DMC) reduces dislocation risk after concomitant internal fixation and total hip arthroplasty (THA) for acetabular fracture in patients who are over 60 years old. A retrospective, observational non comparative and continuous study was conducted from January 2015 to September 2022. Patients aged over 60 years who had displaced acetabular fractures, treated surgically via concomitant internal fixation and THA, utilizing a DMC exclusively through the Kocher-Langenbeck approach and a minimum follow-up was of one year, were included. There were 45 patients (45 hips) who had an average age of 71 (range, 60 to 88) who were included (75.5% men). The main mechanisms of injury were the motor vehicle accidents (in 21 cases (46,7%)). Bi-column fractures were prevalent (46.6%). The analysis of complications included intraoperatively nerve palsy, postoperatively dislocations, deep infections, periprosthetic fractures and loosening. Clinical assessment included the Harris hip score (HHS) and the level of return to previous activities. Radiological evaluation assessed fracture union, periprosthetic osteolysis, graft integration, the presence of leg length discrepancy (LLD) and heterotopic ossification. There was one case of dislocation (2.2%) requiring reoperation for replacement of the prosthetic neck, and one patient (2.2%) experienced early THA infection, successfully treated with surgical lavage and antibiotics. Functional outcomes showed a mean HHS of 88 (range, 69 to 99) and 84% of patients resumed their previous activities. Radiological follow-up revealed no loosening. This study has shown that the use of DMC in concomitant THA with Open Reduction and Internal Fixation (ORIF) for acetabular facture in patient over age 60 years achieved a low dislocation rate with favorable clinical and radiological outcomes and a low complication rate.

Primary stability of multi-hole acetabular cup combined with posterior column plating for the fixation of complex acetabular fractures in elderly patients: a biomechanical analysis.

Acute total hip arthroplasty has gained increasing popularity in the treatment of complex acetabular fractures in elderly patients, but the biomechanical evidence is lacking. Therefore, we measured the primary stability to evaluate whether acute total hip arthroplasty using a multi-hole acetabular cup and posterior column plating through a single K-L approach can safely be used for treating complexed acetabular fractures in the elderly. In 18 composite osteoporotic hemipelves, T-type acetabular fractures were treated in three ways: CSP (Cup with acetabular screws augmentation combined with posterior plate) group, CP (Cup without acetabular screw combined with posterior plate) group and CSPA (Cup with acetabular screws combined with posterior plate and anterior plate) group. Each specimen was dynamically loaded (300 to 1700N, 1Hz). Primary stability of the acetabular cup and fracture gap was evaluated by 3-dimensional (3D) micromotions. No significant differences in the 3D-micromotions were observed among the CSP, CP and CSPA groups except the test point on the anterior column of the acetabulum in the CP scenario (CSP 49.33 ± 21.08μm vs. CP 224.83 ± 52.29μm, p < 0.001; CSPA 45.50 ± 12.16μm vs. CP 224.83 ± 52.29μm, p < 0.001). No significant differences in the fracture gap displacement on the posterior column of acetabulum were observed among the CSP, CP and CSPA groups. Our results show, that acute total hip arthroplasty using a multi-hole cup with acetabular screws and posterior column plating through single a K-L approach offers good primary stability to allow good osseous integration for treating complex acetabular fractures in the elderly. Furthermore, it also provides good fracture gap displacement on the posterior column.

Comparison between Novel Anatomical Locking Guide Plate and Conventional Locking Plate for Acetabular Fractures: A Finite Element Analysis.

The treatment of complex acetabular fractures remains a complicated clinical challenge. Our self-designed novel anatomical locking guide plate (NALGP) has previously shown promising potential in T-shaped acetabular fractures (TAF), but a direct comparison with conventional fixations is yet to be made. The TAF model was established based on a volunteer's computer tomography data and then fixed with double column locking plates (DLP), a posterior column locking plate with anterior column screws (LPACS), and our NALGP. Forces of 200 N, 400 N, and 600 N were then loaded on the model vertically downward, respectively. The stress distribution and peaks and maximum displacements at three sites were assessed. We found that the stress area of all three plates was mainly concentrated around the fracture line, while only the matching screws of the NALGP showed no obvious stress concentration points. In addition, the NALGP and DLP showed significantly less fracture fragment displacement than the LPACS at the three main fracture sites. The NALGP was found to have less displacement than DLP at the posterior column and ischiopubic branch sites, especially under the higher loading forces of 400 N and 600 N. The fixation stability of the NALGP for TAF was similar to that of DLP but better than that of LPACS. Moreover, the NALGP and its matching screws have a more reasonable stress distribution under different loads of force and the same strength as the LPACS.

Mid-term results of the treatment of complex acetabular fractures with combined acute fixation and total hip replacement in the older patient.

The incidence of acetabular fractures in older patients is increasing. The management of these patients is evolving due to the recognition of risks associated with prolonged immobility with conservative treatment. Consecutive patients undergoing fixation and total hip replacement (THR) for displaced acetabular fractures undergoing single operation with acetabular fixation and THR were identified. Outcomes were assessed using radiographs, clinical notes, Oxford Hip Score and EuroQol-5L. 77 patients were identified with 51 completing outcome scores. Mean age 68 years at time of injury. Mean follow-up 5 (2-12) years, OHS 40, EQ-5D 0.78. Revision surgery performed in 7 patients (9%). Acute fixation combined with THR for acetabular fractures in the elderly patient, offers good functional outcomes and a low complication rate in the mid-term.

Management of Complex Acetabular Fractures by Using 3D Printed Models.

Background and Objectives: Using 3D printed models in orthopaedics and traumatology contributes to a better understanding of injury patterns regarding surgical approaches, reduction techniques, and fracture fixation methods. The aim of this study is to evaluate the effectiveness of a novel technique implementing 3D printed models to facilitate the optimal preoperative planning of the surgical treatment of complex acetabular fractures. Materials and Methods: Patients with complex acetabular fractures were assigned to two groups: (1) conventional group (n = 12) and (2) 3D printed group (n = 10). Both groups included participants with either a posterior column plus posterior wall fracture, a transverse plus posterior wall fracture, or a both-column acetabular fracture. Datasets from CT scanning were segmented and converted to STL format, with separated bones and fragments for 3D printing in different colors. Comparison between the two groups was performed in terms of quality of fracture reduction (good: equal to, or less than 2 mm displacement, and fair: larger than 2 mm displacement), functional assessment, operative time, blood loss, and number of intraoperative x-rays. Results: A significant decrease in operative time, blood loss, and number of intraoperative x-rays was registered in the 3D printed group versus the conventional one (p < 0.01), with 80% of the patients in the former having good fracture reduction and 20% having fair reduction. In contrast, 50% of the patients in the conventional group had good reduction and 50% had fair reduction. The functional score at 18-month follow-up was better for patients in the 3D printed group. Conclusions: The 3D printing technique can be considered a highly efficient and patient-specific approach for management of complex acetabular fractures, helping to restore patient′s individual anatomy after surgery.

Treatment of complex acetabular fractures with improved Stoppa combined with Kocher-Langenbeck approach assisted by 3D printing technology

To explore the clinical effect of the modified Stoppa combined with Kocher-Langenbeck(K-L) approach and 3D printing technology in the treatment of complex acetabular fractures. The surgical methods of 70 patients with complex acetabular fractures admitted from April 2013 to July 2019 were retrospectively analyzed. Among them, 25 cases were operated with 3D printing technology(3D printing group) and 45 cases were operated with conventional operation(conventional operation group). The operation time, intraoperative blood loss, intraoperative fluoroscopy times, complications and functional recovery of the hip joint of two groups were recorded. There were statistically significant differences between two groups in terms of operation time, intraoperative bleeding volume and intraoperative fluoroscopy times(P<0.01). All patients were followed up for (15.8±3.5) months, and all patients achieved bony healing. There was no significant difference in the results of Matta reduction between two groups(P>0.05). There was no significant difference in Harris score at 6 months after operation between two groups(P>0.05). With the aid of 3D printing technology, the improved Stoppa combined with K-L approach is used to treat complex acetabular fractures. It has certain advantages in helping clinicians to formulate a reasonable operation plan before operation, avoid unnecessary operation and trauma during operation, shorten the operation time and reduce the amount of bleeding during operation. It can improve the safety during the perioperative period, facilitate the accurate reduction of fractures during operation and facilitate the recovery of patients.

The Pararectus approach in acetabular fractures treatment: functional and radiologcial results

BackgroundThe surgical treatment of complex acetabular fractures is one of the most challenging procedures for orthopedic surgeons. The Pararectus approach, as a reasonable alternative to the existing surgical procedures, was performed for the treatment of acetabular fractures involving the anterior column. This study aimed to evaluate outcome using the Pararectus approach for acetabular fractures involving anterior columns.MethodsThirty-seven with displaced acetabular fractures involving anterior columns were treated between July 2016 and October 2019 using the Pararectus approach. The functional outcomes (using the Merle d Aubigné and Postel scoring system, WOMAC and modified Harris scoring), the quality of surgical reduction (using the Matta criteria), and postoperative complications were assessed during approximately 26 months follow-up period.ResultsThirty-seven patients (mean age 53 years, range: 30–71; 28 male) underwent surgery. Mean intraoperative blood loss was 840 ml (rang: 400–2000 ml) and mean operating time was 210 min (rang: 140–500 min). The modified Merle d Aubigné score was excellent and good in 27 cases (73%), fair in 6 cases (16%), and poor in 3 cases (11%). The mean score was 88.5 (range:77–96) for the modified Harris Hip scores, and 22 (range:7–35) for the WOMAC scores after operation. Postoperative functional outcomes were significantly improved compared with preoperative outcomes (P < 0.0001). The quality of reduction was anatomical in 21 cases (57%), satisfactory in 9 cases (24%), and unsatisfactory in 7 cases (19%). At follow-up, four patients developed a DVT, and heterotopic bone formation was observed in one patient. The hip osteoarthritis was not observed.ConclusionThe Pararectus approach achieved good functional outcomes and anatomical reduction in the treatment of acetabular fractures involving anterior column with minimal access morbidity.

APACHE—Anterior Plating of the Acetabulum in Hemi-Endoscopic Technique: An Alternative Method for Internal Fixation of the Acetabulum

Injuries of the acetabulum are often challenging in treatment and aftercare. One reason is the required surgical approach, which has high complication rates, including vascular lesion, hernias, and wound infection. We present an alternative endoscopic-assisted approach for the internal fixation of acetabular fractures to avoid the Pfannenstiel incision. An endoscopic approach similar to that used for endoscopic hernia surgery was used. The ilioinguinal approach’s lateral window was used to achieve reduction and insertion of a reconstruction plate. The purpose of this study is to describe a minimally invasive technique as a possible method to reduce hospitalization and complications. Another goal is to give detailed technical recommendations and to assess the potential pitfalls of this surgical approach. The APACHE technique is a safe and suitable minimally-invasive approach for the successful treatment of complex acetabular fractures and can be considered in similar cases.

Modified Stoppa Approach for the Treatment of Complex Acetabular Fractures.

Complex acetabular fractures are due to high-energy trauma in most cases. The operative management of these types of fractures is often difficult and technically challenging. Almost all of these types of fractures are treated through extensile approaches, and a variety of them have been described. Some of these approaches are associated with complications such as infection, heterotopic ossification, and increased blood loss in addition to increased operative time. This retrospective study was performed at an academic Level I trauma center. From January 2013 to March 2019, 21 patients with complex acetabular fractures were treated with open reduction and internal fixation through a single anterior modified Stoppa approach. The average operative time was 98.80 minutes (range, 60-180 minutes), the average follow-up time was 40 months (range, 24-72 months), and the average Harris Hip Score (HHS) was 87.85 (range, 75-100). At the latest follow-up, 12 (57.1%) patients had an excellent HHS, 8 (38.1%) patients had a good HHS, and 1 (4.8%) patient had a fair HHS. Complex acetabular fractures can be effectively managed by a modified Stoppa approach without the need for extensile or combined approaches. [Orthopedics. 2021;44(3):e353-e358.].

Risk of Injury to the Neurovascular Structures in the Pararectus Approach Used in Acetabular Fractures: A Cadaver Study.

Complex acetabular fractures involving the quadrilateral plate may necessitate infrapectineal buttress plating, which can be performed through the pararectus approach. The aim of this cadaveric study was to identify the anatomical guide points to protect neurovascular structures at the risk of injury during the pararectus approach. Six fresh frozen cadavers (12 hemipelves) were dissected in this study. Location of the inferior epigastric artery (IEA), obturator nerve and corona mortis (CM) was measured using common anatomic landmarks, namely, anterior superior iliac spine, symphysis pubis (SP), and sacroiliac (SI) joint. In the superficial dissection of the abdominal wall, the mean distance between the IEA and anterior superior iliac spine was 106.7 ± 5.2 (range, 99.2-116.4) mm, and the mean distance between IEA and SP was 77.9 ± 3.5 (range, 70.6-82.2) mm. In deep dissection, the mean distance between the SI joint and the SP was 133.1 ± 5.7 (range, 126.0-142.0) mm. The mean distance between the SI joint and ON was 37.3 ± 2.8 (range, 31.0-41.0) mm. The CM was unable to be detected in 2 cadavers, 1 on the right and 1 on the left hemipelves. The mean distance between the CM and SP was 47.7 ± 3.9 (range, 43.0-55.0) mm. A pararectus approach is a useful approach which allows infrapectineal plating in the treatment of complex acetabular fractures; however, the preservation of critical neurovascular structures is essential during dissection. This study is helpful to identify the structures at risk according to commonly used anatomic landmarks. These data might be a necessary guideline for hip and trauma surgeons.

The effect of new preoperative preparation method compared to conventional method in complex acetabular fractures: minimum 2-year follow-up.

This study aimed to compare the efficacy and safety of the new method including 3D printing-based preoperative planning, surgical workshop, and contouring of the plate versus conventional method in the surgical treatment of complex acetabular fractures. We retrospectively analyzed the data in a cohort of 88 patients of complex acetabular fracture with mean 29.95 ± 4.84months (24-41months) follow-up. Patients were divided into two groups. Group 1 consisting of 41 patients were performed previewed surgery with a 3D printing-based pre-contoured plate on a 3D printing model. Group 2, comprised of 47 patients, were treated by the traditional contoured plate technique. The quality of reduction was assessed using criteria described by Matta. Functional outcome was evaluated using Modified Postel Merle D'Aubigne score. A custom-made quiz was used to evaluate the chief assistant. The study showed no significant differences in measured preoperative variables except for the age between the Group 1 and Group 2 (p > 0.05). Compared with the Group 2, the intraoperative blood loss, operative time was significantly decreased in Group 1 (p < 0.05). There were no significant statistical differences in the quality of reduction and Modified Postel Merle D'Aubigne score (p > 0.05). The result of evaluation of assistant in Group 1 was significantly high than in Group 2 (p < 0.05). 3D printing-based pre-contoured plate is a more effective and reliable method than traditional contoured plate technique for treating the complex acetabular fractures. Meanwhile, the 3D printing is a useful orthopedic surgical education tool which can improve the understanding of the complex acetabular fracture for a young surgeon.

The supra-pectineal quadrilateral surface buttress plate for the treatment of complex acetabular fractures

Objective To introduce a novel anatomical supra-pectineal quadrilateral surface buttress plate, and explore its advantages, disadvantages and clinical efficacy in the treatment of complex acetabular fractures. Methods Data of eighteen cases of acetabular fractures treated in our department from March 2017 to March 2019were retrospectively analyzed. There were 15 males and 3 females with an average age of 49.6 years (range, 27-62 years). According to the Letournel-Judet’s classification, there were 3 cases of anterior column fractures (involving quadrilateral surface), 2 cases of T shaped, 8 of cases anterior column and posterior hemi-transverse (ACPHT) and 5 cases of double columns fractures. The time from injury to operation was 5-14 days (mean, 7 days). Before operation, all patients were taken pelvic anterior-posterior X-ray and CT scan. All patients were adopted supra-ilioinguinal approach and fixed by supra-pectineal quadrilateral surface buttress plate. Surgical time, intraoperative blood loss and postoperative complications were collected. After operations all patients were taken pelvic X-ray in anterior-posterior and Judet position, as well as CT scan. The radiographic quality of reduction was evaluated by Matta criteria and hip functions were evaluated by Matta Modified Merle d’Aubigne-Postel scoring system. Results The average surgical time was 130 min (range, 100-200 min). The average blood loss was 560 ml (range, 400-900 ml). An additional shaping was unnecessary in 18 patients who were implanted with the anatomical supra-pectineal quadrilateral surface buttress plate and all patients were operated successfully. All patients were followed up for an average time of 9 months (range, 6-15 months). The quality of fracture reduction was evaluated according to Matta standard, of which there were 11 cases excellent, 4 cases good, and 3 cases poor, with an excellent rate of 83.3% (15/18). At the latest follow-up, the function of the hip joint was evaluated according to the Matta Modified Merle d’Aubigne-Postel scoring system for a mean of 15.8 scores (range, 12-18 scores), of which there were 10 cases excellent, 6 cases good, 2 cases fair, with an excellent rate of 88.9% (16/18). All patients recovered well, and there were 2 cases of lateral femoral cutaneous nerve injury postoperative who had recovered one month later. There was no other postoperative complications. Conclusion The anterior and posterior column and quadrilateral surface could be stabilized simultaneously by the anatomical supra-pectineal quadrilateral surface buttress plate without intraoperative shaping. Moreover, it is more likely to obtain a satisfactory clinical outcome by using this special plate with lower complications and rigid fixation. Therefore, it is a kind of internal fixation method worthy of promotion in the treatment of complex acetabular fractures. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Internal fixators

Treatment of complex acetabular fractures involving the posterior column by anterograde lag screws via the ilioinguinal approach

Objective To evaluate the treatment of complex acetabular fractures involving the posterior column by anterograde lag screws via the ilioinguinal approach. Methods A retrospective study was conducted of the 8 patients with complex acetabular fracture involving the posterior column who had been treated at Department of Orthopaedics, The Second Affiliated Hospital to Inner Mongolia Medical University from January 2017 to June 2018. They were 5 males and 3 females, aged from 35 to 62 years (average, 43.5 years). According to the Letournel-Judet classification, 3 cases were T-shaped fractures, 4 anterior column plus posterior hemitransverse fractures and one both column fracture. The interval from injury to operation averaged 8 days (from 7 to 17 days). The anterior acetabulum was fixated by a reconstruction plate and the posterior column by antegrade lag screws, all through the ilioinguinal approach. The quality of fracture reduction, fracture union time, function of the affected hip and complications were recorded. Results By the Matta imaging criteria, the quality of fracture reduction was rated as excellent in 7 cases and as fine in one. Intraoperative major hemorrhage or injury to sciatic nerve occurred in none of the patients. This cohort obtained an average follow-up of 8 months (from 6 to 18 months). All fractures united well after an average of 10 weeks (from 8 to 12 weeks). The function of affected hip evaluated by the improved Merle d’Aubigne & Postel criteria at the last follow-up was excellent in 7 cases and fine in one. Follow-ups revealed no incidence of deep vein thrombosis or heterotopic ossification. Conclusions For patients with complex acetabular fracture involving the posterior column, internal fixation of the anterior acetabulum with a reconstruction plate through the ilioinguinal approach and fixation of the posterior column with antegrade lag screws also through the ilioinguinal approach can result in fine therapeutic effects, because complications like ectopic ossification and sciatic nerve injury related to the Kocher-Langenbeck approach can be prevented. This treatment is particularly suitable for the patients whose condition of the soft tissues at the posterior pelvis is poor. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Bone nails; Surgical approach

Kocher-Langenbeck approach combined with screw technique for the treatment of complex acetabular fractures

Objective To evaluate the efficacy and reliability of K-L approach combined with screw technique for the treatment of acetabular transverse combined with T shaped fractures. Methods Data of 17 patients with acetabular fractures who were treated by K-L approach combined with screw technique from April 2015 to April 2018 were retrospectively analyzed. There were 11 males and 6 females, aged 28-69 years (mean, 44 years). Injury mechanism: 11 cases were car accident injuries, 4 cases from fall injuries, and 2 cases from ski injury. Letournel-Judet classification: 11 cases in the front with the posterior transverse, 6 cases in the T-shaped (including 3 cases T-shaped plus the posterior wall). The time from injury to surgery was 3-20 days, with an average of 9.8 days. All cases were treated by single K-L approach open reduction and internal fixation. The hip joint function was evaluated by hip Harris score and the Matta's improved Merle d'Aubigne-Postel scores system. Results All the 17 patients were followed up for 7-26 months with an average of 14 months. The operation time was 171-310 min, with an average of 220 min. The intraoperative blood loss was 360-1 800 ml with an average of 810 ml. All the patients were healed. The healing time was 2-3 months, with an average of 2.5 months. The Matta's improved Merle d'Aubigne-Postel scores was 10-18 points, with an average of 16.7 points. The results were excellent in 12 cases, good in 3 cases, fair in 1 case, and poor in 1 case. The excellent and good rate was 88.2% (15/17). The Harris score at the latest follow-up was 69-96 points, with an average of 88 points. Among them, 10 cases were excellent, 4 cases good, 2 cases fair, and 1 case was poor. The excellent and good rate was 82.4% (14/17). Four patients had deep venous thrombosis of the lower extremities. The deep venous thrombosis of the lower extremities was found at 1-3 days after operation. The thrombus disappeared after 3 months of anticoagulant therapy with low molecular weight heparin. Sensory motor ability decreased in 8 cases after surgery because of sciatic never injury. After mecobalamin drug therapy, 7 patients recovered within 2-3 months, and 1 patient recovered 6 to 12 months later. Eight patients had heterotopic ossification, according to Brooker classification, there were 5 cases of grade I, 2 of grade II and 1 of grade III. Conclusion K-L approach combined with screw technique for the treatment of complex acetabular fractures has satisfactory clinical results but may potentially increase the risk of sciatic nerve injury. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal

Treatment of complex quadrilateral surface fractures of the acetabulum by internal fixation with dynamic anterior plate-screw system

Objective To explore the clinical efficacy of internal fixation with dynamic anterior plate-screw system for quadrilateral area(DAPSQ) in the treatment of complex acetabular fractures involving the quadrilateral surface. Methods Between January 2005 and January 2017, a series of 143 patients with complex quadrilateral surface fracture of the acetabulum were treated at Department of Orthopaedics, General Hospital of Central Theater Command. They were 86 males 57 females, with a mean age 46.6 years (range, from 19 to 77 years). By the Letournel-Judet classification, there were 38 anterior column plus posterior hemitransverse fractures, 26 T-shaped fractures and 79 double column fractures. They were all closed. The delay from injury to surgery averaged 9.6 days(range, from 3 to 21 days). All the cases were treated with DAPSQ internal fixation via the ilioinguinal approach. Their operation time, intraoperative bleeding volume, quality of fracture reduction, hip function and complications were recorded. Results The operation time for this series ranged from 2.5 to 5.0 hours, averaging 3.8 hours. The intraoperative blood bleeding ranged from 400 to 2,500 mL, with an average of 680 mL. By the Matta criteria for fracture reduction, 76 cases were rated as excellent, 51 as good and 16 as poor, giving an excellent and good rate of 88.8%. The 143 patients were followed up from 4 months to 10 years (mean, 4.1 years). The clinical fracture union was achieved after 2 to 4 months (mean, 3 months). By the modified Merle d’Aubigne & Postel criteria, the affected hips scored 9 to 18 points (mean, 16.3 points) at the final follow-ups, with 64 excellent, 52 good, 19 fair and 8 poor cases, giving an excellent and good rate of 81.1%. The postoperative complications included lesion of lateral femoral cutaneous nerve in 7 cases, urinary tract infection in 15 ones, traumatic osteoarthritis in 20 ones 5 of whom had to receive total hip arthroplasty, and heterotopic ossification (Brooker Grade Ⅰ) in 5 ones. Conclusion Internal fixation with DAPSQ is safe and effective for the treatment of complex acetabular fractures involving the quadrilateral surface. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Bone plates; Bone nails

Surgical treatment of complex acetabular fractures through the lateral-rectus approach with pelvic reconstructive plate and antegrade posterior-column lag screws

Objective To evaluate the surgical treatment of complex acetabular fractures through the lateral-rectus approach with pelvic reconstructive plate and antegrade posterior-column lag screws. Methods Between January 2014 and April 2018, 29 patients were surgically treated for complex acetabular fractures at Department of Orthopaedic and Trauma, Taihe Hospital. They were 22 males and 7 females, aged from 19 to 72 years(mean, 41.7 years). According to the Letournel-Judet classification, there were 4 transverse fractures, 7 T-shape fractures, 15 both column fractures and 3 anterior plus posterior hemitransverse fractures. In all the patients, the lateral-rectus approach was adopted; their anterior column fractures were fixated with pelvic reconstructive plate and screws and their posterior column fractures with antegrade lag screws. The operation time, intraoperative bleeding, fracture reduction, fracture union time, function of the affected hip and complications were recorded. Results The operation time ranged from 50 to 140 min, averaging 85 min; the volume of intraoperative bleeding ranged from 150 to 1,100 mL, averaging 315 mL. By the Matta criteria, the reduction was rated as excellent in 21 cases, as good in 7 and as poor in one, giving an excellent to good rate of 96.6%. The average follow-up was 16.2 months (from 6 to 30 months) for the 29 patients. Their fractures got united after an average of 11 weeks (from 7 to 13 weeks). According to the Merle d'Aubigne & Postel scoring system at the last follow-up, the function of the affected hip was excellent in 20 cases, good in 7 and fair in 2, yielding an excellent to good rate of 93.1%. There was one case of vasospasm of external iliac artery. No such complications were observed by follow-up as infection, deep venous thrombosis, heterotopic ossification, osteoarthritis or avascular necrosis of the femoral head. Conclusions The lateral-rectus approach with pelvic reconstructive plate and antegrade posterior-column lag screws is a suitable surgical treatment for complex acetabular fractures, leading to satisfactory clinical results. The lateral-rectus approach provides adequate exposure of the quadrilateral surface and facilitates insertion of the posterior column antegrade lag screws. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Bone nails; Surgical approach

Application of customized variable-angle locking acetabular wing plates in treatment of acetabular fractures in the elderly via the lateral-rectus approach

Objective To evaluate clinical efficacy and surgical techniques of customized variable-angle locking acetabular wing plates in treatment of complex acetabular fractures in the elderly through the lateral-rectus approach. Methods Data of 11 elder patients of complex acetabular fractures (mean age 75 y, range: 60-93 y; 8 males, 3 females) admitted to our department from March 2016 to March 2017 were retrospectively analyzed. According to Judet-Letournel classification of acetabular fractures, there were 2 cases of anterior column and posterior hemitransverse fractures, 9 cases of both-column fractures. The customized variable-angle locking acetabular wing plates were designed by mimics software and then produced before surgery. During the operation, the customized variable-angle locking acetabular wing plate was applied to reduction and fixation via the anterior lataral-rectus approach. The effect of fracture reduction was assessed by Matta's criteria. The clinical effect was assessed by Harris Hip score and the modified Merle d' Aubigne-Postal score at the 6th month of postoperative follow-up. Results The average time of designing and producing customized variable-angle locking acetabular wing plates was 4 d (3-5 d), the average operation time was 95 min (45-150 min), and the average intraoperative bleeding was 600 ml (250-1 400 ml). All patients were followed up, with an average follow-up of 18 m (6-24 m). All fractures were healed, with an average healing time of 8 weeks (6-12 weeks). Reduction quality: excellent in 8 cases, good in 2 cases, poor in 1 case, with an overall excellent and good rate of 90.9%. The result of Harris Hip scoring: excellent in 7 cases, good in 3 cases, and acceptable in 1 case, with a total excellent and good rate of 90.9%; Modified Merle d' Aubigne-Postal soring: excellent in 6 cases, good in 3 cases, and acceptable in 2 cases, with an overall excellent and good rate of 81.8%. There were 2 cases of obturator nerve injury, 1 case of fat liquefaction of incision, 3 cases of traumatic hip arthritis. During the follow-up, no complications such as ectopic ossification, plate fracture and screw loosening were found. Conclusion The customized variable-angle locking acetabular wing plates in treatment of complex acetabular fractures in the elderly via the lateral-rectus approach can achieve satisfactory reduction and firm fixtation. Key words: Acetabulum; Fracture; Aged; Fracture fixation, internal

Functional outcome of acute primary total hip replacement after complex acetabular fractures.

To assess the functional outcome of acute primary total hip replacement in the management of complex acetabular fractures. This prospective observational study was conducted in orthopedic department of Liaquat National Hospital and Medical College, Karachi. The study was approved by the Ethics review committee of hospital (0190-2016). Patients who encountered between January 2010 to January 2016 were entered. Fifty-four patients with acetabular fractures with certain indications (marginal impaction or significant comminution (> 3 fragments) of the articular surface of the acetabulum, full-thickness articular injury to the femoral head, an associated femur neck fracture, or preexisting symptomatic osteoarthritis) were treated with primary total hip replacement. Patients were followed in outpatient clinic at regular intervals after discharge to assess the radiological union of fractures and complications. Functional outcome was evaluated after 2years by applying Harris Hip Score. All statistical analysis was done by using SPSS version 20. All patients achieved radiological union of fractures at an average duration of 21weeks. During the follow-up, seven complications were observed. Two patients developed superficial surgical site infection which was treated conservatively. One patient had dislocation which was reduced closely, while two patients had acetabular cup loosening which was revised. We also observed two cases of Brooker I heterotopic ossification and one case of Brooker II. At 2-year follow-up, 78% of patients had an excellent and good functional outcome according to Harris Hip score. Primary total hip replacement is a valid and reasonable one stage surgical treatment of complex acetabular fractures and in aged individuals. However, the complications are not uncommon.

The design, production and clinical application of 3D patient-specific implants with drilling guides for acetabular surgery

An innovative procedure for the development of 3D patient-specific implants with drilling guides for acetabular fracture surgery is presented. By using CT data and 3D surgical planning software, a virtual model of the fractured pelvis was created. During this process the fracture was virtually reduced. Based on the reduced fracture model, patient-specific titanium plates including polyamide drilling guides were designed, 3D printed and milled for intra-operative use. One of the advantages of this procedure is that the personalised plates could be tailored to both the shape of the pelvis and the type of fracture. The optimal screw directions and sizes were predetermined in the 3D model. The virtual plan was translated towards the surgical procedure by using the surgical guides and patient-specific osteosynthesis. Besides the description of the newly developed multi-disciplinary workflow, a clinical case example is presented to demonstrate that this technique is feasible and promising for the operative treatment of complex acetabular fractures.

Operative treatment of complex acetabular fractures with ilioischial plating via modified Stoppa and iliac fossa approaches

Objective To investigate the effectiveness of ilioischial plating through modified Stoppa and iliac fossa approaches for complex acetabular fractures. Methods A consecutive series of 40 patients with complex acetabular fracture were treated operatively from January 2014 to February 2015. Of them, 20 were treated through modified Stoppa plus iliac fossa approaches as an experimental group (including 12 males and 8 females with a mean age of 46.8±10.3 years). The anterior column was stabilized with a recon-struction plate for the iliac wing along the iliopectineal line to the pubis in all cases. The posterior column was fixed with a newly developed ilioischial plate running from the ilium to the ischial ramus. The other 20 patients (10 males and 10 females with a mean age of 45.6±11.7 years) served as a control group, treated with a reconstruction plate for the conventional posterior column fixation through the Kocher-Langenbeck approach. The 2 groups were compared in terms of operative time, intraoperative blood loss, reduction and functional recovery of the hip. Results The 40 patients obtained an average follow-up of 18 months (from 8 to 24 months). The experimental group reported significantly shorter operation time(2.1±0.7 hours) and signifi-cantly less intraoperative bleeding(320.8±100.4 mL) than the control group(2.9±0.6 hours and 621.6±118.7 mL, respectively)(P 0.05). There were no significant differences in the MOS item short form health survey score and postoperative complication rate between the experimental group and the control group. Conclusion Ilioischial plating through modified Stoppa and iliac fossa approaches has advantages of reliable fixa-tion, limited invasion, less intraoperative blood loss and fewer complications for complex acetabular fractures. Key words: Acetabulum; Fractures, bone; Bone plates; Fracture fixation, internal; Sur-gical approach