Management of geriatric acetabular fractures:Contemporary treatment strategies

Acetabular fractures in the geriatric population are typically low-energy fractures resulting from a fall from standing height.Compromised bone quality in the elderly,as well as this population’s concomitant medical comorbidities,render the management of such fractures challenging and controversial.Non-operative management remains the mainstay of treatment,although such a choice is associated with numerous and serious complications related to both the hip joint as well as the general condition of the patient.On the other hand,operatively treating acetabular fractures(e.g.,with osteosynthesis or total hip arthroplasty)is gaining popularity.Osteosynthesis can be performed with open reduction and internal fixation or with minimally invasive techniques.Total hip arthroplasty could be performed either in the acute phase combined with osteosynthesis or as a delayed procedure after a period of non-operative management or after failed osteosynthesis of the acetabulum.Regardless of the implemented treatment,orthogeriatric co-management is considered extremely crucial,and it is currently one of the pillars of a successful outcome after an acetabular fracture.

Interobserver and intraobserver agreement for Letournel acetabular fracture classification system using 3-dimensional printed solid models

BACKGROUND Acetabular fractures pose diagnostic and surgical challenges.They are classified using the Judet-Letournel system,which is based solely on X-ray.However,computed tomography(CT)imaging is now more widely utilized in diagnosing these injuries.The emergence of 3-dimensional(3-D)printing technology in varying orthopedic fields has provided surgeons a solid model that improves their spatial understanding of complex fractures and ability to plan preoperatively.AIM To evaluate the reliability of the Judet-Letournel classification system of acetabular fractures,when using either CT imaging or 3-D printed models.METHODS Seven patients with acetabular fractures underwent pelvic CT imaging,which was then used to create solid,3-D printed models.Eighteen orthopaedic trauma surgeons responded to questionnaires regarding fracture classification and preferred surgical approach.The same questionnaire was completed using only CT imaging,and two weeks later,using only 3-D printed models.The inter-and intra-observer agreement rates were then analyzed.RESULTS Inter-observer agreement rates based on CT imaging or 3-D printed models were moderate for fracture classification:κ=0.44,κ=0.55,respectively(P<0.001)and fair for preferred surgical approach:κ=0.34,κ=0.29,respectively(P<0.005).Intra-observer agreement rates for fracture classification and preferred surgical approach comparing CT imaging or 3-D printed models were moderate:κ=0.48,κ=0.41,respectively.No significant difference in intra-observer agreement was detected when comparing orthopedic pelvic specialists to general orthopedic traumatologists.CONCLUSION The Judet-Letournel classification demonstrated only moderate rates of agreement.The use of 3-D printed models increased the inter-observer agreement rates with respect to fracture classification,but decreased it with respect to the preferred surgical approach.This study highlights the role of 3-D printed models in acetabular fractures by improving spatial understanding of these complex injuries,thus providing more reliable fracture diagnoses and alternative viewpoints for pre-operative planning.

The analysis of relevant risk factors of traumatic arthritis resulting from the surgery of acetabular fractures

Objective To explore the relevant risk factors of tramatic arthritis resulting from the surgery of acetabular fractures. Methods From January 2000 to January 2009,88 patients aged from 20 to 60 years old with acetabular fractures

Total hip arthroplasty for posttraumatic osteoarthritis following acetabular fracture： A systematic review of characteristics, outcomes, and complications

Purpose： Posttraumatic arthritis （PTA） may develop years after acetabular fracture, hindering joint function and causing significant chronic musculoskeletal pain. Given the delayed onset of PTA, few studies have assessed outcomes of delayed total hip arthroplasty （THA） in acetabular fracture patients. This study systematically reviewed the literature for outcomes of THA in patients with PTA and prior acetabular fracture. Methods： Pubmed, EMBASE, SCOPUS, and Cochrane library were searched for articles containing the keywords ＂acetabular＂, ＂fracture＂, ＂arthroplasty＂, and ＂post traumatic arthritis＂ published between 1995 and August 2017. Studies with less than 10 patients, less than 2 years of follow-up, conference abstracts, and non-English language articles were excluded. Data on patient demographics, surgical characteristics, and outcomes of delayed THA, including implant survival, complications, need for revision, and functional scores, was collected from eligible studies. Results： With 1830 studies were screened and data from 10 studies with 448 patients were included in this review, The median patient age on date of THA was 51.5 years, ranging from 19 to 90 years. The median time from fracture to THA was 37 months, with a range of 27-74 months. Mean follow-up times ranged from 4 to 20 years, The mean Harris hip scores （HHS） improved from 41.5 pre-operatively, to 87.6 post-operatively, The most prevalent postoperative complications were heterotopic ossification （28% -63%）, implant loosening （1%-24%）, and infection （0%-16%）. The minimum 5-year survival of implants ranged from 70% to 100%. Revision rates ranged from 2% to 32%. Conclusion： Despite the difficulties associated with performing THA in patients with PTA from previous acetabular fracture （including soft tissue scarring, existing hardware, and acetabular bone loss） and the relatively high complication rates, THA in patients with VIA following prior acetabular fracture leads to significant improvement in pain and function at 10-year follow-up. Further high quality randomized controlled studies are needed to confirm the outcomes after delayed THA in these patients.

Ilioinguinal approach versus Stoppa approach for open reduction and internal fixation in the treatment of displaced acetabular fractures： A systematic review and meta-analysis

Purpose： To compare the efficacy and safety of open reduction and internal fixation through ilioinguinal approach and Stoppa approach for the treatment of displaced acetabular fractures. Methods： Case-controlled trials （CCTs） published from January 2010 to August 2015 that compared the ilioinguinal approach and Stoppa approach in the management of displaced acetabular fractures were retrieved from the databases of Cochrane Library, Pubmed, CNKI, and so on. Methodological quality of the trials was critically assessed. Statistical software RevMan 5.0 was used for data analysis. Results： Eight articles were included in the meta-analysis. Through comparing the efficacy and safety of ilioinguinal approach and Stoppa approach in the treatment of displaced acetabular fracture, statistical significance was found in the average operation time [WMD = 68.29, 95% CI （10.52, 126.05）, p 〈 0.05] and the median intraoperative blood loss [WMD = 142.26, 95% CI （9.30, 275.23）, p 〈 0.05]. However, there existed no statistical significance in the fracture end reset satisfaction rate [RR = 0.63, 95% CI （0.17, 2.37）, p 〉 0.05], the early complications rate [RR = 0.89, 95% CI （0.33, 2.40）, p 〉 0.05], the late complications rate [RR = 0.91, 95% CI （0.27, 3.01）, p 〉 0.05], and Harris hip score good function rate [RR = 0.52, 95% CI （0.25, 1.10）, p 〉 0.05]. Conclusion： Though both techniques can obtain satisfactory clinical functions in the treatment of displaced acetabular fractures, Stoppa approach is superior to the ilioinguinal approach in terms of operation time and intraoperative blood loss.

The role of trochanteric flip osteotomy in fixation of certain acetabular fractures

Purpose： Complete visualization of certain acetabular fractures of posterior wall or column with cranial extension involving superior dome from standard surgical exposures is a challenge. Osteotomy of the greater trochanter has been used to enhance fracture visualization, especially the dome, in posterior and lateral exposures of the acetabulum, it also decreases the need for excessive muscle retraction. The purpose of the study was to investigate the outcome associated with trochanteric flip osteotomy in the management of certain acetahulum fractures. Methods： From January 2011 to December 2013, 25 displaced acetabular fractures were treated by open reduction and internal fixation. The fractures were managed using a Kocher-Langenbeck approach along with trochanteric flip osteotomy. At 3rd, 6th and 24th month follow-up, all patients had radiographic examination and underwent a final clinical evaluation based on the modified Merle d＇Auhigne and Postei score. The strength of the abductors was assessed according to the Medical Research Council （MRC） grading system. Results： Congruent reduction was achieved in all patients and all osteotomies healed within an average period of 3.8 months. All our patients were allowed full weight bearing at the end of 3 months and with no abductor lurch at the end of 6 months follow-up. There were no cases of avascular necrosis of femoral head. None of the patients had any neurovascular complication or infection by the end of the follow-up period. Conclusion： Truchanteric flip osteotomy is a very effective technique to fix certain acetabular fractures especially those with dome involvement. It is more accurate and associated with no significant com- plications compared with conventional way.

Operative strategy of acetabular fractures

Anatomic structure of acetabular fractures are complex and operative exposure and fixation are extremely difficult. For those obviously displaced acetabular fractures, close reduction is doomed to cause deformative healing. Open reduction with internal fixation （ORIF） not only results in anatomic reduction, but also brings complications. No matter which method will be adopted, traumatic arthritis or avascular necrosis of femoral head might occur. In order totreat acetabular fractures more effectively, orthopedic surgeons should be required to fully master the acetabular anatomy, biomechanics, classification and the necessary knowledge for complication prevention.

Three-dimensional printing combined with open reduction and internal fixation versus open reduction and internal fixation in the treatment of acetabular fractures:A systematic review and meta-analysis

Purpose:This meta-analysis compared the clinical outcome of three-dimensional(3D)printing combined with open reduction and internal fixation(ORIF)to traditional ORIF in the treatment of acetabular fractures.Methods:We searched the Cochrane Library,PubMed,Embase,VIP database,CNKI,and Wanfang data-base with keywords"acetabular fracture","3D printing","three-dimensional printing","open reduction and internal fixation","Acetabulum","Acetabula"from January 2000 to March 2020.Two reviewers independently selected articles,extracted data,assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration’s tools and/or Newcastle-Ottawa scale.When the two analysts had different opinions,they would ask the third analyst for opinion.Randomized controlled trials or retrospective comparative studies of 3D printing combined with ORIF(3D printing group)versus traditional ORIF(conventional group)in the treatment of acetabular fractures were selected.The data of operation time,intraoperative blood loss,intraoperative fluoroscopy times,incidence of complications,excellent and good rate of Matta score for reduction,and excellent and good rate of hip function score were extracted.Stata14.0 statistical software was used for data analysis.Results:Altogether 9 articles were selected,including 5 randomized controlled trials and 4 retrospective studies.A total of 467 patients were analyzed,250 in the conventional group,and 217 in the 3D printing group.The operation time in the 3D printing group was less than that in the conventional group and the difference was statistically significant(standardized mean difference(SMD)=-1.19,95%CI:-1.55 to-0.82,p<0.05).The intraoperative bleeding volume of the 3D printing group was significantly lower than that of the conventional group(SMD=-1.08,95%CI:-1.65 to-0.51,p<0.05).The fluoroscopy times were less in the 3D printing group than in the conventional group and the difference was statistically significant(SMD=-1.64,95%CI:-2.35 to-0.93,p<0.05).The total incidence of complications in the 3D printing group was significantly lower than that in the conventional group(OR=0.43,95%CI:0.24-0.79,p<0.05).There was no significant difference in the excellent and good rate of Matta score for reduction between the two groups(OR=0.60,95%CI:0.34-1.06,p>0.05).There was no significant difference in the excellent and good rate of hip function score at the end of postoperative follow-up between the two groups(OR=0.84,95%CI:0.46-1.56,p>0.05),but the follow-up time varies from 6 months to 40 months.Conclusion:Compared with traditional ORIF,3D printing combined with ORIF has certain advantages in terms that 3D printing not only helps surgeons to understand acetabular fractures more intuitively,but also effectively reduces operation time,intraoperative blood loss,intraoperative fluoroscopy times,and postoperative complications.However,there were no significant differences in the excellent and good rate of Matta score for reduction and the excellent and good rate of hip function score at the end of follow-up.

A novel anatomical self-locking plate fixation for both-column acetabular fractures

Purpose:To compare the stability of the posterior anatomic self-locking plate(PASP)with two types of popular reconstruction plate fixation,i.e.double reconstruction plate(DRP)and cross reconstruction plate(CRP),and to explore the influence of sitting and turning right/left on implants.Methods:PASP,DRP and CRP were assembled on a finite element model of both-column fractures of the left acetabulum.A load of 600 N and a torque of 8 N·m were loaded on the S1 vertebral body to detect the change of stress and displacement when sitting and turning right/left.Results:The peak stress and displacement of the three kinds of fixation methods under all loading conditions were CRP>DRP>PASP.The peak stress and displacement of PASP are 313.5 MPa and 1.15 mm respectively when turning right;and the minimal was 234.0 Mpa and 0.619 mm when turning left.Conclusion:PASP can provide higher stability than DRP and CRP for both-column acetabular fractures.The rational movement after posterior DRP and PASP fixation for acetabular fracture is to turn to the ipsilateral side,which can avoid implant failure.

Total Hip Arthroplasty Using Modular Trabecular Metal Acetabular Components for Failed Treatment of Acetabular Fractures： A Mid-term Follow-up Study

Background：Porous-coated cups have been widely used in acetabular reconstruction after failed treatment of acetabular fractures,and good results have been reported with the use of these cups;however,the durability and functionality of modular trabecular metal （TM） acetabular components in acetabular reconstruction after failed treatment of acetabular fractures remain unclear.This study aimed to examine the radiographic and clinical outcomes associated with the use of modular TM acetabular components for failed treatment of acetabular fractures to assess the durability and functionality of these components in acetabular reconstruction after failed treatment of acetabular fractures.Methods：A total of 41 patients （41 hips） underwent total hip arthroplasty （THA） using modular TM acetabular components for failed treatment of acetabular fractures at our hospital between January 2007 and December 2012.Among these patients,two were lost to follow-up.Therefore,39 patients （39 hips） were finally included in this study.The Harris hip score before and after the surgery,satisfaction level of the patients,and radiographic results were assessed.Results：The mean Harris hip score increased from 34 （range,8-52） before surgery to 91 （range,22-100） at the latest follow-up examination （P 〈 0.001）.The results were excellent for 28 hips,good for six,fair for three,and poor for two.Among the 39 patients,25 （64%） and 10 （26%） were very satisfied and somewhat satisfied,respectively.All cups were found to be fully incorporated,and no evidence of cup migration or periacetabular osteolysis was noted.Conclusions：Despite the technically demanding nature of the procedure,THA using modular TM acetabular components showed good durability and functionality and may be an effective reconstruction option for failed treatment of acetabular fractures.

Bilateral central acetabular fracture dislocation in a young patient due to seizure activity： a case report and review of the literature

Various musculoskeletal injuries are well known complications of epilepsy either because of direct trauma or because of unbalanced forceful muscle contraction. We report a case of non-traumatic bilateral central acetabular fracture dislocation due to seizure activity induced by neurocysticercosis of the brain, which was managed conservatively and obtained reasonable good outcome. This case highlights the importance of proper evaluation in young non-osteoporotic patients who have experienced an epileptic attack without any previous history. It is also imperative to mention that these patients should be thoroughly examined neurologically to find out the exact etiology and should be treated accordingly to prevent future seizure activity.

A case of Galen vein thrombosis occurring after bilateral acetabular fractures in the Tibet plateau - what can we learn？

Hypoxia leads to increased red blood cells and blood viscosity at high altitude while moderate trauma increases coagulation in blood. Under the above-mentioned conditions, venous sinus thrombosis is more likely to occur. A patient suffering bilateral acetabular fractures together with the gradual disturbance of consciousness was admitted to our hospital. Though computed tomography arteriogram （CTA） of the brain displayed normal blood vessels; bilateral thalamus and brainstem infarction were found on head computed tomography （CT} and Galen vein thrombosis on cerebral computed tomography venography （CTV）. Dehydration and tracheotomy were immediately conducted with antiplatelet, anticoagulant and neurotrophic medicine administered to the patient. After three days＇ treatment, the patient＇s con- sciousness gradually improved and eventually became clear enough to leave the hospital. On follow-up, no dysfunction was documented.

Open Reduction by Fenestration to the Ilium for Central Acetabular Depression Fractures: A Case Report and Operative Technique

Aim: The aim was to report a fenestration technique for gap reduction of acetabular depression fractures. Case presentation: A 76-year-old man suffered from severe left leg pain. The computed tomography scanning showed a displaced acetabular depression fracture, including a third fracture fragment in the center of the acetabular weight-bearing area. We performed a fenestration technique to fenestrate the outer plate of ilium to push down the dislocated fragment of the fracture. The patient was pain-free with good functional outcome of the hip joint at three years after operation. Conclusion: The fenestration technique is useful for displaced acetabular depression fractures. We performed open reduction in this particular case, but the technique may be done less invasively with the use of hip arthroscopy.

Computer navigation-assisted minimally invasive percutaneous screw placement for pelvic fractures

Pelvic fractures are often caused by high-energy injuries and accompanied by hemodynamic instability.Traditional open surgery has a large amount of bleeding,which is not suitable for patients with acute pelvic fracture.Navigationguided,percutaneous puncture-screw implantation has gradually become a preferred procedure due to its advantages,which include less trauma,faster recovery times,and less bleeding.However,due to the complexity of pelvic anatomy,doctors often encounter some problems when using navigation to treat pelvic fractures.This article reviews the indications,contraindications,surgical procedures,and related complications of this procedure for the treatment of sacral fractures,sacroiliac joint injuries,pelvic ring injuries,and acetabular fractures.We also analyze the causes of inaccurate screw placement.Percutaneous screw placement under navigational guidance has the advantages of high accuracy,low incidence of complications and small soft-tissue damage,minimal blood loss,short hospital stays,and quick recovery.There is no difference in the incidence of complications between surgeries performed by new doctors and experienced ones.However,computer navigation technology requires extensive training,and attention should be given to avoid complications such as screw misplacement,intestinal injury,and serious blood vessel and nerve injuries caused by navigational drift.

Functional Outcomes of Traumatic Complex Acetabulum Fractures with Open Reduction and Internal Fixation: 200 Cases

Objective: Acetabular fractures are common injuries in Iran. We assess the functional outcome of open reduction and internal fixation management of displaced Complex acetabular fractures. Materials and Methods: We analyzed a case series of patients with open reduction and internal fixation (ORIF) for complex acetabular fractures. Two hundred patients (132 men, 68 women) in four age groups including with a mean age of 43.39 ± 6.18 years (range 20 - 59 years) and a mean follow-up of 82.34 ± 12.48 months (range 18 - 109 months) met the inclusion criteria. Functional outcome at final follow-up was graded assessed according to Harris score. Factors affecting were defined. Results: Anatomic reduction was achieved in 192 hips, imperfect in 8 and poor in none. Radiological outcome revealed excellent results in 128 (64%) hips, good in eight, fair in five and none in poor. Harris score were excellent in 139 (69.5%) hips, good in 43 (21.5%) and fair in 18 (9%) and poor in none. The anatomical reduction results had a favorable final functional outcome. (0.003) However, BMI (P Conclusion: Optimal functional and radiological outcomes have been achieved with anatomic postoperative reduction. Also experience of specialist, on time surgery and good recovery lead to receiving excellent functional outcome with at least complications.

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.

Middle-term follow-up results of Pipkin type Ⅳ femoral head fracture patients treated by reconstruction plate and bioabsorbable screws

Purpose： To investigate the mid-term curative effects of the treatment of Pipkin type Ⅳ femoral head fractures using a reconstruction plate and bioabsorbable screws and provide the evidence for clinical practice. Methods： From February 2010 to September 2014, 21 patients with Pipkin type IV femoral head fractures were treated surgically. There were 13 males and 8 females with an average age of 41.1 years （range, 20 -65 years）. The causes of the fractures included traffic accidents （13 cases）, falls from a height （four cases）, heavy lifting injuries （three cases）, and sport injury （one case）. All patients were followed up with radiography and three-dimensional reconstruction computed tomography and other checks and any complications were actively managed. Closed reduction of fracture-dislocation of the hip was attempted under general anesthesia using the Kocher-Langenbeck approach. Femoral head fractures were treated with internal fixation or excision based on the size of the fracture fragments, whereas acetabular fractures were fixed with a reconstruction plate and screws following anatomic reduction. Results： The incisions healed by primary intention in all patients after surgery, without any infection, deep venous thrombosis, or other complications. All 21 patients were followed up for 36-76 months, with an average follow-up duration of 49 months. Postoperative imaging data showed that all dislocations and fractures were anatomically reduced, and bony union of the fractures was achieved. Heterotopic ossification was found in four patients, post-traumatic osteoarthritis in three, and avascular necrosis of the femoral head in two. At the final follow-up, the assessment of hip joint function according to the Thompson-Epstein scoring scale was excellent in 10 cases, good in six cases, fair in three cases, and poor in two cases. The rate of excellent and good functional outcomes was 76.1%. Conclusion： The mid-term curative effects of a reconstruction plate and bioabsorbable screws in the treatment of Pipkin type IV femoral head fractures is significant, and such the treatment can significantly improve the patient＇s joint function and quality of life.