Mapping of both column acetabular fractures with three-dimensional computed tomography and implications on surgical management

Comparative study of the 3D morphological differences in associated both-column acetabular fractures between elderly and young adults

INTRODUCTION

The occurrence of associated both-column acetabular fractures (ABC-AFs) is common in the elderly, yet their morphological characteristics compared to younger adults remain unclear.

MATERIALS AND METHODS

This retrospective study analyzed 123 cases of ABC-AFs: elderly patients (≥ 65 years, n = 47, group A) and younger adults (< 65 years, n = 76, group B). Using Mimics and 3-matic, fracture line (FL) distributions in the anterior column (AC), quadrilateral plate (QP), and posterior wall (PW) fragments were examined. Comparisons focused on the articular surface, ilium, QP area, and retro-acetabular surface (RAS). Harris hip scores (HHS) were recorded and compared one-year post-surgery.

RESULTS

The distribution of FLs of the AC fragment on the anteroinferior wall, acetabulum, inner and outer sides of the ilium was similar between groups A and B except that group A had sparser FL distribution on the posterosuperior rim and fewer FLs extending into the sacroiliac joint. A comparable pattern of FLs of the QP fragments on the QP area and the RAS was also confirmed. On the RAS, group A exhibited fewer cranial transverse lines (8.5% vs. 25.0%) and more inverse lines (44.7% vs. 23.7%) than group B (p = 0.011). A higher incidence of PW fragments was identified in group A (72.3% vs. 53.9%, p = 0.042). The number of intra-articular fragments was higher in group A than group B (3.8 vs. 3.4, p = 0.031), but the composition of the articular surface was similar. The average HHS was 77.6 in group A and 83.0 in group B (p = 0.007), with excellent/good ratios of 59.5% and 74.7% (p < 0.001), respectively.

CONCLUSIONS

The similar morphological patterns of ABC-AFs and favorable functional outcomes suggest that surgical principles for younger patients could be applicable to elderly patients, with careful considerations for osteoporosis and co-morbidities.

Pathoanatomy of the anterior column-posterior hemitransverse acetabular fracture

PURPOSE

To define the pathoanatomy of the anterior column-posterior hemitransverse (ACPHT) subtype of acetabulum fractures and assess the morphologic variation therein.

METHODS

Retrospective cohort study including 50 patients age greater than 60 with an ACPHT acetabular fracture managed operatively over an 11-year period at an ACS Level 1 Trauma center. Cross-sectional CT images were reviewed for anterior column/wall comminution, anterior column fracture exit point, completeness of the anterior column and posterior column fractures, articular impaction and quadrilateral surface continuity with the posterior column.

RESULTS

Comminution of the anterior column/wall was seen in 60% of patients. The anterior column fracture line exit was variable and exited below the anterior inferior iliac spine (AIIS) in 36% of fractures, at the AIIS or between the iliac spines in 40%, and through the iliac crest in 24%. A complete fracture was present in 72% of anterior column fractures and 44% of posterior column fractures. Impaction of the acetabular joint surface was present in 84% of patients. Continuity of the quadrilateral surface with the posterior column was present in 60% of cases.

CONCLUSIONS

Significant variability exists within the ACPHT fracture pattern. Understanding the variability within the ACPHT subtype is critical for adequately analyzing these patterns and has implications in future biomechanical studies and implant design.

LEVEL OF EVIDENCE

Level IV.

Progress of fracture mapping technology based on CT three-dimensional reconstruction

Fracture Mapping is a new technology developed in recent years. This technology visually representing the morphology of fractures by overlaying fracture lines from multiple fracture models onto a standard model through three-dimensional reconstruction. Fracture mapping has been widely used in acetabular fracture, proximal humerus fractures, Pilon fracture, tibial plateau fractures, and so on. This technology provides a new research method for the diagnosis, classification, treatment selection, internal fixation design, and statistical analysis of common fracture sites. In addition, the fracture map can also provide a theoretical basis for the establishment of a biomechanical standardized fracture model. Herein, we reviewed various methods and the most advanced techniques for fracture mapping, and to discuss the issues existing in fracture mapping techniques, which will help in designing future studies that are closer to the ideal. Moreover, we outlined the fracture morphology features of fractures in various parts of the body, and discuss the implications of these fracture mapping studies for fracture treatment, thereby providing reference for research and clinical decision-making on bone and joint injuries to improve patient prognosis.

CT scan-based 3D fracture mapping in civilian gunshot intracapsular fractures of the femur neck

INTRODUCTION

Displaced intracapsular neck of femur (NOF) fractures secondary to civilian gunshots are rare injuries with universally poor outcomes following surgical fixation. No studies have been published on fracture mapping in NOF fractures secondary to civilian gunshots.

OBJECTIVES

We performed CT scan-based fracture mapping to identify the most common fracture patterns in these injuries.

METHODS

Design: Retrospective search of prospectively collected data.

SETTING

Single Level 1 Trauma hospital. Patient selection criteria: All patients presenting with gunshot fractures to the femur neck between 01 January 2009 and 31 December 2022 were identified. Once identified from Picture Archiving and Communication System (PACS), computed tomography (CT) scans in Digital Imaging and Communication in Medicine (DICOM) format were imported into Mimics 16 software and fracture fragments were segmented and three-dimensional (3D) reconstruction was generated. The reduced fractures were exported to 3-Matic software to merge the fragments and adjust the orientation in three planes. An uninjured femur model was used as a template for reduction. Fracture lines and heat maps were then generated. Our outcome measures were successful mapping of the identified fracture lines.

RESULTS

A total of 25 intracapsular femur neck fractures were identified and suitable for CT scan mapping. All patients were male with an average age of 22 (range 18-32). Once generated, fracture maps were used to show the location, distribution and frequency of the fracture lines. In all but two cases the fracture line propagation remained within the confines of the hip joint capsule. In three cases there was fracture extension into the superior aspect of the femur head, and in one case extension into the inferior aspect.

CONCLUSION

This is the first study to perform 3D fracture mapping for intracapsular femur neck fractures secondary to civilian gunshot injuries. The exercise has helped us better understand the commonest fracture patterns and assisted us with surgical planning and execution.

Posterior Wall Fragments in Acetabular Both-Column Fractures: Morphology, Type, and the Significance of its Projection

OBJECTIVE

Most both-column acetabular fractures are combined with posterior wall fragments. However, the morphology of this posterior wall is varied, and how to fix this posterior wall remains a controversial topic. To investigate the morphological characteristics of posterior wall fragments of both-column acetabular fractures and select corresponding fixation methods.

METHODS

Data from 352 patients with acetabular fractures admitted to the level one trauma centre in our hospital between January 2006 and December 2022 were collected. The morphology of posterior wall fragments was observed and analyzed in 83 cases of both-column acetabular fractures and classified according to the consistency of posterior wall morphology. A fracture map of the posterior wall was created on a normal template according to the three morphological types of posterior wall fragments. Finally, the high-incidence area of the posterior wall fracture was projected onto the iliac fossa and the medial side of the posterior column to guide the fixation of the posterior wall fragment using the anterior intrapelvic approach.

RESULTS

Fractures were divided into four types: I, large posterior wall fragment which was high in the ilium bone (34 cases, 41.0%); II, posterior wall fragment in the acetabular parietal region (18 cases, 21.7%); III, posterior wall marginal fracture (10 cases, 12.0%); and IV, non-combined posterior wall fracture (21 cases, 25.3%). The most common morphologies of the posterior wall fragments of the first two types were mapped and projected onto the anterior iliac inner plate and medial side of the posterior column, where the corresponding area could be used to guide the insertion of the internal fixation.

CONCLUSION

Both-column acetabular fractures combined with posterior wall fractures can be divided into four types according to the morphology of the posterior wall fragment. Understanding the corresponding three-dimensional morphology and projection position of different types of these fragments can help surgeons determine the position and orientation of internal fixation of posterior wall fractures.

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

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

Three-Dimensional Mapping of Scapular Body, Neck, and Glenoid Fractures

OBJECTIVES

The purpose of this study was to report patterns of scapular fractures and define them with a contemporary methodology.

METHODS

.

DESIGN

Retrospective study, 2015-2021.

SETTING

Single, academic, Level 1 trauma center.

PATIENT SELECTION CRITERIA

Consecutive patients ≥18 years, presenting with unilateral scapula fracture, with thin-slice (≤0.5-mm) bilateral computed tomography (CT) scans of the entirety of both the injured and uninjured scapulae.

OUTCOME MEASURES AND COMPARISONS

Thin-slice (0.5-mm) CT scans of injured and normal scapulae were obtained to create three-dimensional (3D) virtual models. 3D modeling software (Stryker Orthopedics Modeling and Analytics, Stryker Trauma GmbH, Kiel, Germany aka SOMA) was used to create a 3D map of fracture location and frequency. Fracture zones were delineated using anatomic landmarks to characterize fracture patterns.

RESULTS

Eighty-seven patients were identified with 75 (86%) extra-articular and 12 (14%) intra-articular fractures. The dominant fracture pattern emanated from the superior lateral border (zone E) to an area inferior to the spinomedial angle (zone B) and was present in 80% of extra-articular fractures. A second-most common fracture line propagated from the primary (most-common) line toward the inferior medial scapular border with a frequency of 36%. Bare zones (with 1 or no fractures present) were identified in 4 unique areas. Furthermore, intra-articular fractures were found to be heterogenous.

CONCLUSIONS

The 3D fracture map created in this study confirmed that extra-articular scapular fractures occur in certain patterns with a relatively high frequency. Results provide greater insight into scapular fracture locations and may help to study prognosis of injury and improve treatment strategy including operative approaches and surgical tactics.

OUTCOMES OF SURGICAL TREATMENT FOR DISPLACED BOTH-COLUMN ACETABULAR FRACTURES

Complex both-column acetabulum fractures are severe injuries, often with associated injuries and complications with uncertain clinical and functional outcome. Modern traumatological protocols point to early surgical treatment, with anatomical reduction and stable internal fixation of fragments as a prerequisite for achieving a good treatment outcome. This retrospective-prospective multicenter cohort study was conducted during the 2014-2020 period and included 24 cases that met the input parameters, using the Letournel and Judet classification, and application of a combined surgical approach, a modified Stoppa and Kocher-Langenbeck approach. The results of treatment with complications, associated injuries and functional outcome are described. Fractures were caused by high kinetic energy trauma, and the cause was traffic accident in 17/24 (70.84%), fall from a height in 5/24 (20.83%) and crash injuries in 2/24 (8.33%) cases. The sample included 18 (75.00%) male and 6 (25.00%) female, with 10/24 (41.67%) right sided and 14/24 (58.33%) left sided fractures. Their mean age was 45.06 (range, 24-62) years. The mean follow-up time was 2.8 (range, 1-5) years. Postoperative complications were detected in 14/24 (58.33%) cases, including wound infection in 4/24 (16.67%), deep vein thrombosis in 2/24 (8.33%), heterotopic ossification in 2/24 (8.33%), hip osteoarthrosis in 3/24 (12.50%), avascular necrosis of femoral head in 2/24 (8.33%), total hip arthroplasty procedures in 3/24 (12.50%), abdominal complications in 2/24 (8.33%), urologic complications in 2/24 (8.33%), iatrogenic nerve lesion in 3/24 (12.50%), and fatal pulmonary embolism in 2/24 (8.33%) cases; there was no loss of reduction or non-union acetabular fracture. Associated injuries that we recorded as major trauma were presented in 13/24 (54.17%) study patients. The final functional results according to the Harris Hip Score (HHS) were excellent in 7/22 (31.82%), good in 10/22 (45.45%), moderate in 4/22 (18.18%) patients, and poor in 1/22 (4.55%) patient. The mean HHS was 84 (range 34-98). Complications and results have led us to a conclusion that primary injuries significantly affect the clinical and functional results. A good diagnostic procedure, assessment of the general condition and application of the trauma scoring system, surgical treatment that includes early hip reduction, open reduction internal fixation and physical rehabilitation are necessary.

Rib Fracture Map in High-Energy Injuries

OBJECTIVES

To use a novel rib unfurling technology to investigate the locations of multiple rib fractures occurring from high-energy trauma to discern if there are reproducible rib fracture patterns.

METHODS

Patients between the ages of 18 and 48 years presenting to a Level 1 academic trauma center with ≥2 rib fractures after a high-energy mechanism of injury between 2017 and 2019 were identified. Curved planar reformatting of CT scans was used to create two-dimensional unfurled rib images by flattening out the view of the ribs from a CT scan. Rib fractures were placed on a template map using a standardized measurement method, and subsequent frequency and heat maps were created.

RESULTS

Among 100 consecutive patients, 534 fractures on 454 ribs were identified. The most common high-energy mechanism of injury was motor vehicle accidents (41%). Flail chest occurred in 8% of patients. The mean number of ribs fractured per patient was 4.54 ± 3.14 and included a mean of 5.34 ± 4.38 total fractures. Among all fractures, 50.9% were located on ribs 4 through 7. The most common fracture location was located in the lateral or anterolateral zone of the rib cage.

CONCLUSIONS

Patients with multiple rib fractures from high-energy trauma have rib fractures with locations of common occurrence. An understanding of location and frequency of rib fractures can help inform surgical approaches, prognosis, indications, classifications, and implant design in the management of a complex population of patients with chest wall injury after trauma.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Statistical Morphology and Fragment Mapping of Complex Proximal Humeral Fractures

Background and Objectives: Proximal humerus fractures (PHFs) are common in the elderly, but the treatment results are often poor. A clear understanding of fracture morphology and distribution of cortical bone loss is important for improved surgical decision making, operative considerations, and new implant designs. The aim of this study was to develop a 3D segmentation fracture mapping technique to create a statistical description of the spatial pattern and cortical bone loss of complex PHFs. Materials and Methods: Fifty clinical computed tomography (CT) scans of complex PHFs and their contralateral intact shoulders were collected. In-house software was developed for semi-automated segmentation and fracture line detection and was combined with manual fracture reduction to the contralateral template in a commercial software. A statistical mean model of these cases was built and used to describe probability maps of the fracture lines and cortical fragments. Results: The fracture lines predominantly passed through the surgical neck and between the tuberosities and tendon insertions. The superior aspects of the tuberosities were constant fragments where comminution was less likely. Some fracture lines passed through the bicipital sulcus, but predominantly at its edges and curving around the tuberosities proximally and distally. Conclusions: A comprehensive and systematic approach was developed for processing clinical CT images of complex fractures into fracture morphology and fragment probability maps and applied on PHFs. This information creates an important basis for better understanding of fracture morphology that could be utilized in future studies for surgical training and implant design.

Intra-articular fragment mapping in associated both-column acetabular fractures

INTRODUCTION

Associated both-column acetabular fractures (ABC-AF) are complex. A detailed description of the morphology of the articular surface of the acetabulum is not reported. This study was designed to describe the morphology of the intra-articular fragments using a fracture mapping technique to provide reference in more appropriate approach selection in surgical treatment of the fractures.

MATERIALS AND METHODS

Three-dimensional reconstruction CT images from 100 cases of ABC-AFs were retrospectively analyzed using Mimics and 3-matic software. The fractured as well as the reduced three-dimensional models were investigated, and the intra-articular fragments were identified. The distribution of the fracture lines of each main fragment and the overlapping lines of all the fragments were verified on the images.

RESULTS

The articular surface of ABC-AFS consist of three types of fragments: column fragment (CF), wall fragment (WF) and isolated fragment (IF), with the total number varying from 2 to 6. CF characterized by long fracture lines exited to periphery of innominate bone while the lines of WF were confined to the walls. IF was a free fragment found in the dome and in the quadrilateral plate. The surface was composed only by CFs in 17 cases (17%), by CFs and WFs in 59 cases (59%) and by all fragments in 24 cases (24%). The distribution of the overall fracture lines was a "dumbbell shaped" pattern, starting from the infero-anterior aspect, passing through the junction of the fossa to the anterior lunate surface and extending into the posterior region of the acetabulum.

CONCLUSIONS

The articular fragments of ABC-AFs were composed of CFs, WFs and IFs. The junction of the fossa to the anterior lunate surface and the posterior region of the rim were mostly involved. The location of the articular fragments and their connections to the periphery of the innominate may be considered in selection of approaches.

Three-dimensional mapping of sternum fractures from high-energy trauma

BACKGROUND

Sternum fractures are relatively uncommon injuries, which generally occur as a result of a high-energy mechanism and are often associated with significant concomitant injuries. These injuries may result in decreased quality of life if not properly addressed and yet are rarely operated on. The purpose of this project is to evaluate high-energy sternum fracture patterns using a previously published three-dimensional (3D) computed tomography (CT) reconstruction process to produce fracture frequency maps.

METHODS

Patients 18 years and older presenting to a Level I trauma center with sternum fractures due to high-energy trauma between October 2013 and January 2022 were included. A 3D reconstruction and reduction was performed for each sternum using medical image processing software (Materialize NV, Leuven, Belgium). The reconstructions were subsequently overlaid onto a template sternum and normalized using bony landmarks. Fracture lines for each injured sternum were transferred onto the template, creating 3D frequency maps.

RESULTS

A total of 120 patients met inclusion criteria. The study population had a uniform age distribution and 57.5% were male. The most common mechanism of injury was motor vehicle collision (64.2%). The breakdown of sternum fractures were isolated sternal body (55.8%), isolated manubrium (31.7%), and combined sternal body and manubrium fractures (12.5%). No xiphoid fractures were observed. Sternal body fractures were a near even mix of transverse (31.7%), oblique (32.9%), and comminuted (35.4%), while 75.5% of manubrium fractures were oblique. The most common associated injuries included rib fractures (80.8%) and traumatic brain injury (61.7%).

CONCLUSION

This study presents the fractures from sternum injuries in 3D, and provides insight into reproducible sternum injury patterns that have not previously been analyzed in this format. This fracture mapping technique presents numerous injury patterns simultaneously, such that more frequent morphologies can be appreciated for different patient groups.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level V.

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

OBJECTIVE

To investigate whether the fracture morphology of quadrilateral plate (QP) fragments is associated with the anterior and posterior columns in associated both-column (ABC) fractures.

MATERIALS AND METHODS

Three-dimensional computed tomography data of 100 ABC fractures treated at our hospital from August 2016 to August 2019 were retrospectively analyzed using Mimics and 3-matic software. The distribution of fracture lines was described using the fracture mapping technique.

RESULTS

One fragment presented on the QP was confirmed in 88% of the patients. The QP fragments' fracture lines were divided into the anterior oblique (AO), superior posterior oblique (SPO), and mid-posterior oblique (MPO) lines, occurring in 100, 86, and 8 cases, respectively. AO lines were distributed along the arcuate line. SPO lines were continuations of the AO lines, which were distributed to the posterior column from the greater sciatic notch to the lesser sciatic notch. MPO lines were involved in the QP's central area. A simple fracture was found at the proximal AO and SPO lines in 80% and 86% of all displaced fractures, respectively. AO lines distal to the superior rim of the acetabula were confirmed to be comminuted fractures in 32% of all cases.

CONCLUSIONS

In ABC fractures, there was only one QP fragment in nearly 90% of all cases. The QP fractures were mainly present in the QP's peripheral area. More than 80% of the fracture patterns on the cephalic side of the QP were simple. The reduction and internal fixation of QP fractures in ABC fractures should be in the cephalic region.

Displacement Pattern of Anterior and Posterior Column Fragments in Both-Column Acetabular Fractures: A 3D Reconstruction-Based Study

BACKGROUND

Few studies have been conducted to examine the displacement characteristics of both-column acetabular fractures (BCAFs). The goal of this study was to investigate the displacement pattern of anterior column (AC) and posterior column (PC) fragments in BCAFs using 3D virtual software.

MATERIALS AND METHODS

BCAFs were retrospectively reviewed, and 81 patients were enrolled. Computed tomography (CT) images were imported into Mimics software. A 3D model of each pelvis was generated. Four marked points and the rotation angle of each of the injured ACs and PCs were identified. The fracture fragments were reduced virtually using the software, and the change in coordinates of the marked points after reduction was recorded while the rotation angle was measured. The measurements of positional and directional displacement were analysed using the Mann-Whitney U test and the binomial test, respectively.

RESULTS

There was a propensity for AC fragments to shift superomedially and to rotate externally (p < 0.001). Additionally, the posteroinferior fracture area of AC fragments showed the greatest displacement (p < 0.05). PC fragments moved superomedially (p < 0.001) and moved more at the proximal end than the distal end (p < 0.001). PC displacement was always accompanied by internal rotation (p < 0.001). Greater AC displacement was observed in the fracture area further away from the acetabulum (p < 0.05). Greater rotation was observed for the AC than the PC (p < 0.001).

CONCLUSION

After a BCAF occurs, there are regular patterns regarding the direction and distance of AC and PC fragment displacement. Information on these patterns may provide insight into the injury mechanism and fracture morphology and facilitate surgical decision-making for orthopaedic trauma surgeons.

Both-Column Acetabular Fractures: Should Pelvic Ring Reduction or Acetabulum be Performed First?

OBJECTIVE

Both-column acetabular fracture is a type that accumulates both the pelvis and acetabulum with complex fracture line alignment and has variant fracture fragments. The selection of different reduction landmarks and sequences produces different qualities of reduction. This study aims to compare the operation-related items, quality of reduction, and hip functional outcome by using different reduction landmarks and sequences for management of both-column acetabular fractures (BCAF).

METHODS

A consecutive cohort of 42 patients from January 2013 to January 2019 with BCAF were treated operatively with different reduction landmarks and sequences: pelvic ring fractures reduction first (PRFRF group) and acetabular fractures reduction first (AFRF group). Preoperative computer visual surgical procedures were applied. There were 22 patients in PRFRF group and 20 patients in AFRF group. The surgical details, complications, radiographic and clinical results were recorded. The quality of reduction was assessed by the Matta scoring system. The functional outcome was evaluated by the modified Merle d'Aubigné and Postel scoring system. The measurement data were analyzed using the t-test of independent samples and rank-sum test of ranked data.

RESULTS

The real reduction sequence in both groups was almost identical to the preoperative surgical procedures. The excellent/good quality of reduction in PRFRF group (21/22) was better than AFRF group (17/20). Operative time (152.3 ± 16.3 mins) and intra-operative blood loss (639.5 ± 109.9ml) were significantly reduced in PRFRF group (p < 0.05). The incidence of deep vein thrombosis in PRFRF group (2/22) was less than AFRF group (4/20), but without statistical signification.

CONCLUSION

Selection of an appropriate reduction landmark and sequence could result in better quality of reduction, operative time, and decreased blood loss during treatment of BCAF.

Three-Dimensional Printing and Fracture Mapping in Pelvic and Acetabular Fractures: A Systematic Review and Meta-Analysis

Three-dimensional printing and fracture mapping technology is gaining popularity for preoperative planning of fractures. The aim of this meta-analysis is to further understand for the effects of 3D printing and fracture mapping on intraoperative parameters, postoperative complications, and functional recovery on pelvic and acetabular fractures. The PubMed, Embase, Cochrane and Web of Science databases were systematically searched for articles according to established criteria. A total of 17 studies were included in this study, of which 3 were RCTs, with a total of 889 patients, including 458 patients treated by traditional open reduction and internal fixation methods and 431 patients treated using 3D printing strategies. It was revealed that three-dimensional printing and fracture mapping reduced intraoperative surgical duration (RoM 0.74; 95% CI; 0.66–0.83; I² = 93%), and blood loss (RoM 0.71; 95% CI; 0.63–0.81; I² = 71%). as compared to traditional surgical approaches. In addition, there was significantly lower exposure to intraoperative imaging (RoM 0.36; 95% CI; 0.17–0.76; I² = 99%), significantly lower postoperative complications (OR 0.42; 95% CI; 0.22–0.78; I² = 9%) and significantly higher excellent/good reduction (OR 1.53; 95% CI; 1.08–2.17; I² = 0%) in the three-dimensional printing and fracture mapping group. Further stratification results with only prospective studies showed similar trends. Three-dimensional printing and fracture mapping technology has potential in enhancing treatment of complex fractures by improving surgical related factors and functional outcomes and therefore could be considered as a viable tool for future clinical applications.

Fracture lines and comminution zones in acetabular fractures based on three dimensional computed tomography

PURPOSE

To characterize the fracture patterns of acetabular fractures and create fracture maps and comminution zones based on three-dimensional (3D) computed tomography (CT) images.

METHODS

Sixty-eight computed tomography images of 67 patients (47 male [70.1%] and 20 female [29.9%], mean age: 45.2 ± 17.2 [range, 18-85 years] with the diagnosis of intra-articular acetabulum fracture were analyzed. Individual fracture lines were drawn and superimposed to a healthy acetabular template according to Judet-Letournel and simplified fracture classification systems. Fracture line, comminution zone, and heat maps were created using the computed tomography mapping technique.

RESULTS

Fracture lines were distributed mainly in a horizontal and oblique orientation, which concentrated in the anteroinferior part of the joint in anterior fractures. Posterior fractures mostly had an oblique orientation, which lied between the acetabular dome and middle part of the posterior wall. In complex fractures, fracture lines were concentrated just above the cotyloid fossa, acetabular dome, and posterosuperior part of the acetabulum. The most common comminuted zones were around the central area of the articular surface and the anterior wall in anterior fractures, between the cotyloid fossa and dome in complex fractures, and the upper half posterior wall.

CONCLUSION

Fracture patterns and comminution zones of acetabular fractures displayed certain characteristics. Some areas had higher comminution zones, and some areas remained intact in repeatable fracture patterns. These results may help surgeons in fixing acetabular fractures, designing new implants, and placement of acetabular component while performing THA after acetabular fractures.

Morphological Characteristics of the Posterior Wall Associated with Complex Acetabular Fractures: A Radiological Study Using 3D Software and Fracture Mapping Technique

BACKGROUND

The aim of the study was to compare the morphological distinctions of the posterior wall (PW) in different complex acetabular fractures using 3D software and fracture mapping technique and ultimately to provide for improved clinical treatment.

METHODS

One hundred and fourteen patients with complex acetabular fracture associated with PW were recruited. All patients were divided into two groups according to the injury mechanism of the PW: Group A (both-column and PW) and Group B (including posterior column and PW; T shape and PW; and transverse and PW). Fracture mapping was generated on the intra- and extrasurface of a standard template. The radiological parameters including spatial displacement, articular surface area, articular range, marginal impaction, and multifragments of the two groups were compared.

RESULTS

The spatial displacement, intra-/extra-articular surface area, and start and end point in Group A were 10.9 mm (IQR, 8.4-15.2), 8.2 ± 2.6 cm2, 17.9 ± 5.3 cm2, 0.8° (IQR, -6.0-16.2), and 107.5° (IQR, 97.2-116.9), respectively. The results in Group B were 30.4 mm (IQR, 16.8-48.7), 4.1 ± 2.0 cm2, 10.6 ± 4.4 cm2, 29.5° (IQR, 19.2-38.0), and 117.5° (IQR, 98.2-127.2), respectively. Marginal impaction was defined by Letournel et al. All the differences between two groups were significant (P < 0.05). The fracture map in Group A showed an "L"-shaped pattern and a "cusp" on the ilium, and the PW was located at 1/5 to 1/4 of the posterosuperior part of the acetabulum. The fracture maps in Group B were scattered and lacked consistency, and the PWs were confined to 1/10 to 1/8 of the posterior acetabulum.

CONCLUSIONS

Quantitative measurements and fracture mapping represented the differences in morphological characteristics of PWs associated with complex acetabular fractures.

Is Plating Fixation Through the Kocher-Langenbeck Approach for Associated Posterior Wall Fragment Indispensable in Both-Column Acetabular Fractures?

OBJECTIVE

The treatment methods for posterior wall (PW) in both-column acetabular fractures are controversial. The purpose of this study was to compare reduction quality, clinical outcomes, and complications of nonfixation for posterior wall fragment and plating via the Kocher-Langenbeck (KL) approach after anterior surgical procedures in both-column acetabular fractures.

METHODS

Forty-nine patients with both-column acetabular fractures associated with PW fixed via iliac fossa and Stoppa approaches from October 2012 to October 2017 were recruited into this study and were divided into two groups: Nonfix group (nonfixation for PW) and KL group (PW plating through the KL approach). Operation duration, intraoperative blood loss, reduction quality, fracture healing, and relevant complications of patients were reviewed. Merle d'Aubigné scores were used for assessing functional outcome.

RESULTS

The mean blood loss and operation durations were lower in Nonfix group than in KL group (both p < 0.05). The mean hospital stay durations were (18.54 ± 6.42) days and (21.17 ± 7.32) days in groups Nonfix and KL, respectively (p = 0.186). All fractures healed well with no significant difference in union time between the two groups (p = 0.210). The rates of satisfactory reduction were 84.62% (22/26) in Nonfix group and 86.96% (20/23) in KL group (p = 1.000). The mean Merle d'Aubigné scores were 15.62 ± 2.28 in Nonfix group and 16.17 ± 2.19 in KL group (p = 0.388). The complication rates were 7.69% (2/26) in Nonfix group and 34.78% (8/23) in KL group (p = 0.046).

CONCLUSIONS

For both-column acetabular fractures associated with PW fragment, although fixation of PW was not performed after anterior surgical procedures, satisfactory outcomes could also be obtained. However, nonfixation was a less invasive choice with a lower complication rate.

Mapping of common rib fracture patterns and the subscapular flail chest associated with operative scapula fractures

BACKGROUND

Rib fractures occur in approximately 10% of trauma patients and are associated with more than 50% of patients with scapula fractures. This study investigates the location and patterns of rib fractures and flail chest occurring in patients with operatively treated scapula fractures. Novel frequency mapping techniques of rib fracture patterns in patients who also injure the closely associated scapula can yield insight into surgical approaches and fixation strategies for complex, multiple injuries patients. We hypothesize that rib fractures have locations of common occurrence when presenting with concomitant scapula fracture that requires operative treatment.

METHODS

Patients with one or more rib fractures and a chest computed tomography scan between 2004 and 2018 were identified from a registry of patients having operatively treated scapula fractures. Unfurled rib images were created using Syngo-CT Bone Reading software (Siemens Inc., Munich, Germany). Rib fracture and flail segment locations were marked and measured for standardized placement on a two-dimensional chest wall template. Location and frequency were then used to create a gradient heat map.

RESULTS

A total of 1,062 fractures on 686 ribs were identified in 86 operatively treated scapula fracture patients. The mean ± SD number of ribs fractured per patient was 8.0 ± 4.1 and included a mean ± SD of 12.3 ± 7.2 total fractures. Rib fractures ipsilateral to the scapula fracture occurred in 96.5% of patients. The most common fracture and flail segment location was ipsilateral and subscapular; 51.4% of rib fractures and 95.7% of flail segments involved ribs 3 to 6.

CONCLUSION

Patients indicated for operative treatment of scapula fractures have a substantial number of rib fractures that tend to most commonly occur posteriorly on the rib cage. There is a pattern of subscapular rib fractures and flail chest adjacent to the thick bony borders of the scapula. This study enables clinicians to better evaluate and diagnose scapular fracture patients with concomitant rib fractures.

LEVEL OF EVIDENCE

Diagnostic test, level IV.

Evaluation of Sanders Type 2 Joint Depression Calcaneal Fractures in 197 Patients from a Single Center Using Three-Dimensional Mapping

BACKGROUND This study aimed to evaluate Sanders type 2 calcaneal fractures in 197 patients from a single center using the 3D (three-dimensional) CT (computed tomography) mapping method. MATERIAL AND METHODS A consecutive series of 197 Sanders type 2 joint depression calcaneal fractures was used. The segment and split functions were used to create each calcaneal fragment using Mimics Research 20.0 software. The fracture fragments were reduced in 3-matic Research 12.0 software. In the E-3D Medical 18.01 software, after superimposing the fractured calcaneus entity with the calcaneus template, we drew the fracture line on the template. Finally, the heatmap was obtained by fracture statistical analysis function. Simultaneously, the distribution of the fracture lines in the anterior part of the calcaneus (APC) and middle talar joint was recorded. RESULTS There were 109 cases of Sanders type 2A, 46 cases of Sanders type 2B, and 42 cases of Sanders type 2C. Based on the data, we drew the characteristic fracture map of type 2A 2B and 2C. This study found that the most common types of Sanders type 2A in APC and middle talar articular surface are type AC and type AD. In Sanders type 2B, the most common type is type AC, and in Sanders type 2C it is type ACD. CONCLUSIONS The findings from this study showed that 3D CT imaging and reconstruction of the calcaneus was a useful diagnostic method to evaluate and classify joint depression calcaneal fractures. The calcaneal fracture map can be used to guide surgical planning and optimize the design of internal fixation.

Traditional versus mirror three-dimensional printing technology for isolated acetabular fractures: a retrospective study with a median follow-up of 25 months

Objective

To assess the outcomes of traditional three-dimensional (3D) printing technology (TPT) versus mirror 3D printing technology (MTT) in treating isolated acetabular fractures (IAFs).

Methods

Consecutive patients with an IAF treated by either TPT or MTT at our tertiary medical centre from 2012 to 2018 were retrospectively reviewed. Follow-up was performed 1, 3, 6, and 12 months postoperatively and annually thereafter. The primary outcome was the Harris hip score (HHS), and the secondary outcomes were major intraoperative variables and key orthopaedic complications.

Results

One hundred fourteen eligible patients (114 hips) with an IAF (TPT, n = 56; MTT, n = 58) were evaluated. The median follow-up was 25 months (range, 21–28 months). At the last follow-up, the mean HHS was 82.46 ±14.70 for TPT and 86.30 ± 13.26 for MTT with a statistically significant difference. Significant differences were also detected in the major intraoperative variables (operation time, intraoperative blood loss, number of fluoroscopic screenings, and anatomical reduction number) and the major orthopaedic complications (loosening, implant failure, and heterotopic ossification).

Conclusion

Compared with TPT, MTT tends to produce accurate IAF reduction and may result in better intraoperative variables and a lower rate of major orthopaedic complications.

Associated both-column acetabular fracture: An overview of operative steps and surgical technique

The management of both-column fractures of the acetabulum is challenging for the orthopaedic surgeon. Operative treatment is usually recommended in this particular fracture pattern, as residual joint surface displacement has been shown to increase local contact stress, drastically leading to rapid cartilage destruction. In this review, we present an overview of operative steps and surgical technique for both-column acetabular fracture reconstruction. Therefore, we demonstrate how correct understanding of fracture morphology and displacement, preoperative preparation, including choice of approach and patient positioning, reduction strategies, and programmed sequential fixation, starting from superior fracture lines on the anterior acetabular column and ending on the posterior components of this fracture type, may provide satisfactory outcomes in this difficult acetabular fracture pattern.