Medial buttressing of the quadrilateral surface in acetabular and periprosthetic acetabular fractures

Developing a core outcome set for acetabular fractures: a systematic review (part I)

BACKGROUND

There are indications that clinical studies investigating the surgical treatment of acetabular fractures assess different outcomes. This heterogeneity reduces the comparability of study results and, thus, limits the knowledge generated from research. Core outcome sets (COS) contain a minimum set of outcomes that should be measured in studies investigating a specific disease or injury. A COS for surgically treated acetabular fractures does not yet exist. Therefore, the aim of this study is to identify the reported outcomes in studies investigating the surgical treatment of acetabular fractures.

METHODS

Studies including skeletally mature individuals (≥ 16 years) with isolated acetabular fractures treated surgically were included. Studies with polytrauma patients, pathological fractures, additional pelvic fractures, exclusively non-surgical treatment, or juvenile individuals were excluded. Three databases and two clinical trial registries were searched on 15 November 2022. The identified outcomes were grouped and subsequently categorized according to the Core Outcome Measures in Effectiveness Trials Guidelines.

RESULTS

A total of 193 studies were included, which reported a cumulative total of 2581 outcomes. After grouping, 266 unique outcomes were identified. No outcome was examined in all studies. Pain, ability to walk independently, range of motion, quality of reduction, and heterotopic ossification were the most reported unique outcomes and assessed in at least 60% of included studies. A total of 105 outcomes were only assessed in one of the included studies. Outcomes of all five core areas and 25 outcome domains of the Core Outcome Measures in Effectiveness Trials taxonomy were examined. Furthermore, outcomes were named and defined differently, measured at different time points, and assessed using a variety of measurement instruments.

CONCLUSION

Overall, this systematic review shows that a wide range of outcomes are measured in studies examining surgical treatment of acetabular fractures. The results of this systematic review will be used in a subsequent study to develop the COS for surgically treated acetabular fractures by using the Delphi method.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42022357644; COMET: 2123.

Quadrilateral plate fractures

During the last two decades, extended scientific interest focused on quadrilateral plate (QLP) fractures as part of common acetabular fractures. The QLP corresponds to the medial wall of the acetabulum, and different fracture pattern of Letournel´s fracture types are associated with concomitant QLP fractures. Except anterior and posterior wall fractures, all other fracture types may be associated with QLP fractures. QLP fracture features include simple fracture lines up to highly comminuted fractures. A detailed preoperative analysis of these fractures is important to get a better understanding of intraoperative decision making. No consensus exists regarding the optimal classification and treatment of QLP fractures. Various operative approaches and treatment concepts exists depending on the specific QLP fracture type and the acetabular fracture type. Several new implants were development for optimal but often individual stabilization concepts. The gold-standard is still some medial buttressing during internal fixation predominantly using plates, but also screw fixation is considered an option. Additional dome impactions must be considered as an integral part in any QLP fracture analysis and stabilization.

[Periprosthetic acetabular fractures: classifications, treatment and challenges]

Periprosthetic acetabular fractures (PPAF) are fractures of the acetabulum with a hip endoprosthesis in place. They are a rare complication, although they are occurring more frequently due to the increase in patients being fitted with total hip arthroplasty (THA) and the long service life of the implants. At present, only a small amount of scientific literature exists, particularly regarding the surgical treatment of these fracture types.The aim of this paper is to provide an overview of the topic of PPAF with a critical review of the current literature and to present the necessary surgical treatment.An evaluation of the current literature on the topic of PPAF with a focus on the surgical treatment of fractures is carried out.Surgical treatment is technically demanding due to the pelvic ring instability with removal of the bone tension for secure acetabular cup fixation and should lead to the recovery of the biomechanical stability of the pelvis and thus the secure anchoring of the acetabular cup. An interdisciplinary approach requiring both trauma surgery and orthopaedic expertise is certainly recommended, as older and comorbid patients with poor bone quality are particularly frequently affected.The treatment of periprosthetic acetabular fractures, especially in older patients, requires not only the individual expertise of surgeon involved in the operation but also a goal-oriented and consistent interdisciplinary approach by the surgeons involved from the fields of orthopaedics and trauma surgery in view of the patients' frequent comorbidities. By working together, the optimal and individualized operation can be performed for the patient.

Acetabular fractures in geriatric patients: epidemiology, pathomechanism, classification and treatment options

The incidence of geriatric acetabular fractures has shown a sharp increase in the last decades. The majority of patients are male, which is different to other osteoporotic fractures. The typical pathomechanism generally differs from acetabular fractures in young patients regarding both the direction and the amount of force transmission to the acetabulum via the femoral head. Geriatric fractures very frequently involve anterior structures of the acetabulum, while the posterior wall is less frequently involved. The anterior column and posterior hemitransverse (ACPHT) fracture is the most common fracture type. Superomedial dome impactions (gull sign) are a frequent feature in geriatric acetabular fractures as well. Treatment options include nonoperative treatment, internal fixation and arthoplasty. Nonoperative treatment includes rapid mobilisation and full weighbearing under analgesia and is advisable in non- or minimally displaced fractures without subluxation of the hip joint and without positive gull sign. Open reduction and internal fixation of geriatric acetabular fractures leads to good or excellent results, if anatomic reduction is achieved intraoperatively and loss of reduction does not occur postoperatively. Primary arthroplasty of geriatric acetabular fractures is a treatment option, which does not require anatomic reduction, allows for immediate postoperative full weightbearing and obviates several complications, which are associated with internal fixation. The major issue is the fixation of the acetabular cup in the fractured bone. Primary cups, reinforcement rings or a combination of arthroplasty and internal fixation may be applied depending on the acetabular fracture type.

Treatment of Geriatric Acetabular Fractures Using the Modified Stoppa Approach: A Review Article of Technique, Tips, and Pitfalls

The surgical treatment of geriatric acetabular fractures is becoming increasingly important due to a demographic change in age. While acetabular fractures used to occur more frequently in younger patients, they are currently more prevalent in geriatric patients. This change has also led to an increase in the frequency of anterior and combined anterior acetabular fractures. Surgery for geriatric acetabular fractures is very challenging, and surgeons need years of experience to be able to deal with the advantages and disadvantages of pelvic surgery. This is why a high level of surgical expertise is required. The aim of this article is to provide an insight into the topic of geriatric acetabular fractures with a critical narrative review of the current literature and a focus on minimally invasive surgical treatment using the modified Stoppa approach without patients' own assessment. The modified Stoppa approach offers excellent visibility of the anterior structures of the acetabulum and can address the quadrilateral surface effectively. Pelvic surgery, in particular acetabular surgery, offers patients many advantages, such as rapid mobilization and the quick relief of pain symptoms. Total hip arthroplasty is currently being discussed as an alternative with good results for certain types of acetabular fractures in older patients, though it requires clarification of studies and recommendations.

Update on post-traumatic periprosthetic acetabular fractures

Aims

Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications.

Methods

Patients with this type of fracture were identified retrospectively over a period of six years (January 2016 to December 2021). The following data were collected: demographic characteristics, date of insertion of the prosthesis, details of the intervention, date of the trauma, characteristics of the fracture, and type of treatment. Functional results were assessed with the Harris Hip Score (HHS). Data concerning complications of treatment were collected.

Results

Our series included 20 patients, with a mean age of 77 years (46 to 90). All the patients had at least one comorbid condition. Radiographs showed that 75% of the fractures were pure transverse fractures, and a transverse component was present in 90% of patients. All our patients underwent surgical treatment: open reduction and internal fixation, revision of the acetabular component, or both. Mean follow-up was 24 months, and HHS at last follow-up was 75.5 (42 to 95). The principal complications observed were dislocations of the prosthesis (30%) and infections (20%). A need for revision surgery was noted in 30% of patients. No dislocation occurred in patients undergoing osteosynthesis with acetabular reconstruction. We did not note either mechanical loosening of the acetabular component nor thromboembolic complications. In all, 30% of patients presented acute anemia requiring transfusion, and one death was reported.

Conclusion

Post-traumatic periprosthetic acetabular fractures frequently have a transverse component that can destabilize the acetabular implant. The frequency of complications, principally dislocations, led to a high rate of revision surgery. Improvements in preoperative planning should make it possible to codify management to reduce this high rate of complications. The best results were obtained when the surgical strategy combined osteosynthesis with acetabular reconstruction.