Differences in acoustic parameters of hammering sounds between successful and unsuccessful initial cementless cup press-fit fixation in total hip arthroplasty

Aims

It is important to analyze objectively the hammering sound in cup press-fit technique in total hip arthroplasty (THA) in order to better understand the change of the sound during impaction. We hypothesized that a specific characteristic would present in a hammering sound with successful fixation. We designed the study to quantitatively investigate the acoustic characteristics during cementless cup impaction in THA.

Methods

In 52 THAs performed between November 2018 and April 2022, the acoustic parameters of the hammering sound of 224 impacts of successful press-fit fixation, and 55 impacts of unsuccessful press-fit fixation, were analyzed. The successful fixation was defined if the following two criteria were met: 1) intraoperatively, the stability of the cup was retained after manual application of the torque test; and 2) at one month postoperatively, the cup showed no translation on radiograph. Each hammering sound was converted to sound pressures in 24 frequency bands by fast Fourier transform analysis. Basic patient characteristics were assessed as potential contributors to the hammering sound.

Results

The median sound pressure (SP) of successful fixation at 0.5 to 1.0 kHz was higher than that of unsuccessful fixation (0.0694 (interquartile range (IQR) 0.04721 to 0.09576) vs 0.05425 (IQR 0.03047 to 0.06803), p < 0.001). The median SP of successful fixation at 3.5 to 4.0 kHz and 4.0 to 4.5 kHz was lower than that of unsuccessful fixation (0.0812 (IQR 0.05631 to 0.01161) vs 0.1233 (IQR 0.0730 to 0.1449), p < 0.001; and 0.0891 (IQR 0.0526 to 0.0891) vs 0.0885 (IQR 0.0716 to 0.1048); p < 0.001, respectively). There was a statistically significant positive relationship between body weight and SP at 0.5 to 1.0 kHz (p < 0.001). Multivariate analyses indicated that the SP at 0.5 to 1.0 kHz and 3.5 to 4.0 kHz was independently associated with the successful fixation.

Conclusion

The frequency bands of 0.5 to 1.0 and 3.5 to 4.0 kHz were the key to distinguish the sound characteristics between successful and unsuccessful press-fit cup fixation.

Bilateral acetabular fractures (case report)

INTRODUCTION AND IMPORTANCE

Bilateral acetabular fractures are very rare. They are usually seen in the context of multiple trauma patients. This type of fracture poses a problem and difficulty in therapeutic management, sometimes resulting in serious sequelae and significant morbidity.

CASE PRESENTATION

We report a rare case of bilateral simultaneous acetabular fracture in an adult, forty-seven years old man due to a road accident.

CLINICAL DISCUSSION

Bilateral acetabular fractures are very rare. While bilateral acetabular fracture most frequently occur due to automobile accidents, other mechanism can be responsible for this injury as well. Furthermore, bilateral acetabular fractures are frequently associated with other lesions of the surrounding bones or tissues. Surgery is the most suitable treatment in most cases. The development of osteoarthritis is the most common complication of acetabular fracture and is directly related to the post-operative reduction obtained. Heterotopic ossifications are a complication associated with acetabular fracture. In acetabular fracture, the primary objective of surgical treatment is anatomical reduction of the fracture that will determinate the future of hip.

CONCLUSION

The treatment goal of acetabular fracture is anatomic or near anatomic reduction of the articular surface. The risk of osteonecrosis is mostly related to the initial injury and time to reduction.

Double Trouble: Exploring Bilateral Acetabular Fractures in a Trauma Patient

Bilateral acetabular fractures, though rare, pose significant challenges in both diagnosis and management due to their association with high-energy trauma and the potential for long-term disability. This case report presents the clinical course of a 27-year-old female who presented to our department after a motorcycle accident with bilateral acetabular fractures. Initial assessment revealed nondisplaced bilateral acetabular fractures, along with associated injuries including a right ulnar styloid fracture. Further evaluation via 3D CT scan delineated associated column fractures on the right and posterior + anterior wall fractures on the left, classified according to the Letournel and Judet system. Notably, this specific combination of acetabular fractures has not been documented in existing literature as per our investigation. The surgical intervention involved an anterior intrapelvic approach for open reduction and internal fixation (ORIF) of the right acetabulum, while the left acetabulum was managed conservatively. Postoperatively, the patient is scheduled for non-weightbearing activity until radiographic evidence of fracture healing is observed. This case underscores the importance of tailored surgical approaches and comprehensive management strategies in optimizing outcomes for patients with bilateral acetabular fractures.

Case Report: Hip arthroplasty after fracture-related joint infection caused by extensively drug-resistant Klebsiella pneumoniae

This case-report focuses on a 23-year-old soldier suffering from a fracture-related hip joint infection (FRI) due to extensively drug-resistant Klebsiella pneumoniae and S. epidermidis. The patient underwent multiple septic revision surgeries including the removal of remaining shrapnel accompanied by last-resort antimicrobial therapy with cefiderocol and colistin. Additionally, the surgeries included repeated tissue sampling for microbiological and histopathological analysis. An antibiotic-loaded cemented filler containing cefiderocol was used to improve local antimicrobial therapy. The biopsies prior to and during hip replacement surgery confirmed successful microbe eradication. Hip arthroplasty restored hip joint function and significantly improved patient's quality of life. The utilization of a trabecular metal shell and a meta-diaphyseally anchored cementless hip stem ensured secure implant fixation and early patient mobilisation. An adjusted biofilm active oral antimicrobial therapy after arthroplasty intervention was continued to prevent early periprosthetic joint infection. This case emphasizes the difficulties of managing FRI and multidrug-resistant pathogens. It contributes valuable insight into navigating complex orthopedic cases while ensuring successful hip arthroplasty outcomes. In conclusion, early interdisciplinary collaboration, appropriate antimicrobial therapy along with tailored surgical interventions are crucial for managing such complex cases successfully.

A 'traumatic' mechanical small bowel obstruction after blunt pelvic trauma

Traumatic abdominal wall hernia (TAWH) is a rare form of herniation caused by blunt trauma that can lead to intestinal obstruction. This report details a rare case of delayed mechanical ileus resulting from TAWH due to an acetabular fracture. The patient was successfully treated with laparoscopic closure of the peritoneal orifice, followed by orthopaedic repair of the fracture. The presented scenario underlines the importance of timely diagnosis and interdisciplinary collaboration in addressing complex TAWH cases.

Frequency and Characteristics of Posterior Labral Injuries in Operative Acetabular Fractures Treated Through a Posterior Approach: A Prospective Observational Study

OBJECTIVES

The association between labral injuries and acetabular fractures is unknown. This study aimed to identify the frequency and characteristics of labral injuries in operatively treated acetabular fractures that cannot be identified on preoperative imaging.

METHODS

 .

DESIGN

Prospective observational cohort.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Adult patients with an acetabular fracture operatively treated through a posterior approach.

OUTCOME MEASURES AND COMPARISONS

The frequency and characteristics of labral injuries.

RESULTS

Fifty-three of 71 acetabular fractures (75%; 95% confidence interval, 63%-83%) demonstrated a labral injury visible via the posterior approach. Posterior labral injuries occurred in 89% of operative acetabular fracture patterns involving the posterior wall and most commonly represent a detachment of the posteroinferior labrum (n = 39, 75%). Fractures with a labral injury were more likely to have gluteus minimus damage (93% vs. 61%, P = 0.02), femoral head lesions (38% vs. 17%, P = 0.03), joint capsule detachment (60% vs. 33%, P = 0.05), and fracture patterns involving the posterior wall (89% vs. 50%, P = 0.05).

CONCLUSIONS

This study describes the high rate (89%) of posterior labral injuries in posterior wall fractures, the most common injury pattern being a detachment of the posteroinferior labrum. Labral injuries in acetabular fractures may have important clinical implications and this study is the first to identify the frequency and characteristics of these injuries. Further studies should assess the relationship between labral injuries, treatment strategies, and the progression to post-traumatic osteoarthritis.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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.

Acetabular Fracture in a Skeletally Mature Patient With Osteogenesis Imperfecta Treated With Open Reduction Internal Fixation: A Case Report

Patients with osteogenesis imperfecta often present with and are managed for various fractures given the brittle bones associated with this disease. Acetabular fractures are one of the most complicated presentations and management is often strenuous on both the patient and the treating surgeon. There is a lack of evidence on how to approach these patients and not many cases reported in the literature. Open reduction and internal fixation can be successful for these patients given extra care is undergone to protect the patient's increased risk of intra-operative and post-operative complications, and a thorough understanding of the pathophysiology of this disease.

Clinical and Radiological Outcomes of Patients With Anterior Acetabulum Fractures Treated by the Modified Stoppa Approach

Introduction Acetabular fractures are intra-articular fractures involving the lower extremity's weight-bearing dome. These fractures require an anatomical reduction of the fracture fragments. This aim can be accomplished by the selection of an appropriate surgical approach. This study aimed to analyze the clinical and radiological outcomes of patients with fractures in the anterior part of the acetabulum who were treated by the modified Stoppa approach. Methods This prospective observational study was conducted from April 2022 to September 2023. The inclusion criteria were: (i) age between 18 and 70 years, (ii) displaced acetabular fracture (displacement > 3 mm), (iii) within three weeks of trauma (iv) acetabular fractures with involvement of anterior column. Exclusion criteria included: (i) patients with visceral injuries requiring colostomy, (ii) pathological fracture, (iii) open fractures of the acetabulum, and (iv) neglected fracture (more than three weeks). Intraoperative data regarding surgical time, amount of blood loss, and incidence of intraoperative complications were recorded. In the postoperative period, anteroposterior X-ray and Judet views of the pelvis X-ray were obtained. Matta criteria were used to judge the quality of Fracture reduction and fixation. All the patients to be included in this study had undergone a minimum follow-up duration of six months. At the last follow-up, an assessment of the functional outcome of the affected hip by Merle d'Aubigné Hip Score and Harris Hip Score was done. Results Twenty-four patients were included in the study. The mean patient age was 36.08±11.65 years. Eighteen patients were male (75%) and six patients were female in this study. All acetabular fractures were due to high-energy trauma: road traffic accidents in 22 cases (91%) and fall from height in two cases (9%). According to Judet & Letournel's classification, there were 13 T-type fractures, five transverse fractures, and six associated both column fractures. The mean duration of surgery was 152.08 ±29.19 minutes, and the mean intraoperative blood loss was 277.08±85.95 ml. Intraoperatively one unit of blood transfusion was done in most cases. There were intraoperative complications of rent in the external iliac vein in two patients. Postoperative X-rays showed anatomical reduction in 17 cases, imperfect reduction in five cases, and poor reduction in two cases. Functional outcome of the hip by Merle d'Aubigné Hip Score was very good in 15, good in four, fair in three, and poor in two patients. Similar functional outcomes were obtained with the Harris Hip Score. Conclusion The results of the current study demonstrated that the modified Stoppa approach allows good visualization of the pelvic brim, quadrilateral surface, and posterior column. Lesser experienced orthopedic surgeons should utilize this approach to get good radiological and functional outcomes.

Dome impaction classification in acetabular fractures: Identifying atypical dome impactions with absence of the gull sign: A retrospective descriptive study

We aimed to describe variations of dome impaction fractures and their characteristics using a new classification system, to explore the relationship between dome impaction and the gull sign. The present study was a retrospective descriptive study. All 104 cases of acetabular fracture that were treated in our institution from 2013 to 2022 were enrolled. Of these, 22 had dome impaction fractures. The primary outcome variable was to describe the variations and characteristics of dome impaction fractures. They were classified into 3 major subgroups based on reconstructed axial, coronal, and sagittal computed tomography findings: anteromedial, superomedial (SM), and posteromedial. The secondary outcome variable was to explore the relationship between dome impaction on computed tomography findings and the gull sign on plain radiographs. There were 4 cases of anteromedial (18.2%), 13 of SM (59.1%), and 5 of posteromedial (22.7%). There were 15 cases (68.2%) with the gull sign and 7 cases (31.8%) without the gull sign on plain radiographs. Twelve of fifteen cases (80.0%) with the gull sign had dome impaction fractures of the SM type. We found a variety of patterns of dome impaction fracture. Surgeons should be aware of atypical dome impactions not showing the gull sign.

Comparison of primary total hip arthroplasty with limited open reduction and internal fixation vs open reduction and internal fixation for geriatric acetabular fractures: a systematic review and meta-analysis

Purpose

Comminuted fractures with poor bone quality in the elderly are associated with poor outcomes. An alternative to open reduction and internal fixation (ORIF) alone, primary or acute total hip arthroplasty (aTHA), allows early mobilization with full weight bearing. In this study, we aim to analyze whether treatment of aTHA with/withtout ORIF (limited ORIF) vs ORIF alone yields better intra-operative results, functional outcomes, and less complications.

Methods

PubMed, Cochrane, Embase, and Scopus databases were searched in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Random-effects model and 95% confidence intervals were used. The outcomes of interest were surgery time, blood loss, length of hospital stay, Harris hip score (HHS), 36-Item Short Form Survey (SF-36), complication rate, surgical site infection rate, heterotopic ossification rate, reoperation rate, and mortality rate.

Results

Ten observational studies with a total of 642 patients (415 ORIF alone and 227 aTHA with/without ORIF) were included in the systematic review. Compared to ORIF alone, aTHA with limited ORIF provided higher HHS (P = 0.029), better physical function (P = 0.008), better physical component summary (P = 0.001), better mental component summary (P = 0.043) in postoperative 1-year SF-36, lesser complication rate (P = 0.001), and lesser reoperation rate (P = 0.000), but however greater bodily pain (P = 0.001) in acetabular fractured elderlies.

Conclusions

Acute THA with limited ORIF is favorable alternative to ORIF technique alone. It provided better HHS, physical, and mental component summary in SF-36 and yielded lower complication and reoperation rate compare to ORIF alone.

Analysis of predictive factors for post-traumatic osteoarthritis and poor outcomes in acetabular fractures treated surgically

OBJECTIVE

The aims of this study were (i) to assess the radiological and functional outcomes of surgically treated displaced acetabular fractures and (ii) to analyze the predictive factors of poor outcomes following surgery.

METHODS

A total of 119 patients (24 female, 95 male) who were operated between 2009 and 2019 were included in the study. The mean age was 47.5 years (range=18-61). The mean follow-up was 92.3 months (range=24-120). Failure to preserve the biological hip joint, as treated with total hip replacement or the Girdlestone procedure, was defined as a poor outcome. Patients' demographic information, comorbidities, fracture types, surgical approach, concomitant injuries, reduction quality, and complications were analyzed. Computed tomography was utilized to evaluate the fracture type and quality of reduction. Factors affecting poor outcomes were analyzed by logistic regression analysis. The modified Harris Hip Score was also used to evaluate the functional status.

RESULTS

The poor outcome rate was 10.1%. Multivariate logistic regression analysis revealed that dislocation (odds ratio: 44.87, confi- dence interval: 3.18-633.22, P=.005), wound site problems (odds ratio: 9.09, confidence interval: 1.01-81.12, P=.04), reduction quality (odds ratio: 77.88, confidence interval: 5.95-1019.07, P = .001), and diabetes (odds ratio: 7.29, confidence interval: 1.01-52.07, P = .04) were associated with poor outcomes. Eight of the 12 patients with poor outcomes had a fair Harris Hip Score, and 4 had a poor Harris Hip Score. The relationship between poor outcomes and Harris Hip Score was found to be significant (P < .001).

CONCLUSION

For a favorable functional outcome in acetabular fractures, preservation of the biological hip joint should be a top priority. The accompanying dislocation and the patient's diabetes appear to be uncontrollable factors for the poor prognosis. Good reduction qual- ity and wound infection protection are modifiable factors.

LEVEL OF EVIDENCE

Level IV, Therapeutic Study.

The great pretender: Multi-system tuberculosis and pathological fracture masquerading as a severe acute football groin injury - Case study with a 5-year follow-up

In this clinical case, a man presented with a groin injury on his dominant side, which he apparently sustained in football (soccer) practice on the previous day. The man was unable to walk unassisted and had to be transported in a wheelchair. The consulting practitioner grew suspicious upon finding minimal clinical evidence and nothing notable on the X-ray to suggest a severe acute injury. A subsequent detailed workup revealed extrapulmonary tuberculosis (EPTB) of the musculoskeletal (MSK) and genitourinary tract (GUT) systems, complicated by a pathological fracture of the acetabulum, as the cause of the groin injury. Management of the EPTB resolved the condition with no relapse nor long-term sequelae beyond five years, despite being immunocompromised. We present the clinical case and a five year follow-up. The case serves as a reminder of the possibility that other conditions may mimic sports injuries and further illustrates a rare presentation of such a condition.

Erectile dysfunction after acetabular fracture

Objectives

To determine the rate of erectile dysfunction in male patients who have sustained an acetabular fracture with no previously identified urogenital injury.

Design

Cross-sectional survey.

Setting

Level 1 Trauma Center.

Patients/Participants

All male patients treated for acetabular fracture without urogenital injury.

Intervention

The International Index of Erectile Function (IIEF), a validated patient-reported outcome measure for male sexual function, was administered to all patients.

Main Outcome Measurements

Patients were asked to complete the International Index of Erectile Function score for both preinjury and current sexual function, and the erectile function (EF) domain was used to quantify the degree of erectile dysfunction. Fractures were classified according the OTA/AO classification schema, fracture classification, injury severity score, race, and treatment details, including surgical approach were collected from the database.

Results

Ninety-two men with acetabular fractures without previously diagnosed urogenital injury responded to the survey at a minimum of 12 months and an average of 43 ± 21 months postinjury. The mean age was 53 ± 15 years. 39.8% of patients developed moderate-to-severe erectile dysfunction after injury. The mean EF domain score decreased 5.02 ± 1.73 points, which is greater than the minimum clinically important difference of 4. Increased injury severity score and associated fracture pattern were predictive of decreased EF score.

Conclusion

Patients with acetabular fractures have an increased rate of erectile dysfunction at intermediate-term follow-up. The orthopaedic trauma surgeon treating these injuries should be aware of this as a potential associated injury, ask their patients about their function, and make appropriate referrals.

Level of Evidence

III.

Risk of Revision and Complications after Total Hip Arthroplasty for Acute Treatment of Acetabular Fracture

BACKGROUND

Total hip arthroplasty (THA) for the treatment of acute acetabular fractures may be indicated where there is high risk for failure of open reduction and internal fixation. This study aimed to determine risks of revision and rates of major complications of THA for acute acetabular fractures.

METHODS

A retrospective review was performed (all-claims data files of a large national database) by querying International Classification of Disease, tenth revision procedure codes for THA within 14 days of acetabular fracture. We identified all-cause revision and surgical complications including dislocations, mechanical failures (loosenings or broken prostheses), infections, as well as medical complications. Demographic data collected included age, sex, obesity and Charlson Comorbidity Index (CCI). Multivariate analyses evaluated the association of revision and major surgical complications after adjusting for demographic characteristics and comorbidities. We identified 956 THAs for the treatment of acute acetabular fracture from 2015 to 2020. Of all acute acetabular fractures treated with THA, 241 were concomitant with ORIF, and 715 were THA alone.

RESULTS

All-cause revision risk was 18.2%, overall major surgical complication rate 26.9%, and medical complication rate was 13.2%. Women were associated with increased risk of revision (adjusted Odds Ratio (aOR) 1.8; Confidence Interval (CI) 1.3-2.6, P=0.001), dislocation (aOR 2.0; CI 1.5-3.1, P<0.001), mechanical complication (aOR 2.1; CI 1.4-3.2, P<0.001), and infection (aOR 1.6; CI 1.0-2.5, P=0.044).

CONCLUSION

We noted risk of all-cause revision of 18.2%, overall major surgical complication rate of 26.9%, and overall major medical complication rate of 13.2% for THA as the treatment of acute acetabular fracture. We caution against broad expansion of THA for treatment of acute acetabular fractures. Furthermore, increased risks of revision and complications in women warrant additional investigation into patient and fracture characteristics that may contribute to this finding.

Both-Column Acetabular Fractures: Does Surgical Approach Vary Based on Using Virtual 3D Reconstructions?

Displacement of the anterior and posterior column complicates decision making for both-column acetabular fractures. We questioned whether pelvic surgeons agree on treatment strategy, and whether the use of virtual 3D reconstructions changes the treatment strategy of choice. A nationwide cross-sectional survey was performed in all pelvic trauma centers in the Netherlands. Twenty surgeons assessed 15 both-column fractures in 2D as well as 3D. Based on conventional imaging, surgical treatment was recommended in 89% of cases, and by adding 3D reconstructions this was 93% (p = 0.09). Surgical approach was recommended as anterior (65%), posterior (8%) or combined (27%) (poor level of agreement, κ = 0.05) based on conventional imaging. The approach changed in 37% (p = 0.006), with most changes between a combined and anterior approach (still poor level of agreement, κ = 0.13) by adding 3D reconstructions. Additionally, surgeons' level of confidence increased from good in 38% to good in 50% of cases. In conclusion, surgeons do not agree on the treatment strategy for both-column acetabular fractures. Additional information given by 3D reconstructions may change the chosen surgical approach and increase surgeons' confidence about their treatment decision. Therefore, virtual 3D reconstructions are helpful for assessing both-column fracture patterns and aid in the choice of treatment strategy.

[Surgical technique and effectiveness of titanium elastic nail assisted retrograde channel screw implantation in superior pubic branch]

Objective

To investigate the surgical technique and effectiveness of titanium elastic nail (TEN) assisted retrograde channel screw implantation of superior pubic branch.

Methods

The clinical data of 31 patients with pelvic or acetabular fractures treated with retrograde channel screw implantation in superior pubic branch between January 2021 and April 2022 were retrospectively analyzed. Among them, 16 cases were implanted with assistance of TEN (study group) and 15 cases were implanted under the guidance of C-arm X-ray machine (control group). There was no significant difference in gender, age, cause of injury, Tile classification of pelvic fracture, Judet-Letournal classification of acetabular fracture, and time from injury to operation between the two groups ( P>0.05). The operation time, fluoroscopy times, and intraoperative blood loss of each superior pubic branch retrograde channel screw were recorded during operation. X-ray films and three-dimensional CT were reexamined after operation, the quality of fracture reduction was evaluated by Matta score standard, and the position of channel screw was evaluated by screw position classification standard. The fracture healing time was recorded during the follow-up, and the postoperative functional recovery was evaluated by Merle D'Aubigne Postel score system at last follow-up.

Results

Nineteen and 20 retrograde channel screws of superior pubic branch were implanted in the study group and the control group, respectively. The operation time, fluoroscopy times, and intraoperative blood loss of each screw in the study group were significantly less than those in the control group ( P<0.05). According to the postoperative X-ray films and three-dimensional CT, none of the 19 screws in the study group penetrated out of the cortical bone or into the joint, and the excellent and good rate was 100% (19/19); in the control group, there were 4 screws of cortical bone penetration, and the excellent and good rate was 80% (16/20); the difference between the two groups was significant ( P<0.05). Matta score standard was used to evaluate the quality of fracture reduction, there was no patient in the two groups with poor reduction results, and the difference was not significant between the two groups ( P>0.05). The incisions of the two groups healed by first intention, and there was no complication such as incision infection, skin margin necrosis, and deep infection. All patients were followed up 8-22 months, with an average of 14.7 months. There was no significant difference in healing time between the two groups ( P>0.05). At last follow-up, the difference in functional recovery evaluated by the Merle D'Aubigne Postel scoring system between the two groups was not significant ( P>0.05).

Conclusion

TEN assisted implantation technique can significantly shorten the operation time of retrograde channel screw implantation of superior pubic branch, reduce the times of fluoroscopy, and have less intraoperative blood loss and accurate screw implantation, which provides a new safe and reliable method for minimally invasive treatment of pelvic and acetabular fractures.

Application of an Intraoperative Limb Positioner for Adjustable Traction in Both-Column Fractures of the Acetabulum: A Technical Note with Clinical Outcome

Traction of the ipsilateral leg is usually required to facilitate fracture reduction while operating both-column acetabular fractures. However, it is challenging to maintain constant traction manually during the operation. Herein, we surgically treated such injuries while maintaining traction using an intraoperative limb positioner and investigated the outcomes. This study included 19 patients with both-column acetabular fractures. Surgery was performed after the patient's condition had stabilized, at an average of 10.4 days after injury. The Steinmann pin was transfixed to the distal femur and connected to a traction stirrup; subsequently, the construct was affixed to the limb positioner. A manual traction force was applied through the stirrup and maintained with the limb positioner. Using a modified Stoppa approach combined with the lateral window of the ilioinguinal approach, the fracture was reduced, and plates were applied. Primary union was achieved in all cases at an average of 17.3 weeks. The quality of reduction at the final follow-up was found to be excellent, good, and poor in 10, 8, and 1 patients, respectively. The average Merle d'Aubigné score at the final follow-up was 16.6. Surgical treatment of both-column acetabular fracture using intraoperative traction with a limb positioner yields satisfactory radiological and clinical outcomes.

Third-Generation Dynamic Anterior Plate-Screw System for Quadrilateral Fractures: Digital Design Based on 834 Pelvic Measurements

Background and Objectives: To investigate the digital measurement method for the plate trajectory of dynamic anterior plate-screw system for quadrilateral plate (DAPSQ), and then design a third-generation DAPSQ plate that conforms to the needs of the Chinese population through collating a large sample anatomical data. Materials and Methods: Firstly, the length of the pubic region, quadrilateral region, iliac region, and the total length of the DAPSQ trajectory were measured by a digital measurement approach in 22 complete pelvic specimens. Then, the results were compared with the direct measurement of pelvic specimens to verify the reliability of the digital measurement method. Secondly, 504 cases (834 hemilateral pelvis) of adult pelvic CT images were collected from four medical centers in China. The four DAPSQ trajectory parameters were obtained with the digital measurement method. Finally, the third-generation DAPSQ plate was designed, and its applicability was verified. Results: There was no statistically significant difference in the four trajectory parameters when comparing the direct measurement method with the digital measurement method (p > 0.05). The average lengths of the pubic region, quadrilateral region, iliac region, and the total length in Chinese population were (60.96 ± 5.39) mm, (69.11 ± 5.28) mm, (84.40 ± 6.41) mm, and (214.46 ± 10.15) mm, respectively. Based on the measurement results, six models of the DAPSQ plate including small size (A1,A2), medium size (B1,B2), and the large size (C1,C2) were designed. The verification experiment showed that all these six type plates could meet the requirement of 94.36% cases. Conclusions: A reliable computerized method for measuring irregular pelvic structure was proposed, which not only provided an anatomical basis for the design of the third-generation DAPSQ plate, but also provided a reference for the design of other pelvic fixation devices.

Spring Plates as a Valid Additional Fixation in Comminuted Posterior Wall Acetabular Fractures: A Retrospective Multicenter Study

BACKGROUND

The posterior wall fracture is the most frequent pattern of acetabular fractures. Many techniques of fixation have been described in the literature and involve plates, screws, or a combination of both. This study aims to investigate the clinical and radiological outcomes of spring plates in the treatment of comminuted posterior wall acetabular fractures. (2) Methods: A retrospective multicenter (four level I trauma centers) observational study was performed. Patients with a comminuted posterior wall acetabular fracture treated with a spring plate (DePuy Synthes, West Chester, PA) were included. Diagnosis was made according to the Judet and Letournel classification. Diagnosis was confirmed with plain radiographs in an antero-posterior view and Judet views, iliac and obturator oblique views, and thin-slice CT with multiplanar reconstructions. (3) Results: Forty-six patients (34 males and 12 females) with a mean age of 51.7 years (range 19-73) were included. The most common mechanism of injury was motor vehicle accident (34 cases). In all cases, spring plates were placed under an overlapping reconstruction plate. The mean follow-up was 33.4 months (range 24-48). The mean period without weight-bearing was 4.9 weeks (range 4-7), and full weight-bearing was allowed at an average of 8.2 weeks (range 7-11) after surgery. (4) Conclusions: According to the present data, spring plates can be considered a viable additional fixation of the posterior wall acetabular fractures.

Current indications for acute total hip arthroplasty in older patients with acetabular fracture: Evidence in 601 patients from 2002 to 2021

Purpose

Older patient population with acetabular fractures is increasing rapidly, requiring enhanced recovery. Acute total hip arthroplasty (THA) is a good option for these patients, and it is becoming increasing popular. However, acute THA has different indications in different studies. Therefore, a systematic review is needed to assess and comprehend the indications for acute THA in older patients.

Methods

A systematic literature review was conducted to identify a retrospective series or prospective studies in older patients (>60 years) with acetabular fractures. The search timeline was from database construction till December 2021; PubMed, Embase, and Cochrane Library databases were searched. Two trained professional reviewers independently read the full text of documents that met the inclusion criteria and extracted information on the specific methods used and indication information based on the research design.

Results

In total, there were 601 patients with acetabular fractures aged >60 years from 33 studies were obtained. Twenty-eight studies reported that THA was a feasible treatment option for acetabular fractures in geriatric patients with good outcome. The primary indications were dome impaction, irreducible articular comminution, femoral head injury, and pre-existing osteoarthritis or avascular necrosis. The most common patterns were anterior column and posterior hemitransverse, posterior wall, both columns, and T-type.

Conclusion

Acute THA is an effective treatment strategy for older patients with acetabular fractures and should be considered when the abovementioned indications are observed on preoperative images. (PROSPERO: CRD42022329555).

Development and validation of a deep learning-based model to distinguish acetabular fractures on pelvic anteroposterior radiographs

Objective: To develop and test a deep learning (DL) model to distinguish acetabular fractures (AFs) on pelvic anteroposterior radiographs (PARs) and compare its performance to that of clinicians. Materials and methods: A total of 1,120 patients from a big level-I trauma center were enrolled and allocated at a 3:1 ratio for the DL model's development and internal test. Another 86 patients from two independent hospitals were collected for external validation. A DL model for identifying AFs was constructed based on DenseNet. AFs were classified into types A, B, and C according to the three-column classification theory. Ten clinicians were recruited for AF detection. A potential misdiagnosed case (PMC) was defined based on clinicians' detection results. The detection performance of the clinicians and DL model were evaluated and compared. The detection performance of different subtypes using DL was assessed using the area under the receiver operating characteristic curve (AUC). Results: The means of 10 clinicians' sensitivity, specificity, and accuracy to identify AFs were 0.750/0.735, 0.909/0.909, and 0.829/0.822, in the internal test/external validation set, respectively. The sensitivity, specificity, and accuracy of the DL detection model were 0.926/0.872, 0.978/0.988, and 0.952/0.930, respectively. The DL model identified type A fractures with an AUC of 0.963 [95% confidence interval (CI): 0.927-0.985]/0.950 (95% CI: 0.867-0.989); type B fractures with an AUC of 0.991 (95% CI: 0.967-0.999)/0.989 (95% CI: 0.930-1.000); and type C fractures with an AUC of 1.000 (95% CI: 0.975-1.000)/1.000 (95% CI: 0.897-1.000) in the test/validation set. The DL model correctly recognized 56.5% (26/46) of PMCs. Conclusion: A DL model for distinguishing AFs on PARs is feasible. In this study, the DL model achieved a diagnostic performance comparable to or even superior to that of clinicians.

Total hip arthroplasty for posttraumatic osteoarthritis secondary to acetabular fracture: An evidence based on 1,284 patients from 1970 to 2018

BACKGROUND

Posttraumatic osteoarthritis (PTOA) can be a crippling sequela of acetabular fracture (AF), and total hip arthroplasty (THA) is often necessary to alleviate the clinical progression of symptoms. The purpose of this study was to summarize the existing clinical evidence concerning the surgical management of AF with THA through meta-analyses.

METHODS

Databases were searched for articles published between 1995 and January 2022 that contained the keywords "acetabular," "fracture," "arthroplasty," and "osteoarthritis." Our study was registered in PROSPERO under number CRD42022314997.

RESULTS

We screened 3,125 studies and included data from 31 studies with 1,284 patients. The median patient age at the time of THA was 52 years and ranged from 19 to 94 years. The pooled overall survival rate was 88% [86%-90%, 95% confidence interval (CI)] and could reach 83% at ≥15-year follow-up. For the Harris Hip Score, we pooled 22 studies with an overall mean difference of 43.25 (40.40-46.10, 95% CI; P < 0.001), indicating a large clinical effect. The pooled complications (incidence rates) across studies were: heterotopic ossification (22.53%), implant dislocation (4.66%), implant infection (3.44%), and iatrogenic nerve injury (1.07%).

CONCLUSION

THA in patients with PTOA following AF leads to significant improvement in symptoms and function at ≥15-year follow-up. Survival rates of implants free from re-operation or revision after THA decreased with follow-up time and could still reach 83% at ≥15-year follow-up. THA might be an effective therapeutic method for patients with PTOA due to AF.

Fracture-Related Infection in Bicolumnar Acetabular Fracture: A Case Report

Case: A 51-year-old man was affected by a fracture-related infection after a bicolumnar acetabular fracture. A significant alteration of the anatomy was present; thus, a 3D-printed model was useful for planning. A two-stage treatment was planned: in the first stage, implant removal with irrigation and debridement was performed, while in the second stage, a new osteosynthesis and implant of a THA were planned. During the second stage, the patient suffered a cardiogenic shock, so a third surgical procedure was necessary to implant THA. Targeted antibiotic therapy was administered eight weeks after the first stage, with the resolution of the infection. Conclusions: The infection was resolved following the recent guidelines and treating it like a periprosthetic infection with a two-stage revision. A collaboration between specialists in orthopaedics and infectious disease, respectively, and using multidisciplinary approach, were mandatory.

Revision of a Failed Primary Total Hip Arthroplasty following Excessive Reaming with a Medial Cup Protrusion

Background and Objectives: Atraumatic intrapelvic protrusion of the acetabular component following excessive reaming of the acetabulum with a far medial positioning of the cup is a rare, but serious complication of a total hip arthroplasty (THA). This study analyzes the factors contributing to this uncommon complication and presents the outcome after the revision surgery using the Ganz reinforcement ring combined with a bone graft and plating of the posterior column and/or screws for the anterior column. Materials and Methods: A retrospective case series study with seven patients (four males, mean age 76 ± 10 years (60−86)) that underwent a revision THA within 24 ± 17 days (5−60) after an atraumatic periprosthetic acetabular fracture with a medial cup protrusion was performed. All fractures were reconstructed with a Ganz reinforcement ring and bone graft with a mean follow-up of 1.7 ± 1.7 years (0.5−5). Radiographs were evaluated for the following: (i) cup positioning immediately after the primary THA and the revision surgery, (ii) cup migration in the follow-up, and (iii) fracture healing. Results: The position of the acetabular component as assessed on the postoperative radiographs after the index surgery and before the complete medial cup protrusion showed a cup placement beyond the ilioischial line indicative of a fracture of the medial wall. The revision surgery with the reconstruction of the medial wall with a Ganz reinforcement ring combined with a bone graft restored in the presented cases the center of rotation in the horizontal direction with a statistical significance (p < 0.05). During the follow-up, there was no aseptic loosening with the relevant cup migration or significant change in the position of the acetabular cup at the final follow-up (p > 0.05) after the revision. All seven fractures and bone grafts realized a bone union until the latest follow-up. Conclusions: Following excessive reaming, the acetabular component was placed too far medially and resulted in an intrapelvic cup protrusion. An unstable cup following a fracture of the medial wall was evident on the immediate postoperative radiographs. In the case of the medial wall perforation with an intrapelvic cup protrusion after the primary THA, the reconstruction with a Ganz reinforcement ring was a successful treatment option resulting in the fracture healing and a stable cup positioning. Surgeons should be aware of that rare and probably underreported complication and restore the anatomic center of rotation by treating the defect intraoperatively.

Quantitative Three-Dimensional Measurements of Acetabular Fracture Displacement Could Be Predictive for Native Hip Survivorship

This study aims to develop a three-dimensional (3D) measurement for acetabular fracture displacement, determine the inter- and intra-observer variability, and correlate the measurement with clinical outcome. Three-dimensional models were created for 100 patients surgically treated for acetabular fractures. The ‘3D gap area’, the 3D surface between all the fracture fragments, was developed. The association between the 3D gap area and the risk of conversion to a total hip arthroplasty (THA) was determined by an ROC curve and a Cox regression analysis. The 3D gap area had an excellent inter-observer and intra-observer reliability. The preoperative median 3D gap area for patients without and with a THA was 1731 mm2 versus 2237 mm2. The median postoperative 3D gap area was 640 mm2 versus 845 mm2. The area under the curve was 0.63. The Cox regression analysis showed that a preoperative 3D gap area > 2103 mm2 and a postoperative 3D gap area > 1058 mm2 were independently associated with a 3.0 versus 2.4 times higher risk of conversion to a THA. A 3D assessment of acetabular fractures is feasible, reproducible, and correlates with clinical outcome. Three-dimensional measurements could be added to the current classification systems to quantify the level of fracture displacement and to assess operative results.

[Orthopedic robot based on 5G technology for remote navigation of percutaneous screw fixation in pelvic and acetabular fractures]

Objective

To investigate the accuracy and safety of percutaneous screw fixation for pelvic and acetabular fractures with remote navigation of orthopedic robot based on 5G technology.

Methods

Between January 2021 and December 2021, 15 patients with pelvic and/or acetabular fractures were treated with percutaneous screws fixation which were placed by remote navigation of orthopedic robot based on 5G technology. There were 8 males and 7 females. The age ranged from 20 to 98 years, with an average of 52.1 years. The causes of trauma included traffic accident injury in 6 cases, falling from height injury in 6 cases, fall injury in 2 cases, and heavy object smashing injury in 1 case. The time from injury to operation ranged from 3 to 32 days, with an average of 10.9 days. There were 8 cases of simple pelvic fractures, 2 simple acetabular fractures, and 5 both pelvic and acetabular fractures. There were 7 cases of pelvic fractures of Tile type B2, 2 type B3, 1 type C1, and 3 type C2; 4 cases of unilateral anterior column fracture of the acetabulum, 2 bilateral anterior column fractures, and 1 anterior wall fracture. CT images within 5 days after operation were collected for screw position assessment. The screw planning time and guidewire placement time were recorded, as well as the presence of intraoperative adverse events and complications within 5 days after operation.

Results

All patients achieved satisfactory surgical results. A total of 36 percutaneous screws were inserted (20 sacroiliac screws, 6 LC Ⅱ screws, 9 anterior column screws, and 1 acetabular apical screw). In terms of screw position evaluation, 32 screws (88.89%) were excellent and 4 screws (11.11%) were good; there was no screw penetrating cortical bone. The screw planning time ranged from 4 to 15 minutes, with an average of 8.7 minutes. The guidewire placement time ranged from 3 to 10 minutes, with an average of 6.8 minutes. The communication delayed in 2 cases, but the operation progress was not affected, and no serious intraoperative adverse events occurred. No delayed vascular or nerve injury, infection, or other complications occurred within 5 days after operation. No cases need surgical revision.

Conclusion

The fixation of pelvic and acetabular fractures by percutaneous screw with remote navigation of orthopedic robot based on 5G technology is accurate, safe, and reliable.

The effect of tranexamic acid in open reduction and internal fixation of pelvic and acetabular fracture: A systematic review and meta-analysis

BACKGROUND

Pelvic bone fractures may cause extensive bleeding; however, the efficacy of tranexamic acid (TXA) usage in pelvic fracture surgery remains unclear. In this systematic review and meta-analysis, we aimed to evaluate the efficacy of TXA in open reduction and internal fixation surgery for pelvic and acetabular fracture.

METHODS

MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before April 22, 2020, that investigated the effect of TXA in the treatment of pelvic and acetabular fracture with open reduction and internal fixation. A pooled analysis was used to identify the differences between a TXA usage group and a control group in terms of estimated blood loss (EBL), transfusion rates, and postoperative complications.

RESULTS

We included 6 studies involving 764 patients, comprising 293 patients who received TXA (TXA group) and 471 patients who did not (control group). The pooled analysis showed no differences in EBL between the groups (mean difference -64.67, 95% confidence interval [CI] -185.27 to -55.93, P = .29). The study period transfusion rate showed no significant difference between the groups (odds ratio [OR] 0.77, 95% CI 0.19-3.14, P = .71, I2 = 82%), nor in venous thromboembolism incidence (OR 1.53, 95% CI 0.44-5.25, P = .50, I2 = 0%) or postoperative infection rates (OR 1.15, 95% CI 0.13-9.98, P = .90, I2 = 48%).

CONCLUSIONS

Despite several studies having recommended TXA administration in orthopedic surgery, our study did not find TXA usage to be more effective than not using TXA in pelvic and acetabular fracture surgery, especially in terms of EBL reduction, transfusion rates, and the risk of postoperative complications.

Acetabular fractures treatment needs in the elderly and nonagenarians

Different treatment options for acetabular fractures in the elderly and nonagenarians exist; a consistent guideline has not been established, yet. The purpose of this study is to give an overview of how those fractures can be handled and compares two different surgical treatment methods. A total of 89 patients ≥ 18 years between 2016 and 2021 with acetabular fractures in our department received a surgical intervention with plate fixation via the Stoppa approach or a total hip arthroplasty with a Burch-Schneider ring and integrated cup. 60 patients ≥ 65 were compared in two groups, 29 patients between 65 and 79 and 31 patients ≥ 80. For comparison, data on operation times, hospitalization, complications during operation and hospital stay, blood loss and postoperative mobilization were collected. Characteristics could be found for indications for operative osteosynthesis or endoprosthetics based on the X-ray analysis. There was a tendency to treat simple fractures with osteosynthesis. Patients between 65 and 79 with an osteosynthesis had benefits in almost every comparison. Patients ≥ 80 with a plate fixation had advantages in the categories of postoperative complications, blood loss and transfusion of erythrocyte concentrates. Statistical significant differences were noticed in both groups regarding the operation time. Patients between 65 and 79 with osteosynthesis had significant benefits for postoperative complications, hospitalization, number of blood transfusions and postoperative mobilization. Finding the best supportive treatment option is difficult, and decision-making must respect fracture patterns and individual risk factors. This study shows that plate fixation via the Stoppa approach has some benefits.

Which Pelvic Fractures Are Associated With Extravasation on Angiography?

BACKGROUND

Bleeding from pelvic fractures can result in a high mortality rate unless quickly triaged by the trauma surgeon. Upon presentation, pelvic radiography may identify fractures that require angiography with possible embolization. We sought to address which fracture patterns seen on initial x-ray are associated with extravasation on angiography.

METHODS

Data from a single institution retrospective review were collected on trauma patients admitted from 2011 to 2018 with pelvic fractures that required angiography. These fractures were identified by initial pelvic x-ray in the trauma bay and include anteroposterior compression (APC), lateral compression (LC), vertical shear (VS), and combined mechanism (CM) fractures, which are graded by severity. Fracture patterns high risk for bleeding, defined as APC II, APC III, LC III, VS, and CM, were compared to low-risk fracture patterns.

RESULTS

Of the patients reviewed, 28 underwent pelvic angiography, 16 (57%) of which had extravasation. The difference in the incidence of extravasation between high and low-risk fracture patterns did not reach significance (36% vs 79%, P = .05). When comparing patients with acetabular fractures to those without, there was a significantly higher rate of extravasation associated with acetabular fractures (89% vs 42%, P value = .04), which were more likely to occur with LC I fractures (56% vs 11%, P = .02).

CONCLUSION

Our data suggest that traditional pelvic fracture patterns may overestimate the presence of extravasation. Acetabular fractures had a high rate of extravasation, suggesting that these fractures should be considered for early angiography with possible embolization when clinically warranted.

Sciatic nerve injury after acetabular fractures: a meta-analysis of incidence and outcomes

PURPOSE

To investigate the incidence and the outcome of post-traumatic and iatrogenic sciatic nerve palsy (SNP) associated with fractures of the acetabulum. The results of sciatic nerve grafting for treatment were also investigated.

METHODS

PUBMED, SCOPUS and COCHRANE databases were searched for longitudinal observational studies reporting sciatic nerve palsy related to acetabular fractures in adult patients over the last 20 years. Data regarding patients demographics, type of acetabular fracture, rate of post traumatic and iatrogenic sciatic nerve palsies as well as recovery rate are reported. Studies were assessed for their quality. Random effects meta-analyses were carried out to pool overall proportions of SNP incidence and complete recovery. Variations in SNP incidence by main study characteristics were assessed by subgroup analysis and meta-regression. A narrative review of sciatic nerve grafting was also conducted.

RESULTS

Twenty studies reporting 44 post-operative and 18 iatrogenic SNPs in 651 patients were reviewed. The pooled incidence of posttraumatic SNP was 5.1% (95% CI 2.7-8.2%). The pooled incidence of iatrogenic SNP was 1.4% (95% CI 0.3-2.9%). Complete recovery of post-traumatic and iatrogenic SNP occurred in 64.7% (95% CI 41.7-85.4%) and 74.1% (95% CI 31.5-100%), respectively.

CONCLUSION

A favorable outcome of both post-traumatic and iatrogenic SNP related to acetabular fractures has been found. Due to the poor results of sciatic nerve grafting, a "wait and see" approach may be the best option, in cases of a contused but anatomically intact sciatic nerve.

Algorithm Improves Acetabular Fracture Radiograph Interpretation Among Inexperienced Practitioners

Acetabular fractures are often first evaluated in the emergency department, where physicians with little experience reading pelvic radiographs may be required to make an accurate diagnosis and early management decisions. In this study, medical students classified radiographs of 20 acetabular fractures and repeated the exercise three weeks later with the aid of a previously described algorithm; half the students were given a lesson prior to using the algorithm. The pre-algorithm accuracy was 4/20 and the post-algorithm accuracy was 8.3/20 (p<0.01). The lesson provided no difference (p=0.5). This algorithm is therefore a useful reference to help classify and triage acetabular fractures.

Minimizing misclassification bias with a model to identify acetabular fractures using health administrative data: A cohort study

Acetabular fractures (AFs) are relatively uncommon thereby limiting their study. Analyses using population-based health administrative data can return erroneous results if case identification is inaccurate ('misclassification bias'). This study measured the impact of an AF prediction model based exclusively on administrative data upon misclassification bias.We applied text analytical methods to all radiology reports over 11 years at a large, tertiary care teaching hospital to identify all AFs. Using clinically-based variable selection techniques, a logistic regression model was created.We identified 728 AFs in 438,098 hospitalizations (15.1 cases/10,000 admissions). The International Classification of Disease, 10th revision (ICD-10) code for AF (S32.4) missed almost half of cases and misclassified more than a quarter (sensitivity 51.2%, positive predictive value 73.0%). The AF model was very accurate (optimism adjusted R2 0.618, c-statistic 0.988, calibration slope 1.06). When model-based expected probabilities were used to determine AF status using bootstrap imputation methods, misclassification bias for AF prevalence and its association with other variables was much lower than with International Classification of Disease, 10th revision S32.4 (median [range] relative difference 1.0% [0%-9.0%] vs 18.0% [5.4%-75.0%]).Lone administrative database diagnostic codes are inadequate to create AF cohorts. The probability of AF can be accurately determined using health administrative data. This probability can be used in bootstrap imputation methods to importantly reduce misclassification bias.

Case Report on Locked Pubic Symphysis with Concomitant Ipsilateral Acetabular Fracture

Background

Locked pubic symphysis or overlapping symphysis is a rare injury which happens when a pubic bone displaces behind the contra lateral pubic rami. It usually arises from lateral compression injuries. In this case report, we try to share our experience on the operative fixation of locked pubic symphysis and concomitant ipsilateral acetabular fracture.

Case Presentation

A 24-year-old male patient presented after a road traffic accident with lateral compression injury to the pelvis. He was found to have locked pubic symphysis, right side transverse acetabular, and right side closed tibial fracture. He was taken to the operation theater 10 days later after he was managed for the additional chest contusion he had. Successful open reduction and plate fixation of the overlapped symphysis and percutaneous screw fixation of the ipsilateral acetabulum were done at the same time. An intramedullary nail was inserted for the tibial fracture.

Conclusion

Locked symphysis is a rare trauma and even more complex when associated with acetabular fracture. Both situations may happen at the same time and could be managed operatively.

Prediction of fracture initiation and propagation in pelvic bones

The objective is developing an XFEM model that is capable of predicting different types of fracture in the pelvic bone under various loading conditions. Previously published mechanical and failure characteristics of cortical and cancellous tissues were implemented and assigned to an intact pelvic bone with specified cortical and cancellous tissues. Various loading conditions, including combined load directions, were applied to the acetabulum to model different types of fracture (e.g., anterior/posterior wall fracture and transverse fracture) in the pelvic bone. The predicated types of fracture and the maximum force at fracture were compared to those acquired from previously published experimental tests. Anterior/posterior wall fracture and transverse fracture were the most common types of fractures determined in the simulations. The XFEM simulations were able to predict similar fractures to those reported in the experimental tests. The maximum fracture force in the XFEM model was found to be 18.6 kN compared to 8.85 kN reported in the previous experimental tests. The results revealed that different types of fracture in the pelvic bones can be caused by the various loading conditions in unstable high-rate impact loads. Using proper mechanical and failure behaviors of cortical and cancellous tissues, XFEM modeling of pelvic bone is capable of predicting bone fracture. In future work, the XFEM models of cancellous and cortical tissues can be assigned to other bones in human body skeleton so that the failure mechanism in such bones can be investigated.

Does 3D-Assisted Acetabular Fracture Surgery Improve Surgical Outcome and Physical Functioning?-A Systematic Review

Three-dimensional technology is increasingly being used in acetabular fracture treatment. No systematic reviews are available about the added clinical value of 3D-assisted acetabular fracture surgery compared to conventional surgery. Therefore, this study aimed to investigate whether 3D-assisted acetabular fracture surgery compared to conventional surgery improves surgical outcomes in terms of operation time, intraoperative blood loss, intraoperative fluoroscopy usage, complications, and postoperative fracture reduction, and whether it improves physical functioning. Pubmed and Embase databases were searched for articles on 3D technologies in acetabular fracture surgery, published between 2010 and February 2021. The McMaster critical review form was used to assess the methodological quality. Differences between 3D-assisted and conventional surgery were evaluated using the weighted mean and odds ratios. Nineteen studies were included. Three-dimensional-assisted surgery resulted in significantly shorter operation times (162.5 ± 79.0 versus 296.4 ± 56.0 min), less blood loss (697.9 ± 235.7 mL versus 1097.2 ± 415.5 mL), and less fluoroscopy usage (9.3 ± 5.9 versus 22.5 ± 20.4 times). The odds ratios of complications and fracture reduction were 0.5 and 0.4 for functional outcome in favour of 3D-assisted surgery, respectively. Three-dimensional-assisted surgery reduces operation time, intraoperative blood loss, fluoroscopy usage, and complications. Evidence for the improvement of fracture reduction and functional outcomes is limited.

Application of three-dimensional printing technology in peripheral hip diseases

The incidence of peripheral hip diseases is increasing every year, and its treatment is always tricky due to the complexity of hip joint anatomy and a variety of surgical methods. This paper summarizes the application research and progress of three-dimensional (3D) printing technology in different peripheral hip diseases in recent years published by PubMed from January 2017 to July 2021 with the search terms including “3D or three-dimensional, print*, and hip*. In general, the application of 3D printing technology is mainly to print bone models of patients, make surgical plans, and simulate pre-operation, customized surgical navigation templates for precise positioning or targeted resection of tissue or bone, and customized patient-specific instruments (PSI) fully conforms to the patient’s anatomical morphology. It mainly reduces operative time, intraoperative blood loss, and improves joint function. Consequently, 3D printing technology can be customized according to the patient’s disease condition, which provides a new option for treating complex hip diseases and has excellent application and development potential.

Italian Consensus Conference on Guidelines for preoperative treatment in acetabular fractures

Preoperative management of acetabular fracture is a major problem and no consensus has been reached in literature on the optimal treatment of this problem. We present the results of the First Italian Consensus Conference on Acetabular fracture. An extensive review of the literature has been undertaken by the organizing committee and forwarded to the panel. Members were appointed by surgical experience with acetabular fractures. From November 2017 to January 2018, the organizing committee undertook the critical revision and prepared the presentation to the Panel on the day of the Conference. Then 11 recommendations were presented according to the 11 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on, a second debate took place in September 2018 to reach a unanimous consent. We present results of the following questions: does hip dislocation require reduction? Should hip reduction be performed as soon as possible? In case of unsuccessful reduction of the dislocation after attempts in the emergency department, how should it be treated? If there is any tendency toward renewed dislocation, how should it be treated? Should Computed Tomography (CT) scan be performed before reduction? Should traction be used? How can we treat the pain? Is preoperative ultrasound exam to rule out vein thrombosis always necessary? Is tranexamic acid intravenous (IV) preoperatively recommended? Which antibiotic prophylactic protocols should be used? Is any preoperative heterotopic ossification prophylaxis suggested? In this article we present the indications of the First Italian Consensus Conference: a hip dislocation should be reduced as soon as possible. If unsuccessful, surgeon may repeat the attempts optimizing the technique. Preoperative CT scan is not mandatory before reduction. Skeletal traction is not indicated in most of the acetabular fracture. Standard pain and antibiotic prophylactic protocols for trauma patient should be used. Preoperative ultrasound exam is not recommended in all acetabular fracture. Tranexamic acid should be preoperatively used. There is no indication for preoperative heterotopic ossification.

Which general functional outcome measure does a better job of capturing change in clinical status in pelvic and acetabular fracture patients? An analysis of responsiveness over the first year of recovery

OBJECTIVE

To compare the responsiveness of the Short Form-36 (SF-36) physical component score (PCS) to the Short Musculoskeletal Function Assessment (SMFA) dysfunction index (DI) in pelvic and acetabular fracture patients over multiple time points in the first year of recovery.

DESIGN

Prospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Four hundred seventy-three patients with surgically treated pelvic and acetabular fractures (Orthopaedic Trauma Association B or C-type pelvic ring disruption or acetabular fracture) were enrolled into the center's prospective orthopaedic trauma database between January 2005 and February 2015. Functional outcome data were collected at baseline, 6 months, and 12 months.

MAIN OUTCOME MEASUREMENTS

Evaluation was performed using the SF-36 Survey and Short Musculoskeletal Function Assessment. Responsiveness was assessed by calculating the standard response mean (SRM), the minimal clinically important difference (MCID), and floor and ceiling effects.

RESULTS

Three hundred five patients had complete data for both outcome scores. SF-36 PCS and SMFA DI scores showed strong correlation for all time intervals (r = -0.55 at baseline, r = -0.78 at 6 months, and r = -0.85 at 12 months). The SRM of the SF-36 PCS was greater in magnitude than the SRM of SMFA DI at all time points; this was statistically significant between baseline and 6 months (P < .001), but not between 6 and 12 months (P = .29). Similarly, the proportion of patients achieving MCID in SF-36 PCS was significantly greater than the proportion achieving MCID in SMFA DI between baseline and 6 months (84.6% vs 69.8%, P < .001), and between 6 and 12 months (48.5% vs 35.7%, P = .01). There were no ceiling or floor effects found for SF-36 PCS at any time intervals. However, 16.1% of patients achieved the highest level of functioning detectable by the SMFA DI at baseline, along with smaller ceiling effects at 6 months (1.3%) and 12 months (3.3%).

CONCLUSIONS

SF-36 PCS is a more responsive measure of functional outcome than the SFMA DI over the first year of recovery in patients who sustain a pelvic ring disruption or acetabular fracture. This superiority was found in using the SRM, proportion of patients meeting MCID, and ceiling effects. Furthermore, the SF-36 PCS correlated with the more disease-specific SMFA DI.

LEVEL OF EVIDENCE

Prognostic Level II.

Omega plate for the treatment of acetabular fractures involving the quadrilateral plate

This retrospective study aimed to assess the outcome of a modified Stoppa approach using an anatomically precontoured plate for the treatment of acetabular fractures. In total, 30 patients (mean age 50.3 years; 25 men and 5 women) with acetabular fractures were treated between January 1, 2018 and December 31, 2019. In all 30 cases, fracture reduction was performed through a modified Stoppa approach and fixed with the omega plate. In specific fracture patterns, additional approaches were needed (lateral window in 4 cases and posterior Kocher-Langenbeck approach in 7 cases). Patients were assessed for restoration of the hip joint congruency, complications, and overall fracture reduction. Quality of reduction was categorized based on Matta's radiological principles and to assess functional outcome the Merle d'Aubigné-Postel and Harris hip score was used. The average anesthesia time was 253.6 min, the mean intraoperative blood lost was 266.6 ml and the mean intraoperative fluoroscopy dose was 3.21 mGy. According to Matta criteria for reduction quality, anatomical reduction was recorded in 22 cases, imperfect reduction in 6 cases and 2 cases had poor reduction. The average follow-up was 22.5 months. Malunion, loss of reduction or implant loosening were not recorded. Late complications included one case of avascular necrosis of the femoral head and post-traumatic arthritis changes in 5 cases. At the final follow-up, a mean Merle d'Aubigné-Postel score of 13.26±4.46 and a mean Harris score of 86.03±13.37 were recorded. The possibility of an anatomically precontoured plate with subsequent lower operative time combined with stable fixation of the primary acetabular fracture fragments and the quadrilateral plate makes the omega plate a viable option for treating acetabular fractures with a very low complication rate and good to excellent results in 89% of the cases.

Functional Outcome of Surgical Stabilisation of Acetabular Fractures

Introduction:

Approach to the management of displaced acetabular fractures has evolved from conservative to operative management after the work of Judet and Letournel. Various surgical methods have been explored and described by authors to address this type of fracture, leading to improved clinical outcome. This study aimed to evaluate functional outcome of surgically treated displaced acetabular fractures in the Malaysian context.

Materials and methods:

We analysed 43 patients with isolated acetabular fractures who were treated operatively with a minimum of three years follow-up. Anthropometric data, Judet-Letournel fracture pattern, surgical approach and complications were recorded. Post-operative Matta radiological outcome were evaluated for joint congruency and hip functional outcome was evaluated using Merle d’Aubgine-Postel and Harris Hip Score (HHS). All statistical analyses were analysed using SPSS version 24.0.

Results:

The most frequent elementary fracture type was posterior wall (30.2%) while associated type was both columns (23.3%). Mean functional outcome of Merle d'Aubigné-Postel was 15.77 and HHS was 86.6. Thirty-three (76.7%) patients achieved satisfactory functional outcome, 19 (44.1%) patients achieved anatomic reduction (<2 mm step-off) based on Matta classification while 24 (55.8%) did not achieve the desired outcome. Fracture pattern exhibited strong association with post-operative Matta radiological outcome (p-value 0.001). However both fracture pattern and Matta radiological outcome did not exhibit association with the functional outcome group. The mean time for surgical interventions was 10.8 days and there was no significant association with final functional outcome score.

Conclusion:

Fracture pattern is a strong contributing factor towards post-operative Matta radiological outcome. However, achieving the perfect anatomical reduction is not of utmost important factor to predict the good functional outcome.

Accuracy of Patient-Specific Drilling Guides in Acetabular Fracture Surgery: A Human Cadaver Study

Due to the complex anatomical shape of the pelvis, screw placement can be challenging in acetabular fracture surgery. This study aims to assess the accuracy of screw placement using patient-specific surgical drilling guides applied to pre-contoured conventional implants in acetabular fracture surgery. CT scans were made of four human cadavers to create 3D models of each (unfractured) pelvis. Implants were pre-contoured on 3D printed pelvic models and optically scanned. Following virtual preoperative planning, surgical drilling guides were designed to fit on top of the implant and were 3D printed. The differences between the pre-planned and actual screw directions (degrees) and screw entry points (mm) were assessed from the pre- and postoperative CT-scans. The median difference between the planned and actual screw direction was 5.9° (IQR: 4–8°) for the in-plate screws and 7.6° (IQR: 6–10°) for the infra-acetabular and column screws. The median entry point differences were 3.6 (IQR: 2–5) mm for the in-plate screws and 2.6 (IQR: 2–3) mm for the infra-acetabular and column screws. No screws penetrated into the hip joint or caused soft tissue injuries. Three-dimensional preoperative planning in combination with surgical guides that envelope pre-contoured conventional implants result in accurate screw placement during acetabular fracture surgery.

Comparison of segmentation software packages for in-hospital 3D print workflow

Purpose: In-hospital three-dimensional (3D) printing of patient-specific pathologies is increasingly being used in daily care. However, the efficiency of the current conversion from image to print is often obstructed due to limitations associated with segmentation software. Therefore, there is a need for comparison of several clinically available tools. A comparative study has been conducted to compare segmentation performance of Philips IntelliSpace Portal^® (PISP), Mimics Innovation Suite (MIS), and DICOM to PRINT^® (D2P). Approach: These tools were compared with respect to segmentation time and 3D mesh quality. The dataset consisted of three computed tomography (CT)-scans of acetabular fractures (ACs), three CT-scans of tibia plateau fractures (TPs), and three CTA-scans of abdominal aortic aneurysms (AAAs). Independent-samples t -tests were performed to compare the measured segmentation times. Furthermore, 3D mesh quality was assessed and compared according to representativeness and usability for the surgeon. Results: Statistically significant differences in segmentation time were found between PISP and MIS with respect to the segmentation of ACs ( p = < 0.001 ) and AAAs ( p = 0.031 ). Furthermore, statistically significant differences in segmentation time were found between PISP and D2P for segmentations of AAAs ( p = 0.008 ). There were no statistically significant differences in segmentation time for TPs. The accumulated mesh quality scores were highest for segmentations performed in MIS, followed by D2P. Conclusion: Based on segmentation time and mesh quality, MIS and D2P are capable of enhancing the in-hospital 3D print workflow. However, they should be integrated with the picture archiving and communication system to truly improve the workflow. In addition, these software packages are not open source and additional costs must be incurred.

Usefulness of the obturator hook technique for guiding the initial trajectory control in infra-acetabular screw placement

PURPOSE

Proper placement of infra-acetabular screws is technically demanding; there is a limited safe zone for screw fixation because of the complexity of the bone anatomy around the hip joint and the vulnerability of the major neurovascular bundles in the pelvic cavity. We aimed to present the obturator hook technique as a surgical technique for infra-acetabular screw placement in acetabular and pelvic fractures and report its radiological outcomes.

METHODS

Patients treated with infra-acetabular screw placement using the obturator hook technique between January 2015 and August 2020 were enrolled in this study. We collected data on demographics, surgical approach, reduction status, complications, and outcomes. The radiological outcomes of infra-acetabular screw placement based on computed tomography findings were evaluated as follows: success, articular penetration, or out of the bone.

RESULTS

Thirty-five patients underwent infra-acetabular screw placement (26 men, 9 women; mean age, 55 years; range, 27-90 years). One patient underwent bilateral infra-acetabular screw placement; therefore, 36 infra-acetabular screws were inserted in all patients. An ideal placement was achieved with 27 infra-acetabular screws (27/36, 75%). Seven infra-acetabular screws (7/36, 19%) showed articular penetration, and two infra-acetabular screws (2/36, 6%) were placed outside the bone. One patient with articular penetration and mechanical symptoms of the hip joint required screw replacement. No other complications, including obturator nerve and vascular injuries, were observed.

CONCLUSION

The obturator hook technique could be a favorable and individualized method for infra-acetabular screw placement in patients with acetabular and pelvic fractures.

LEVEL OF EVIDENCE

IV, retrospective descriptive study.

Which radiograph is most accurate for assessing hip joint penetration in infra-acetabular screw placement?

Although infra-acetabular screws have been used for anterior and posterior column transfixation, a screw penetrating the hip joint can result in harmful complications. However, the most accurate intraoperative radiologic imaging tool for identifying articular penetration has not been established. The purpose of the present study was, therefore, to evaluate the consistency with which standard pelvic radiographs compared with computed tomography (CT) can be used for demonstrating articular penetration.This retrospective review was performed between January 2015 and December 2020. We evaluated the records of patients with acetabular or pelvic fractures who underwent open reduction and internal fixation with infra-acetabular screw placement. We collected demographic data and described infra-acetabular screw placement as follows: ideal placement, articular penetration, and out of the bone. Articular penetration was assessed independently on each pelvic radiograph and compared statistically with the CT scans. Sensitivity, specificity, correct interpretation rate, and prevalence-adjusted bias-adjusted kappa (PABAK) were calculated for each radiograph.Thirty-nine patients underwent infra-acetabular screw placement. The mean age of patients was 55 years (range, 27-90 years); there were 29 men and 10 women. One patient underwent bilateral infra-acetabular screw placement; therefore, 40 infra-acetabular screws were included in total. Six (6/40, 15%) infra-acetabular screws showed articular penetration on CT and two (2/40, 5%) showed infra-acetabular screws extending out of the bone. Hip joint penetration was correctly identified at a rate of 92.5% (95% confidence interval [CI], 79.6-98.4%) on the outlet view and 87.5% (95% CI, 73.2-95.8%) on the anteroposterior (AP) view. The PABAK for the agreement between pelvic radiographs and CT scans was 0.85 in the outlet view and 0.75 in the AP view.The outlet view is an accurate method for detecting articular penetration of infra-acetabular screws. We recommend the insertion of an infra-acetabular screw under fluoroscopic outlet view to avoid articular penetration intraoperatively.

Efficacy of repeated intravenous tranexamic acid in reducing perioperative bleeding of acetabular fractures

BACKGROUND

Application of tranexamic acid (TXA) in the treatment of acetabular fractures could reduce intraoperative and postoperative blood loss.

OBJECTIVE

To investigate the effect of single and repeated intravenous infusion of TXA on blood loss of acetabular fractures.

METHODS

120 patients with acetabular fractures admitted to our hospital from January 2017 to September 2020 were retrospectively divided into three groups: Patients accepted 1g TXA at preoperative 30 minutes were defined as single TXA group (n = 40); Patients accepted 1g TXA at preoperative 30 minutes and 1g TXA at 3 hours after the start of surgery were defined as repeated TXA group (n = 40); Patients accepted normal saline at preoperative 30 minutes were defined as control group (n = 40).

RESULTS

The total blood loss in single TXA group and repeated TXA group were significantly lower than control group, and the total blood loss in the repeated TXA group was significantly lower than single TXA group (P <  0.05). The hidden blood loss from surgery to postoperative 1 day in repeated TXA group was significantly lower than single TXA group and the control group(P <  0.05). No significant differences were observed in the operative time, postoperative transfusion rate and thrombosis rate among the three groups (P >  0.05).

CONCLUSION

Repeated TXA is more recommended during acetabular fracture surgery since it can reduce the total blood loss without increasing the operative time, postoperative transfusion rate and thrombosis rate compared with single TXA.

Treatment of anterior column posterior hemitransverse fracture with supra-ilioinguinal approach

Objective

To report the feasibility and effect of the supra-ilioinguinal approach for treatment of anterior posterior hemitransverse fracture of the acetabulum.

Methods

Nineteen consecutive patients who underwent treatment for an anterior column posterior hemitransverse fracture of the acetabulum from January 2013 to June 2018 were retrospectively analyzed. All patients underwent treatment by the single supra-ilioinguinal approach with at least 1 year of follow-up.

Results

The mean time to surgery, operative time, incision length, and blood loss were 10.2 ± 3.8 days, 157 ± 125 minutes, 10.2 ± 0.6 cm, and 876 ± 234 mL, respectively. According to the Matta scoring system, the reduction quality was excellent in 13 patients, good in 6, and poor in 0. According to the Merle d'Aubigné scoring system, the outcome at the last follow-up was excellent in 12 patients, good in 5, fair in 1, and poor in 1. Postoperative complications occurred in three patients (deep vein thrombosis in one, lateral femoral cutaneous nerve injury in one, and both complications in one).

Conclusions

Use of the supra-ilioinguinal approach for treatment of anterior column posterior hemitransverse fracture of the acetabulum produced excellent clinical results because of the direct visualization of the anterior column and quadrilateral plate.

A new method for reduction quality assessment in acetabular fractures: acetabular congruency measurement

INTRODUCTION

The determination of adequate reduction is difficult perioperatively due to inadequate radiographic scanning and objective measurement methods. The purpose of the present study is to evaluate an objective measurement of the weight bearing acetabular dome congruency. The sensitivity and specificity of 2 measurement methods after acetabular fracture fixation are compared.

PATIENTS AND METHODS

Postoperative acetabular reduction was assessed based on postoperative anteroposterior radiographs according to hip joint congruency and Matta's classification in 55 patients. For hip joint congruency measurements, one circle was drawn as superior femoral head border and another one was drawn as weight-bearing acetabular dome border. The difference between the centres of the circles was measured in millimetres. Comparative studies were performed between groups according to reduction quality and clinical and radiological results.

RESULTS

The threshold value for the difference between the 2 circle centres was found as 4.4 mm according to the clinical outcomes; 3.8 mm according to radiological outcomes in joint congruency method. The sensitivity of this method was found as 90.2% and 92.7%, and specificity as 64.3% and 57.1% considering the clinical and radiological results, respectively. In the assessment of joint congruency, false positive rate was lower than assessing reduction quality using the method defined by Matta.

CONCLUSIONS

Joint congruency assessment based on a postoperative anteroposterior radiograph in patients treated with open reduction internal fixation for acetabular fractures is a suitable method for assessing the adequacy of reduction. This method can be used intraoperatively using fluoroscopy imaging during surgery.

Epidemiology of pelvic and acetabular fractures in a tertiary hospital in Singapore

Introduction:

Pelvic and acetabular fractures (PAFs) usually result from high-energy, potentially life-threatening accidents. They are one of the major injuries that lead to death in patients involved in such accidents. We studied the recent epidemiology of these injuries in Singapore.

Methods:

This is a retrospective data analysis of all trauma patients who underwent surgery for PAFs from 2008 to 2016 in a tertiary trauma centre in Singapore. Data including patient demographics, mechanism of injury and associated injuries was collected.

Results:

A total of 169 patients were admitted for PAFs over the eight-year period. The majority (79.3%) were male. The mean age was 41 (range 13–79) years. Most patients (51.5%) were Chinese. The most common mechanisms of injury were road traffic accidents (53.8%), falls (33.1%) and crush injuries (13.0%). 46.2% sustained acetabular fractures, while 44.4% sustained pelvic fractures. PAFs were most commonly associated with upper and lower limb injuries, followed by spinal and thoracic injuries. Average of length of stay in hospital was 24 (range 2–375) days.

Conclusion:

PAF predominantly affects young working males. Compared to previously published local data, there has been a significant reduction in the incidence of PAFs, likely due to improved road and work safety. The demographics of PAFs have changed, with fewer injuries in females (20.7% vs. 33.3%), a reduction in the proportion of injuries in the Chinese (51.5% vs. 70.1%). While road traffic accidents remain the most common cause, crush injuries are now more prevalent (13.0%).

Traditional three-dimensional printing technology versus three-dimensional printing mirror model technology in the treatment of isolated acetabular fractures: a retrospective analysis

OBJECTIVE

This study was performed to compare the clinical outcomes of traditional three-dimensional (3D) printing technology and 3D printing mirror model technology in the treatment of isolated acetabular fractures.

METHODS

Prospectively maintained databases were reviewed to retrospectively compare patients with an isolated acetabular fracture who were treated with traditional 3D printing technology (Group T) or 3D printing mirror model technology (Group M) from 2011 to 2017. In total, 146 advanced-age patients (146 hips) with an isolated acetabular fracture (Group T, n = 72; Group M, n = 74) were assessed for a mean follow-up period of 29 months (range, 24-34 months). The primary endpoint was the postoperative Harris hip score (HHS). The secondary endpoints were the operation time, intraoperative blood loss, fluoroscopy screening time, fracture reduction quality, and incidence of postoperative complications at the final follow-up.

RESULTS

The HHS, operation time, intraoperative blood loss, fluoroscopy screening time, and incidence of postoperative complications were significantly different between the groups, with Group M showing superior clinical outcomes.

CONCLUSION

In patients with an isolated acetabular fracture, 3D printing mirror model technology might lead to more accurate and efficient treatment than traditional 3D printing technology.