How to improve the performance of acetabulum fracture diagnoses: investigating the use of three-dimensional CT-scan reconstructions.

PURPOSE: The classification of acetabular fractures remains a challenge for the junior radiologist, although he is the first line of diagnosis in Emergency Department. The advantages of three-dimensional reconstructions have yet to be evaluated on a large scale. METHOD: A total of 212 fractures were classified according to Letournel and Judet by a senior orthopaedic surgeon, a senior radiologist, and a resident radiologist. The CT scans were first analysed in 2D and then a second time using 2D + 3D reconstructions of the acetabulum excluding the femoral head. RESULTS: 3D reconstructions improved correct classification not only for the radiologist resident (+ 5%) but also for senior radiologist and orthopaedist (+ 2 and + 3%). 3D reconstructions also more significantly improved the diagnoses of complex fractures (+ 8.3%) compared to simple fractures (+ 0.4%). CONCLUSIONS: 3D reconstructions have improved the routine diagnosis of acetabular fractures, especially for junior radiologist or in cases of complex fractures.

What is the value of 3D virtual reality in understanding acetabular fractures?

BACKGROUND: Acetabular fractures are difficult to classify owing to the complex three-dimensional (3D) anatomy of the pelvis. 3D printing helps to understand and reliably classify acetabular fracture types. 3D-virtual reality (VR) may have comparable benefits. Our hypothesis is that 3D-VR is equivalent to 3D printing in understanding acetabular fracture patterns. METHODS: A total of 27 observers of various experience levels from several hospitals were requested to classify twenty 3D printed and VR models according to the Judet-Letournel classification. Additionally, surgeons were asked to state their preferred surgical approach and patient positioning. Time to classify each fracture type was recorded. The cases were randomized to rule out a learning curve. Inter-observer agreement was analyzed using Fleiss' kappa statistics (κ). RESULTS: Inter-observer agreements varied by observer group and type of model used to classify the fracture: medical students: 3D print (κ = 0.61), VR (κ = 0.41); junior surgical residents: 3D print (0.51) VR (0.54); senior surgical residents: 3D print (0.66) VR (0.52); junior surgeons: 3D print (0.56), VR (0.43); senior surgeons: 3D print (κ = 0.59), VR (κ = 0.42). Using 3D printed models, there was more agreement on the surgical approach (junior surgeons κ = 0.23, senior surgeons κ = 0.31) when compared with VR (junior surgeons κ = 0.17, senior surgeons 0.25). No difference was found in time used to classify these fractures between 3D printing and VR for all groups (P = 1.000). CONCLUSIONS: The Judet-Letournel acetabular classification stays difficult to interpret; only moderate kappa agreements were found. We found 3D-VR inferior to 3D printing in classifying acetabular fractures. Furthermore, the current 3D-VR technology is still not practical for intra-operative use.

Short-term follow-up of anterior and posterior both column fractures of acetabulum managed through both column plating.

OBJECTIVE: To evaluate the results of short-term follow-up of patients of both column acetabular fractures managed through anterior and posterior column plating. INTRODUCTION: Both column acetabular fractures are challenging articular injuries. Majority of them are treated operatively. The concept of "secondary congruence" was introduced by Letournel. Despite this, biomechanical data on secondary congruence indicate that nonoperative treatment leads to an increase in peak pressures in the supraacetabular region with the potential risk of developing posttraumatic degenerative osteoarthritis. Operative management is therefore justified. METHODOLOGY: A cohort of 10 patients having both column (anterior and posterior) acetabular fractures managed using bicolumnar plating between January 2016 and December 2017 were enrolled in the study and were analyzed during follow-up period. RESULTS: In total, 80% of the patients had excellent to good result. Average postoperative score was 85.7. Assessment was done using modified Harris Hip score.

Standardized three dimensional computerised tomography scanner reconstructions increase the accuracy of acetabular fracture classification.

PURPOSE: Evaluate the role of four standardized 3D reconstruction views in the accurate diagnosis of acetabular fractures. MATERIALS AND METHODS: Thirty-five acetabular fracture cases were selected from a tertiary centre database. Fourteen reviewers with different experience level evaluated this set of images which were provided in axial 2D views and multiplanar reconstruction (MPR) without 3D views in the first two readings then the standardized 3D views were added for the subsequent two readings. The primary outcome was the accuracy of diagnosis while inter-observer reliability and reading time as well as time needed for accurate diagnosis were evaluated. RESULTS: Accuracy of classification was 56.7% using the 2D and 73% using the described 3D (p < 0.001). Improvement was noted in all groups even though the expert group showed the least improvement (6.7% (p = 0.04)) and the least experience group showed the most improvement (35.7% (p < 0.001)). Average time of interpretation was 96 minutes for the 2D sets and 47 minutes for the 3D sets. Finally, the adding of the four standardized views increased the inter-observer reliability in all groups compared to the standard 2D sets with MPR. CONCLUSION: Acetabular fracture diagnosis according to Letournel classification is difficult and depends greatly on the experience of the reader. The described set of 3D images yields better accuracy and renders the diagnosis more repeatable and faster. We recommend the use of these images in classifying acetabular fractures.

Association of femoral head and acetabular fractures on computerized tomography: correlation with the Judet-Letournel classification.

PURPOSE: Tha aims of this study were to identify the incidence of femoral head fractures in the setting of acetabular fractures and to determine the relationship between acetabular fracture pattern, the degree of acetabular fracture displacement, and the incidence of femoral head fractures. MATERIALS AND METHODS: This is a retrospective cross-sectional study of 274 patients with 300 acetabular fractures diagnosed on pelvic CT. Acetabular fractures were categorized using the Judet-Letournel classification system. RESULTS: Femoral head fractures were present in 18.0% of acetabular fractures. Fracture patterns with a posterior wall component had a very high (56.3%) incidence of femoral head fracture. Anterior column and anterior column with posterior hemitransverse fractures have a very low (3.4%) incidence of femoral head fracture. Anterior hip dislocation had a 66.7% incidence of femoral head fracture, while posterior dislocation had a 71.9% incidence. Acetabular fractures displaced by more than 5 mm had a 26.9% incidence of femoral head fracture, while acetabular fracture displaced less than 5 mm had only 4.2% incidence of femoral head fracture. CONCLUSION: Femoral head fractures are a very common associated finding in patients presenting with acetabular fractures. In patients with a posterior wall component of the fracture or associated hip dislocation, a femoral head fracture is more likely than not present. Conversely, in acetabular fractures with less than 5 mm displacement or anterior column fractures without posterior acetabular involvement, femoral head fractures are very unlikely in the absence of a dislocation event.

[Letournel ilioinguinal approach in the management of acetabular fractures]. / Abordaje ilioinguinal de Letournel en el manejo de fracturas de acetábulo.

The ilioinguinal approach described by Emile Letournel in 1961 allows an extensive exposure of the anterior elements of the pelvis and acetabular fractures involving the anterior wall and/or column, pubic symphysis, and sacroiliac joint. It also facilitates a rapid recovery of muscle function and leaves a cosmetic scar.

El abordaje ilioinguinal descrito por Emile Letournel en 1961 permite una extensa exposición de los elementos anteriores de la pelvis y de las fracturas acetabulares que involucran la pared o columna anterior, sínfisis del pubis y articulación sacroilíaca. Facilita una rápida recuperación de la función muscular y deja una cicatriz cosmética.

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.

Identification and treatment of atypical acetabular fractures having an independent acetabular roof fragment: Three-column fractures.

INTRODUCTION: A unique type of both-column fracture of the acetabulum that also has an independent roof fragment seems to occur relatively often. It is challenging to diagnose, thus our ability to detect it and its frequency are not known. This led us to analyze a database of acetabular fractures to 1) determine the incidence of this type of fracture, 2) describe its radiological characteristics, 3) attempt to set out a specific treatment strategy. HYPOTHESIS: The need for a dual surgical approach depends on the type and displacement of the independent roof fragment. METHODS: Four surgeons and radiologists independently analyzed a set of acetabular fractures that occurred between 2007 and 2017. The diagnosis was made using two-dimensional (2D) and three-dimensional (3D) CT reconstructions. Once the fractures had been identified, a detailed description was made of all 2D and 3D slices. A retrospective analysis was done of the reduction and fixation of the independent roof fragment relative to the chosen surgical approach. RESULTS: The study comprised 534 acetabular fractures, of which 96 where both-column fractures. In that subset, 41% (39 fractures) had an independent roof fragment. A detailed analysis resulted in the identification of two subtypes of three-column fracture with independent fragment: type 1 has a posterosuperior fragment (22 cases); type 2 has an independent fragment separated by a juxtatectal fracture line (17 cases). The best radiological outcomes were achieved when the independent fragment was minimally displaced and did not require additional reduction. CONCLUSION: The isolated roof fragment is common, as it occurs is more than one-third of both-column fractures. We were able to identify two subtypes that require different surgical strategies. Surgical treatment of these fractures is difficult; thus a combined surgical approach (anterior followed by posterior) may provide the best reduction, especially for subtype 1. LEVEL OF EVIDENCE: IV.

Scapulothoracic fusion using nonabsorbable suture fixation: surgical technique and review of the literature.

Background: Historically, scapulothoracic fusion (STF) is performed using steel wire and plate construct fixation. The purpose of this study is to report a recent fusion achieved through ultra-high-molecular-weight polyethylene-reinforced suture fixation as well as to perform a systematic literature review of techniques, fusion rates, complications, and reoperation. Methods: Patient data were gathered from chart review and clinical encounters. For the review, MEDLINE, Embase, and Ovid databases were queried for STF cases. Thirty articles reporting on 386 fusion procedures were included. Results: Including this patient, 5 of 387 (1.3%) STFs have been attempted with fiber suture. Fusion rates of metal-only constructs is 90.8% (346 of 381) with 11.3% (43 of 381) requiring wire removal or trimming because of symptomatic hardware and 7% (27 of 381) causing a postoperative pneumothorax. Although a small sample size, all fiber-suture constructs have achieved union without implant removal and without pneumothorax development. In this patient, fusion was determined radiographically at 6 months with substantial improvement in pain level and function. Conclusion: Scapulothoracic fusion has benefit to patients to have failed other management options for winged scapula, most commonly those with neurologic trauma or facioscapulohumeral muscular dystrophy. With advancements in surgical options, fiber-suture offers an alternative to steel wire to achieve fusion. Further cases with longer term follow-up are needed to determine if significant differences in outcomes exist between constructs.

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

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

A study on fracture lines of the quadrilateral plate based on fracture mapping.

BACKGROUND: Quadrilateral plate fractures are a challenging group of acetabular fractures to manage. However, there is little literature that describes the fracture lines of the quadrilateral plate. The aim of this study was to explore the fracture lines of the quadrilateral plate and relevant clinical significance. METHODS: CT data from a series of acetabular fractures were retrospectively analyzed. According to the X-ray, CT, and operative records of the patients, Judet-Letournel classification was carried out for acetabular fractures involving quadrilateral plate. Then, the fracture maps of different types of acetabular fractures in the quadrilateral plate were drawn. To facilitate the characterization of fracture maps, we defined six basic fracture lines. RESULTS: The fracture lines of the three types of acetabular fractures (double-column fracture, T-type fracture, and anterior column with posterior hemitransverse fracture) mainly included upper transverse lines and upper oblique lines. Although the fracture lines of posterior wall fracture and anterior column fracture were mainly upper transverse lines, the fracture lines of the former were in a low position. The fracture lines of transverse fracture and transverse with posterior wall fracture were similar, both of which were mainly upper oblique lines. The fracture lines of posterior column fractures mainly included posterior vertical lines. CONCLUSIONS: The fracture lines of different types of acetabular fractures have certain regularity respectively. Observation of the fracture lines of the quadrilateral plate based on fracture mapping can help orthopedic surgeons to enhance the understanding of the Judet-Letournel classification, which may have some significant guidance on the choice of operation approach and the design of internal fixation devices.

Abordaje ilioinguinal de Letournel en el manejo de fracturas de acetábulo / Letournel ilioinguinal approach in the management of acetabular fractures

Resumen: El abordaje ilioinguinal descrito por Emile Letournel en 1961 permite una extensa exposición de los elementos anteriores de la pelvis y de las fracturas acetabulares que involucran la pared o columna anterior, sínfisis del pubis y articulación sacroilíaca. Facilita una rápida recuperación de la función muscular y deja una cicatriz cosmética.

Abstract: The ilioinguinal approach described by Emile Letournel in 1961 allows an extensive exposure of the anterior elements of the pelvis and acetabular fractures involving the anterior wall and/or column, pubic symphysis, and sacroiliac joint. It also facilitates a rapid recovery of muscle function and leaves a cosmetic scar.

Does semi-automatic bone-fragment segmentation improve the reproducibility of the Letournel acetabular fracture classification?

BACKGROUND: The Letournel classification of acetabular fracture shows poor reproducibility in inexperienced observers, despite the introduction of 3D imaging. We therefore developed a method of semi-automatic segmentation based on CT data. The present prospective study aimed to assess: (1) whether semi-automatic bone-fragment segmentation increased the rate of correct classification; (2) if so, in which fracture types; and (3) feasibility using the open-source itksnap 3.0 software package without incurring extra cost for users. HYPOTHESIS: Semi-automatic segmentation of acetabular fractures significantly increases the rate of correct classification by orthopedic surgery residents. METHODS: Twelve orthopedic surgery residents classified 23 acetabular fractures. Six used conventional 3D reconstructions provided by the center's radiology department (conventional group) and 6 others used reconstructions obtained by semi-automatic segmentation using the open-source itksnap 3.0 software package (segmentation group). Bone fragments were identified by specific colors. Correct classification rates were compared between groups on Chi2 test. Assessment was repeated 2 weeks later, to determine intra-observer reproducibility. RESULTS: Correct classification rates were significantly higher in the "segmentation" group: 114/138 (83%) versus 71/138 (52%); P<0.0001. The difference was greater for simple (36/36 (100%) versus 17/36 (47%); P<0.0001) than complex fractures (79/102 (77%) versus 54/102 (53%); P=0.0004). Mean segmentation time per fracture was 27±3min [range, 21-35min]. The segmentation group showed excellent intra-observer correlation coefficients, overall (ICC=0.88), and for simple (ICC=0.92) and complex fractures (ICC=0.84). CONCLUSION: Semi-automatic segmentation, identifying the various bone fragments, was effective in increasing the rate of correct acetabular fracture classification on the Letournel system by orthopedic surgery residents. It may be considered for routine use in education and training. LEVEL OF EVIDENCE: III: prospective case-control study of a diagnostic procedure.

Long-term results of Letournel scapulothoracic fusion in facioscapulohumeral muscular dystrophy: A retrospective study of eight cases.

BACKGROUND: The aim of this study was to evaluate long-term radio-clinical outcome in scapulothoracic fusion using the Letournel technique (where the fourth rib is passed through the wing of the scapula and cerclage wires are tightened to the two ribs below) for patients suffering from facioscapulohumeral muscular dystrophy (FSHMD), a degenerative pathology affecting scapula-stabilizing muscles, leading to scapular winging, shoulder pain and restricted shoulder abduction and flexion, despite a functional deltoid muscle. METHODS: This retrospective study, with an average follow-up of 14 years (168 months; σ=73 months), included four patients who underwent a bilateral procedure, one side after the other, with shoulder abduction and flexion gain as primary endpoints. RESULTS: Mean improvement in range of motion was 36° (σ=32°) in abduction and 40° (σ=44°) in flexion. Postoperatively, active abduction averaged 99° (σ=28°) and active flexion 110° (σ=45°). In one case, a 58 year-old patient, gain in motion was 50° for abduction and 60° for anterior elevation. In one patient, range of motion showed bilateral decrease due to the natural course of the FSHMD. No intraoperative complications were reported. DISCUSSION: The Letournel technique seems to be an effective long-term solution in FSHMD, without age limit. Improvements appear to be steady over time, the only long-term limitations being the natural course of the disease itself. LEVEL OF EVIDENCE: IV - retrospective case series.