|Year : 2022 | Volume
| Issue : 1 | Page : 14-17
Spring plate for fixation of comminuted posterior wall acetabular fractures
Ashwini Gaurav1, Kaushlendra Kumar1, Ranjit Kumar Singh2
1 Department of Orthopaedics, NSMCH, Patna, Bihar, India
2 Department of Orthopaedics, NMCH, Patna, Bihar, India
|Date of Submission||10-Oct-2021|
|Date of Decision||21-Dec-2021|
|Date of Acceptance||26-Dec-2021|
|Date of Web Publication||15-Mar-2022|
Department of Orthopaedics, NSMCH, Bihta, Patna, Bihar
Source of Support: None, Conflict of Interest: None
Introduction: Comminuted posterior wall acetabular fractures always remain difficult and challenging to assemble and stabilize with surgical management without any intraoperative or postoperative complications and satisfactory functional outcomes. Hence, correct selection of implant and correct technique are always key steps in the surgical management of comminuted posterior wall fractures of the acetabulum. Methods: We performed a retrospective observational study on 16 patients that were operated between July 2016 and December 2017 at Patna Medical College and Hospital, Patna. Medical reports of all patients with comminuted posterior wall fractures operated with locally crafted spring plates placed under 3.5 mm pelvic reconstruction plates were evaluated radiographically and with the past Harris Hip Scores (HHSs). Results: The average follow-up was of 15.8 months, and there were no occurrences of implant migration, loss of reduction, or joint incongruity. One patient had developed a superficial infection that was treated with dressings and oral antibiotics. Two patients had preoperative sciatic nerve palsy, which improved gradually over the course of 3 months. No instances of hip arthrosis or osteonecrosis were found. Thirteen patients scored excellent, whereas three scored good on the past HHS records. Conclusion: Our study strongly supports the concept that locally crafted spring plates placed under 3.5 mm pelvic reconstruction plates are a good fixation strategy in the management of comminuted posterior wall acetabular fractures.
Keywords: Acetabular fracture, comminuted posterior wall, spring plates
|How to cite this article:|
Gaurav A, Kumar K, Singh RK. Spring plate for fixation of comminuted posterior wall acetabular fractures. J Orthop Dis Traumatol 2022;5:14-7
|How to cite this URL:|
Gaurav A, Kumar K, Singh RK. Spring plate for fixation of comminuted posterior wall acetabular fractures. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 Aug 20];5:14-7. Available from: https://jodt.org/text.asp?2022/5/1/14/339677
| Introduction|| |
Acetabular fractures are challenging fractures as injury patterns are frequently varied and complex. These fractures are rare fractures and are very commonly associated with high-velocity trauma mechanisms. These are also frequently associated with other fractures and are commonly referred to specialized centers or surgeons for management. The introduction of three-dimensional computed tomography scanning has definitely improved the understanding of the fracture lines in the bone. The obturator oblique Judet view is required to visualize the posterior wall of the acetabulum, but it also does not give detailed information on the level of communication. Letournel et al. and Letournel et al., have classified acetabular fractures into five simple and five complex types with posterior wall fracture as type 1 in the simple group. Although posterior wall fractures are the most common type, they are far from anything simple. An isolated posterior wall fracture is rare to find and is commonly associated with the posterior dislocation of the hip. This dislocation adds to the vascular insult to the femoral head and this complicates the situation.
Many times, there is a single large fragment of the posterior wall associated with dislocation, but also frequently, they are associated with comminution of the rim which makes the reconstruction difficult. The single large fragment posterior wall fractures are comparatively easier to reduce and can be stabilized using interfragmentary lag screws or posterior wall buttress plates which take purchases in the supra acetabular part of the dome and the ischial tuberosity.
However, the comminuted wall fractures are difficult to assemble and stabilize using conventional plates and lag screws used for fixation of other types. Spring plates are used as a buttress over the wall fragments by placing them perpendicular to the fracture line, and these plates are then fixed to the pelvis using a single screw in the poster column part. A second plate is applied over the spring plates to increase the strength of the construct. These predesigned spring plates are available by various national and international implant manufacturers, but here, we are discussing the results of spring plate fixation in these comminuted wall fractures crafted locally on the table using stainless steel one-third tubular plates.
The purpose of this study is to evaluate the functional outcome and rate of implant failure or other complications when using spring plates under traditional 3.5 mm pelvic recon plates.
| Methods|| |
We performed a retrospective observational study on 16 patients that were operated between July 2016 and December 2017 at Patna Medical College and Hospital, Patna. Medical reports of all patients with comminuted posterior wall fractures operated with locally crafted spring plates [Figure 1] placed under 3.5 mm pelvic reconstruction plates using the Kocher-Langenbeck (KL) approach [Figure 2] were evaluated radiographically and with the past Harris Hip Scores (HHSs).
|Figure 1: Locally crafted spring plates by cutting and bending one-third of tubular plates|
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|Figure 2: Intraoperative placement of spring plates under 3.5 pelvic recon plates|
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All surgeries were done by the same surgeon using the same implants.
Posterior wall fractures with more than two fragments [Figure 3]. Exclusion criteria: Associated posterior column fractures, head impaction injuries, and nonreconstructable comminutions.
All patients had been evaluated postoperatively using Judet view radiographs. Patients had been allowed toe-touch weight-bearing from the 2nd day, with progressive weight-bearing at every follow-up. Full weight-bearing was allowed after confirmation of union at the fracture site by radiological evaluation and painless weight-bearing by the patient.
All patients were called to follow-up at 2 weeks, 8 weeks, 3 months, and then every 6 months.
At every follow-up, radiographs [Figure 4] were done to confirm the reduction maintenance, implant position, union, and any arthritic changes. All patients were then evaluated functionally using HHSs and recorded. Simple statistical data analysis was done and plotted in [Table 1].
| Results|| |
The average patient's age was 29.5 years, with a standard deviation of 9.7 years (range 18-47 years) and an average follow-up of 15.8 months (range 8-23 months). The average period for full weight-bearing was 9 weeks (range 7-12 weeks). The HHS at the last follow-up was 92.22 (range 80.8-99.6) with a standard deviation of 4.6.
[Table 1] depicts the HHS of a different patient. The HHS was created to measure the outcomes of hip surgery and is meant to evaluate various hip impairments and treatment approaches in an adult population. HHP scores range from 70 to 100, with 70 indicating poor, 70–80 indicating fair, 80–90 indicating good, and 90–100 indicating excellent. In our study, 13 patients scored excellent, whereas three had scored good. Moreover, [Table 1] also depicts the weight-bearing time of different patients in weeks.
There were no occurrences of implant migration, loss of reduction, or joint congruity. One patient had developed a superficial infection that was treated with dressings and oral antibiotics. Two patients had preoperative sciatic nerve palsy, which improved gradually over the course of three months. No instances of hip arthrosis or osteonecrosis were found.
| Discussion|| |
Comminuted posterior wall fractures are the uncommon one among most common variants, i.e., posterior wall fracture of acetabular fractures.,, The comminuted posterior wall fractures have always remained the most challenging acetabular fracture to treat with satisfactory functional outcome postoperatively due to its variable and complex fracture patterns in each different patient.,,,,,
The concept of spring plates for adjunctive fixation of comminuted posterior wall fragments was first proposed by Mast et al. in the year 1989. Ritcher et al. in the year 2004 published their studies further enlightening spring plate fixation to be the most successful technique and demonstrated acceptable stability to comminuted posterior wall fragments. In the year 2011, Ziran et al. in his studies evaluated a T-plate as a spring plate to give a technical modification to the traditional use of spring plates. In their study on 33 patients with comminuted posterior wall fragments, one patient had fixation failure, i.e., only a 3% failure rate. In this series of our studies, we found similar results. There were no hardware failures in all 16 patients treated with spring plates in addition to 3.5 mm pelvic reconstruction plates.
In our study, none of the patients came up with postoperative complications such as subsequent Total hip arthroplasty (THA) secondary to posttraumatic osteoarthritis. Although this is similar with what has been reported in previous studies.,,, In the study by Tannast et al., the survivorship average of 816 acetabular fractures treated with open reduction internal fixation was 79%, with a hip arthroplasty conversion rate of long-term results of 13%. Risk factors for conversion to THA included age older than 40 years, nonanatomical fracture reduction, anterior hip dislocation, the postoperative incongruence of the acetabular roof, involvement of the posterior wall, acetabular impaction, a femoral head cartilage lesion, recurrent femoral head dislocation or subluxation, initial displacement of the articular surface of >20 mm, and utilization of the extended iliofemoral approach.,
Peroneal nerve palsies due to nerve injury reported in earlier studies after using the KL approach were found to be zero in our study. However, in earlier studies, nerve injuries reported after surgical treatment of acetabular fractures were 3% to 23%.,,,,,, This was reported in the study by Lehman et al., in their study, 41/52 patients were operated on using the KL approach (79%). Eleven out of 52 patients (21%) required a Gibson approach combined with surgical dislocation and reduction through a transtrochanteric exposure.
In Lehman et al. study, some form of heterotopic ossification (HO) was developed in 11 out of 52 patients (21%). However, 1/52 patients (1.9%) required HO resection as a subsequent procedure for a limited range of motion. In literature, HO after surgical treatment of acetabular fractures ranges from 7% to 100%, whereas exact pathogenesis remains unknown.,, In the study by Firazooabadi et al., the only risk factor which predicted severe HO was prolonged mechanical ventilation. In their study, 38 patients (12%) developed severe HO, and five of these patients (13%) required HO resection. In our study, no patient developed HO, in contrast to other studies, but probably due to a smaller group of patients and the use of the KL approach which is less frequently associated with HO.
Retrospective design, a limited number of patients, and limited follow-up are basic limitations to our study. However, there were no fixation failures in all 16 patients using this technique of spring plate fixation. There always remains the possibility that a large sample of patients with longer follow-up could reveal implant failures that were not found in this study. The Mast et al. concept of a combination of customized spring plates under screw compression combined with a 3.5 mm pelvic compression reconstruction plate excessively offers significantly augmented stability in treating comminuted posterior wall fractures without customized implant failure in the study cohort., Many of the confounding factors present in this study could be eliminated by conducting a prospective, randomized study.
| Conclusion|| |
Our study strongly supports the concept that customized recon plates as spring plates are the best adjunctive fixation in the management of comminuted posterior wall acetabular fractures. We hope that our results will definitely encourage further studies with greater patient numbers.
In summary, spring plates under traditional 3.5 mm recon plates are an acceptable means of fixation of comminuted posterior wall fragments not amenable to lag screw fixation. Spring plates successfully allow for definitive fixation of comminuted posterior wall acetabular fractures and stability to allow mobilization of patients without a significant risk of hardware failure or intra-articular hardware penetration.
Ethical committee permission
Permission was obtained from the institute's ethical committee at the beginning of the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Letournel E, Judet R. In: Fractures of the Acetabulum. New York: Springer;1993.
Letournel E. Acetabulum fractures: Classification and management. Clin Orthop Relat Res 1980;151:81-106.
Matta JM. Fractures of the acetabulum: Accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am 1996;78:1632-45.
Tannast M, Najibi S, Matta JM. Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures. J Bone Joint Surg Am 2012;94:1559-67.
Mayo KA, Letournel E, Matta JM, Mast JW, Johnson EE, Martimbeau CL. Surgical revision of malreduced acetabular fractures. Clin Orthop Relat Res 1994;305:47-52.
Wright R, Barrett K, Christie MJ, Johnson KD. Acetabular fractures: Long-term follow-up of open reduction and internal fixation. J Orthop Trauma 1994;8:397-403.
Olson SA, Bay BK, Chapman MW, Sharkey NA. Biomechanical consequences of fracture and repair of the posterior wall of the acetabulum. J Bone Joint Surg Am 1995;77:1184-92.
Mitsionis GI, Lykissas MG, Motsis E, Mitsiou D, Gkiatas I, Xenakis TA, et al.
Surgical management of posterior hip dislocations associated with posterior wall acetabular fracture: A study with a minimum follow-up of 15 years. J Orthop Trauma 2012;26:460-5.
Mast J, Jakob R, Ganz R. Planning and Reduction Technique in Fracture Surgery. New York: Springer-Verlag; 1989. p. 244.
Richter H, Hutson JJ, Zych G. The use of spring plates in the internal fixation of acetabular fractures. J Orthop Trauma 2004;18:179-81.
Ziran BH, Little JE, Kinney RC. The use of a T-plate as “spring plates” for small comminuted posterior wall fragments. J Orthop Trauma 2011;25:574-6.
Dunbar RP Jr., Gardner MJ, Cunningham B, Routt ML Jr. Sciatic nerve entrapment in associated both-column acetabular fractures: A report of 2 cases and review of the literature. J Orthop Trauma 2009;23:80-3.
Fassler PR, Swiontkowski MF, Kilroy AW, Routt ML Jr. Injury of the sciatic nerve associated with acetabular fractures. J Bone Joint Surg Am 1993;75:1157-66. doi:10.2106/00004623-199308000-00005.
Middlebrooks ES, Sims SH, Kellam JF, Bosse MJ. Incidence of sciatic nerve injury in operatively treated acetabular fractures without somatosensory evoked potential monitoring. J Orthop Trauma 1997;11:327-9.
Lehmaan W, Hoffmann M, Fensky F, Nüchtern J, Großterlinden L, Aghayev E, et al. What is the frequency of nerve injuries associated with acetabular fractures? Clin Orthop Relat Res 2014;472:3395-403. doi: 10.1007/s11999-014-3838-9.
Daum WJ, Scarborough MT, Gordon W Jr., Uchida T. Heterotopic ossification and other perioperative complications of acetabular fractures. J Orthop Trauma 1992;6:427-32.
Ghalambor N, Matta JM, Bernstein L. Heterotopic ossification following operative treatment of acetabular fracture. An analysis of risk factors. Clin Orthop Relat Res 1994;305:96-105.
Kaempffe FA, Bone LB, Border JR. Open reduction and internal fixation of acetabular fractures: Heterotopic ossification and other complications of treatment. J Orthop Trauma 1991;5:439-45.
Firoozabadi R, O'Mara TJ, Swenson A, Agel J, Beck JD, Routt M. Risk factors for the development of heterotopic ossification after acetabular fracture fixation. Clin Orthop Relat Res 2014;472:3383-8.
Goulet JA, Roulen JP, Mason DJ, Goldstein SA. Comminuted fractures of the posterior wall of the acetabulum: A mechanical evaluation of fixation methods. J Bone Joint Surg Am 1994;76A: 1457-63. doi: 10.2106/00004623-199410000-00004.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]