Advertisement
Research Article| Volume 11, ISSUE 6, P1045-1052, November 2020

Download started.

Ok

Does use of a quadrilateral surface plate improve outcome in elderly acetabular fractures?

Published:October 06, 2020DOI:https://doi.org/10.1016/j.jcot.2020.10.001

      Abstract

      Background

      Acetabular fractures in the elderly frequently involve segmental quadrilateral plate injury, yet no consensus exists on how to best control the femoral head medial displacement. Quadrilateral surface plates (QSP) were developed to help buttress these challenging fractures. The study aims to 1) Determine the prevalence of segmental quadrilateral plate fractures (SQPF) in elderly patients; and 2) Assess if utilization of a QSP is associated with improved acetabulum fracture reduction and outcome.

      Methods

      This was a retrospective study conducted at a level-1 trauma centre. . All patients over 60-years that sustained an acetabular fracture between 2007 and 2019 were reviewed. Pre-operative pelvic radiographs and CT imaging were reviewed for 96 patients, to assess for SQPF. From the 96 patients reviewed, over one third of patients (n = 40, 41.6%) sustained a SQPF. Patients that had an acute-THA (n = 7) were excluded as were patients that underwent an ORIF but did not have a QSP or an anterior column buttress plate (n = 3). The remaining 30 formed the study’s cohort. We assessed the ability to achieve and maintain reduction in this elderly population, and compared outcomes using traditional anterior column buttress plates (ilioingual or intra-pelvic approach) versus an intra-pelvic pre-contoured buttress suprapectineal plate (QSP). Outcome measures included: fracture reduction using the Matta classification (desirable: anatomical/imperfect and poor), re-operations, conversion to THA and Oxford Hip Score (OHS) (for the preserved hips).

      Results

      Ten patients had an ORIF with utilization of a QSP (QSP-group), and 20 had an ORIF but did not have the QSP (non-QSP-group). There was no difference in patient demographics between groups. Fracture patterns were also similar (p = 0.6). Postoperative fracture reduction was desirable (anatomical/imperfect) in 17 patients and poor in 13. Improved ability to achieve a desirable reduction was seen in the QSP-group (p = 0.02). Conversion to THA was significantly lower in patients that had a desirable fracture reduction (appropriate: 3/17; poor: 7/13). No patients in the QSP-group have required a THA to-date, compared to 10/20 patients in the non-QSP-group (p = 0.01). The mean time to THA was 1.6 ± 2.1 year. There was no difference in OHS between the two groups (34.4 ± 10.3).

      Conclusion

      Elderly acetabulum fractures have a high incidence (approaching 40%) of segmental QPF. Desirable (anatomical/imperfect) fracture reduction was associated with improved outcome. The use of a QSP was associated with improved ability to achieve an appropriate reduction. A QSP should be considered as they are both reliable and reproducible with a significantly improved fracture reduction and lower conversion to THA.

      Keywords

      1. Introduction

      Acetabular fractures in the elderly population are the fastest growing cohort of acetabular fractures,
      • Rinne P.P.
      • Laitinen M.K.
      • Huttunen T.
      • Kannus P.
      • Mattila V.M.
      The incidence and trauma mechanisms of acetabular fractures: a nationwide study in Finland between 1997 and 2014.
      • Melhem E.
      • Riouallon G.
      • Habboubi K.
      • Gabbas M.
      • Jouffroy P.
      Epidemiology of pelvic and acetabular fractures in France.
      with 12–14% occurring in patients over 65-years of age.
      • Firoozabadi R.
      • Cross W.W.
      • Krieg J.C.
      • Routt M.L.C.
      Acetabular fractures in the senior population- epidemiology, mortality and treatments.
      • Papadakos N.
      • Pearce R.
      • Bircher M.D.
      Low energy fractures of the acetabulum.
      This population displays a different distribution of fracture patterns and fracture characteristics than the one seen in the younger population.
      • Ferguson T.A.
      • Patel R.
      • Bhandari M.
      • Matta J.M.
      Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study.
      This is related to the mechanism of injury, most commonly a fall from standing height (47%)
      • Rinne P.P.
      • Laitinen M.K.
      • Huttunen T.
      • Kannus P.
      • Mattila V.M.
      The incidence and trauma mechanisms of acetabular fractures: a nationwide study in Finland between 1997 and 2014.
      , and the underlying bone quality, with higher incidence of osteoporotic bone.
      • Mears D.C.
      Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone.
      These differences result in an increased incidence of acetabular roof and posterior marginal impaction, comminution and segmental quadrilateral plate fractures (SQPF).
      • Ferguson T.A.
      • Patel R.
      • Bhandari M.
      • Matta J.M.
      Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study.
      • White G.
      • Kanakaris N.K.
      • Faour O.
      • Valverde J.A.
      • Martin M.A.
      • Giannoudis P.V.
      Quadrilateral plate fractures of the acetabulum: an update.
      • Laflamme G.Y.
      • Hebert-Davies J.
      • Rouleau D.
      • Benoit B.
      • Leduc S.
      Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate.
      • Butterwick D.
      • Papp S.
      • Gofton W.
      • Liew A.
      • Beaulé P.E.
      Acetabular fractures in the elderly: evaluation and management.
      These fracture characteristics have all been associated with inferior patient outcome and a higher conversion rate to THA following fracture fixation.
      • Ferguson T.A.
      • Patel R.
      • Bhandari M.
      • Matta J.M.
      Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study.
      .
      SQPF are associated with many fracture patterns described by Letournel; most commonly both column, anterior column posterior hemi-transverse (ACPHT), anterior column, transverse, and T-shaped fractures, but do not as an entity contribute to the main fracture classification systems.
      • Laflamme G.Y.
      • Hebert-Davies J.
      • Rouleau D.
      • Benoit B.
      • Leduc S.
      Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate.
      • Letournel E.
      Acetabulum fractures: classification and management.
      • LaflammeGY DelisleJ.
      • LeducS UzelPA.
      Isolated quadrilateral plate fracture: an unusual acetabular fracture.
      • Qureshi A.A.
      • Archdeacon M.T.
      • Jenkins M.A.
      • Infante A.
      • DiPasquale T.
      • Bolhofner B.R.
      Infrapectineal plating for acetabular fractures: a technical adjunct to internal fixation.
      Perhaps due to the fact SQPF can be associated with many types of acetabulum fractures, there is no consensus on the optimum management to maintain SQPF reduction and control the associated femoral head medial displacement, particularly in the elderly population.
      • White G.
      • Kanakaris N.K.
      • Faour O.
      • Valverde J.A.
      • Martin M.A.
      • Giannoudis P.V.
      Quadrilateral plate fractures of the acetabulum: an update.
      • Hutt J.R.
      • Ortega-Briones A.
      • Daurka J.S.
      • Bircher M.D.
      • Rickman M.S.
      The ongoing relevance of acetabular fracture classification.
      However failure to achieve reduction of the columns and recreate the buttress function of the columns and the medial wall to reduce the central displacement of the femoral head results in hip incongruity and a poor outcome despite reduction of acetabular columns and other wall fragments.
      • Tile M.
      • Helfet D.
      • Kellam J.
      Fractures of the Pelvis and Acetabulum.

      Sanders E, Finless A, Adamczyk A, et al. Outcome Following Open Reduction Internal Fixation (ORIF) of Acetabular Fractures in the Elderly– Comparison to ORIF-THA. COA, June 2020, Halifax, Nova Scotia

      • Laflamme G.Y.
      • Hebert-Davies J.
      • Rouleau D.
      • Benoit B.
      • Leduc S.
      Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate.
      .
      Elderly patients often have an array of confounding factors that can make control of the medial femoral head displacement more challenging, such as poor bone quality and limited tolerance for periods of non-weightbearing.
      • Mears D.C.
      Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone.
      • Kammerlander C.
      • Pfeufer D.
      • Lisitano L.A.
      • Mehaffey S.
      • Böcker W.
      • Neuerburg C.
      Inability of older adult patients with hip fracture to maintain postoperative weight-bearing restrictions.
      In some cases, the damage to the joint is such that an acute THA is recommended.
      • Salama W.
      • Mousa S.
      • Khalefa A.
      • et al.
      Simultaneous open reduction and internal fixation and total hip arthroplasty for the treatment of osteoporotic acetabular fractures.
      • De Bellis U.G.
      • Legnani C.
      • Calori G.M.
      Acute total hip replacement for acetabular fractures: a systematic review of the literature.
      • McMahon S.E.
      • Diamond O.J.
      • Cusick L.A.
      Coned hemipelvis reconstruction for osteoporotic acetabular fractures in frail elderly patients.
      Options available for surgical fixation to address the SQPF and medial femoral head displacement include a combination of Supra/infrapectineal reconstruction plates and column lag screw fixation, braided cables or heavy wires
      • Mears D.C.
      Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone.
      , percutaneous screw fixation “magic Screw”
      • Starr A.
      • Borer D.
      • Reinert C.
      Technical aspects of limited open reduction and percutaneous screw fixation of fractures of the acetabulum.
      or buttress screw fixation.
      • Karim M.A.
      • Abdelazeem A.H.
      • Youness M.
      • El Nahal W.A.
      Fixation of quadrilateral plate fractures of the acetabulum using the buttress screw: a novel technique.
      Anatomical Quadrilateral Surface plates (QSP) have also been developed to buttress the quadrilateral plate in the management of these challenging fractures.
      • Kistler B.J.
      • Smithson I.R.
      • Cooper S.A.
      • et al.
      Are quadrilateral surface buttress plates comparable to traditional forms of transverse acetabular fracture fixation? [published correction appears in Clin Orthop Relat Res. 2015 Jan;473(1):402.
      .
      Anterior intrapelvic surgical approaches such as the modified Stoppa have been popularized to aid with SQPF visualization and the application of a QSP.
      ColeJD,BolhofnerBR.AcetabularfracturefixationviaamodifiedStoppalimited
      Intrapelvic approach. Description of operative technique and preliminary treatment results.
      • Sagi H.C.
      • Afsari A.
      • Dziadosz D.
      The anterior intra-pelvic (modified Rives-Stoppa) approach for fixation of acetabular fractures.
      • Chen K.
      • Yang F.
      • Yao S.
      • Xiong Z.
      • Sun T.
      • Guo X.
      Biomechanical comparison of different fixation techniques for typical acetabular fractures in the elderly: the role of special quadrilateral surface buttress plates [published online ahead of print, 2020 mar 23].
      Fixation of SQPF using an intrapelvic approach has been shown in the younger population to give satisfactory fixation.
      • Zhang R.
      • Yin Y.
      • Li S.
      • et al.
      Fixation of displaced acetabular fractures with an anatomic quadrilateral surface plate through the stoppa approach.
      • Nikolopoulos F.V.
      • Tzoras N.T.
      The advantages of stoppa approach-ilioinguinal modification, for surgical treatment of the acetabulum fractures with the traditional plate and the new anatomical suprapectineal plate system.
      In addition, biomechanics testing using composite hemipelvis has revealed similar fixation to a suprapectineal pelvic brim plate with periarticular screw fixation, and in some fracture patterns superior fixation, with the added benefit of a less invasive anterior intrapelvic approach.
      • Chen K.
      • Yang F.
      • Yao S.
      • Xiong Z.
      • Sun T.
      • Guo X.
      Biomechanical comparison of different fixation techniques for typical acetabular fractures in the elderly: the role of special quadrilateral surface buttress plates [published online ahead of print, 2020 mar 23].
      • Kistler B.J.
      • Smithson I.R.
      • Cooper S.A.
      • et al.
      Are quadrilateral surface buttress plates comparable to traditional forms of transverse acetabular fracture fixation? [published correction appears in Clin Orthop Relat Res. 2015 Jan;473(1):402].
      .
      Fracture characteristics and bone quality in the elderly are dissimilar to the younger population, and plates used in buttress mode have demonstrated superior outcomes in most articular fracture patterns. It remains unknown whether the use of a QSP to buttress and stabilize these challenging fractures in this population. The aims of this study were to 1. Determine the prevalence of segmental quadrilateral plate fractures (SQPF) in elderly patients; and 2. Assess if utilization of a QSP is associated with improved acetabulum fracture reduction and outcome when compared to isolated suprapectineal pelvic reconstruction plates.

      2. Materials and methods

      This is an IRB-approved, multi-surgeon, retrospective, consecutive case series between 2007 and 2019 from a level 1 trauma centre. Inquiring into the institutional database, 120 patients that had sustained an acetabular fracture who were over the age of 60 at the time of the injury were identified. Strict inclusion criteria were applied and patients that underwent a two-stage ORIF, conservative management, those with inaccessible medical records, associated femoral injury or acetabular fracture following hemi-arthroplasty were excluded. The decision to proceed with acetabular ORIF was made by the on-call pelvic trauma surgeon taking into consideration, age, comorbidities, bone quality, pre-existing osteoarthritis and fracture characteristics.

      2.1 Patient identification

      Ninety-six patients satisfied potential inclusion criteria and their pre-operative pelvic radiographs and CT imaging were reviewed by an Arthroplasty fellow (GN) who has completed a pelvic and acetabulum trauma fellowship and two senior P&A trauma surgeons (AL & SP). The review was performed in a blinded manner with the reviewer not knowing the fracture management undertaken or the patient outcome. Patients were selected if there was an acetabulum fracture with a segmental SQPF, and it was felt a QSP would have benefited fracture reduction and fixation.
      Deciding if the QSP would benefit reduction and maintenance was a critically step in the process (Fig. 1). In some cases, the femoral head did have medial displacement, but this was caused by dome impaction with a “gull sign”
      • Anglen J.O.
      • Burd T.A.
      • Hendricks K.J.
      • Harrison P.
      The "Gull Sign": a harbinger of failure for internal fixation of geriatric acetabular fractures.
      together with displacement of the columns. The quadrilateral plate, although fractured did not have segmentation. In these cases, the quadrilateral plate would move with the columns. As long as any dome impaction had been addressed, reducing and fixing the columns would correct femoral head medialization and control the quadrilateral plate fracture line, regardless of the type of plate used (Fig. 2). Therefore, these cases were not included in the study. However, if the quadrilateral plate was a separate fragment (i.e. not attached to either the anterior or posterior column fragment) it was thought the QSP could aid with the fracture reduction, fracture control, and aid with the medial support of the femoral head via the floor of the acetabulum, helping to protect the corrected dome impaction. In these cases, the patient was included in the study cohort (Fig. 3).
      Fig. 2
      Fig. 2This patient was excluded as there is medial displacement of the femoral head, however the QPF does not play a role. Reconstructing the columns, and dome impaction will control the femoral head medial displacement.
      Fig. 3
      Fig. 3This patient was included as there is medial displacement of the femoral head and it was felt a QSP would help control the QSF which would potentially benefit in controlling the medial femoral head displacement.
      Review of the radiological imaging identified that over one third (n = 40, 41.6%) of the elderly patients had sustained a SQPF that was felt would benefit from a QSP. Seven of the patients underwent concomitant THA at the time of the ORIF and three patients had fixation using a Kocher Langenbeck approach without plate fixation of the anterior column and were hence excluded from further analysis. The remaining (n = 30) patients formed the study’s cohort.

      2.2 Data collection

      The hospital’s medical records were used to collect data on the (n = 30) cohort; including patient demographics, mechanism of injury, Charlson Comorbidity Index (CCI), American Society of Anaesthesiologists (ASA) Grade, operative records including surgical approach, post-operative complications and reoperations including conversion to THA. The integrated suprapectineal and QSP was introduced to our centre in 2015, surgeons have been able to decide since then if it is the best management option for their patients’ fracture pattern. Prior to this the stoppa approach with separate medial and anterior column buttress plates were being utilised as a surgical approach in this centre for the management of similar fractures.

      2.3 Radiographic analysis

      Pre-operative radiograph and CT scans were also used to identify fracture pattern and characteristics. Post-operative antero-posterior pelvic, and Judet radiographs of the acetabulum were used to assess the postoperative quality of reduction according to the Matta grade
      • Matta J.M.
      • Merrit P.O.
      Displaced acetabular fractures.
      with reduction being sub-classified into desirable (anatomical/imperfect) and poor. The assessments were performed by a staff orthopaedic surgeon, blinded to the patient outcome and not directly involved with patient care.

      2.4 Outcome measures

      Outcome measures of interest included quality of fracture reduction according to Matta, post-operative complications, reoperations, conversion to THA and patient reported outcome measures (PROMs) at follow-up, using the Oxford Hip Score (OHS) (range 0–48, worst-best) were recorded amongst the non-replaced hips. An anatomical or imperfect reduction as per Matta classification was considered desirable.

      2.5 Statistical analysis

      Analysis was performed using SPSS. Intergroup comparisons were made using Mann-Whitney U for continuous variables, cross-tabulation and Chi-Square for categorical variables. Significance was set at p < 0.05.

      Source of funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      3. Results

      3.1 Fixation method

      Of those 30 patients, ten had an ORIF with utilization of a QSP and formed the (QSP-group) and 20 had an ORIF but did not have the QSP, forming the (non-QSP-group). Patients in the non-QSP-group had fixation in the form of a combination of Supra/infrapectineal reconstruction plates and column lag screw fixation. No patients received braided cables, heavy wires, percutaneous screw fixation alone or buttress screw fixation. Fig. 4 is a histogram displaying the use of a QSP for the management of the patient cohort over the years investigated. Indicating the change in practice at our unit. There were only 6 cases that met the inclusion criteria after July 2015 (when the plate had been introduced) in which the QSP was not used, that were identified as potentially benefitting from a QSP. Since the introduction of the plate, 10/16 patients (63%) had a QSP. The remaining were done before July 2015.
      Fig. 4
      Fig. 4Histogram of fracture management by year.

      3.2 Patient demographics

      The QSP-group and the non-QSP-group had no difference in patient demographics (Table 1). Patient age at time of the ORIF was (74 ± 8 years) in the non-QSP-group compared to (70 ± 9 years) in the QSP-group (p = 0.2). There were no sex differences (14 M/6F Vs. 6 M/4F) (p = 0.6) or differences in mechanism of injury with regards low (8 vs. 3) or high (12 vs. 7) energy (p = 0.6). Charlson comorbidity index was similar between groups (4 ± 2 Vs. 3 ± 1) (p = 0.2) as was ASA grade (p = 0.1). The fracture patterns were similar between groups; with the most common patterns being either anterior column posterior hemi-transverse (n = 11) or associated both columns (n = 16) (p = 0.6).
      Table 1Demographics of cohort.
      Non QSP group (n = 20)QSP group (n = 10)p-value
      Age (years)74 ± 870 ± 9p = 0.2
      Gender14 M/6F6 M/4Fp = 0.6
      Mechanism of injury (L = low energy, H = High energy)8 L/12H3/7p = 0.6
      Charlson comorbidity index4 ± 23 ± 1p = 0.2
      ASA GradeI/II: 7I/II: 1p = 0.1
      III/IV: 13III/IV: 9
      Fracture Pattern (Letournel)ACPHT: 7ACPHT: 4p = 0.6
      ABC: 10ABC: 6
      Transverse: 1Transverse: 0
      AC: 2AC: 0
      Operative time, Surgical Approach and length of hospital stay:
      The mean operative time was 251 ± 112 min, there was no difference in operative time in the QSP-group compared to non-QSP group (222 ± 59 Vs. 261 ± 91): (p = 0.3). There was no difference in the surgical approach or use of dual approach between groups (p = 0.7) Table 2.
      Table 2Surgical approach.
      Surgical ApproachGroup
      Non QSP group (n = 20)QSP group (n = 10)
      Ilioinguinal123
      Stoppa99
      Dual Approach12
      The mean length of stay was 18 ± 9 days; no difference was seen between the QSP-group and non-QSP group (17 ± 8 Vs. 19 ± 11): (p = 0.9).

      3.3 Radiological analysis

      Fracture reduction according to Matta was desirable (anatomical/imperfect) in 17/30 patients and poor in 13/30. Improved ability to achieve desirable fracture reduction was seen in the QSP-group compared to the non-QSP-group (p = 0.03) (Table 3) (Fig. 5, Fig. 6). The odds ratio of having a better reduction, avoiding a poor reduction, using a QSP was 9.8, (p = 0.04) Table 3.
      Table 3Fracture reduction quality.
      Non QSP group (n = 20)QSP group (n = 10)p-value
      Matta GradeAnatomic: 1Anatomic: 30.02
      Imperfect: 7Imperfect: 6
      Poor: 12Poor: 1
      Fig. 5
      Fig. 5An example of the fracture reduction and the loss of fracture position This shows the imperfect reduction obtained from the patient previously shown in .
      Fig. 6
      Fig. 6An example of the fracture reduction and the loss of fracture position. This shows a similar fracture configuration to that in again with a QPF, but managed with a QSP, with improved fracture reduction.

      3.4 Complications and reoperations

      The mean follow-up for the QSP-group was 1.9 ± 1.2 years and for the non-QSP-group was 5.6 ± 4.0 years. Patients who had an appropriate fracture reduction (n = 17) had a significantly lower conversion rate to THA with three patients requiring a THA, in comparison to the (n = 13) patients with a poor reduction, in which 7 required a THA (p = 0.04). No patients in the QSP-group have gone on to require conversion to THA compared to 10/20 patients in the non-QSP-group (p = 0.01), the mean time to THA was 1.6 ± 2.1 years. Comparing only the appropriate reductions in QSP and the non-QSP groups, there was no significant difference in the conversion to THA. In the non-QSP group, 3 out of 8 patients required conversion to THA in comparison to 0 out of 9 in the QSP group (p = 0.08). Two patients in the QSP-group required a re-operation due to infection.

      3.5 Patient reported outcomes

      There was no statistical difference in patient reported outcomes comparing the patients that had not gone onto have a THA the QSP-group recorded an OHS of 35+/10 Vs. 34 ± 11 in the non-QSP-group (p = 0.7).

      4. Discussion

      Failure to reduce the central displacement of the femoral head results in hip incongruity and a poor outcome despite reduction of acetabular columns and other wall fragments.
      • Laflamme G.Y.
      • Hebert-Davies J.
      • Rouleau D.
      • Benoit B.
      • Leduc S.
      Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate.
      • Tile M.
      • Helfet D.
      • Kellam J.
      Fractures of the Pelvis and Acetabulum.

      Sanders E, Finless A, Adamczyk A, et al. Outcome Following Open Reduction Internal Fixation (ORIF) of Acetabular Fractures in the Elderly– Comparison to ORIF-THA. COA, June 2020, Halifax, Nova Scotia

      Similarly, in this study, we observed worse outcomes with more conversion to THA in cases in which fracture reduction was poor. Interestingly, we found improved fracture reduction and reduced conversion to THA when using a QSP. These results support the results of recent biomechanical studies, that have shown there is equivalent and in some fracture patterns superior fixation with a QSP.
      • Chen K.
      • Yang F.
      • Yao S.
      • Xiong Z.
      • Sun T.
      • Guo X.
      Biomechanical comparison of different fixation techniques for typical acetabular fractures in the elderly: the role of special quadrilateral surface buttress plates [published online ahead of print, 2020 mar 23].
      • Kistler B.J.
      • Smithson I.R.
      • Cooper S.A.
      • et al.
      Are quadrilateral surface buttress plates comparable to traditional forms of transverse acetabular fracture fixation? [published correction appears in Clin Orthop Relat Res. 2015 Jan;473(1):402].
      However in this population with poor bone quality, there appears to be a biomechanical advantage of the direct visualization of reduction from a medial window and medial buttress plating. This differs from younger patients with good bone quality, in which reconstruction plates with column screws together with a “magic screw” are often excellent fixation methods in patients.
      Elderly osteoporotic acetabulum fractures are the most rapidly growing subgroup of acetabular fractures and present a unique set of medical and surgical challenges.
      • Rinne P.P.
      • Laitinen M.K.
      • Huttunen T.
      • Kannus P.
      • Mattila V.M.
      The incidence and trauma mechanisms of acetabular fractures: a nationwide study in Finland between 1997 and 2014.
      • Melhem E.
      • Riouallon G.
      • Habboubi K.
      • Gabbas M.
      • Jouffroy P.
      Epidemiology of pelvic and acetabular fractures in France.
      There are a number of fracture characteristics more commonly seen in this population including; segmental quadrilateral plate fractures.
      • Ferguson T.A.
      • Patel R.
      • Bhandari M.
      • Matta J.M.
      Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study.
      • White G.
      • Kanakaris N.K.
      • Faour O.
      • Valverde J.A.
      • Martin M.A.
      • Giannoudis P.V.
      Quadrilateral plate fractures of the acetabulum: an update.
      • Laflamme G.Y.
      • Hebert-Davies J.
      • Rouleau D.
      • Benoit B.
      • Leduc S.
      Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate.
      This study with an initial cohort of 96 patients, has observed that in elderly patients with acetabulum fractures the prevalence of SQPF is over one third (n = 40). This trauma centre’s approach to the management of these difficult fractures has changed over the past 5 years following the introduction of the QSP which is now used in 63% of elderly acetabular cases with a SQPF. This change in practice appears to have had a direct effect on the fracture reduction quality and failure rate.
      The study cohort consisted of 30 patients; (n = 10) formed the QSP-group and (n = 20) the non-QSP-group. No difference was seen in patient demographics between groups. They were matched with age, sex, mechanism of injury, Charlson comorbidity index, as well as ASA grade. The fracture patterns were also similar between groups; (p = 0.6) as was the length of hospital stay (p = 0.09).The surgical approach (p = 0.7) was similar as was the operative time (p = 0.3). In the future, once the learning curve associated with the novel technology, we anticipate the operative time to be shorter in the QSP group. This is a result of the time used to contour the pelvic reconstruction plate being eliminated by the pre-contoured QSP.
      Comparing the fracture reduction and patient outcome following surgical fixation. In the 30-patient cohort the postoperative fracture reduction was desirable (anatomical or imperfect) in 17 patients and poor in 13. The quality of the reduction had a direct impact on the conversion to THA, as conversion to THA was significantly lower in patients that had an improved reduction 3 Vs. 7 (p = 0.04). Reviewing only the appropriate reductions in the QSP and non-QSP groups, there was no significant difference in the conversion to THA (p = 0.08). If a desirable fracture reduction is achieved, there is a reduced conversion rate to THA regardless which of these two fixation methods are used. In patients who have not been converted to a THA, there is no difference in OHS 35+/10 Vs. 34 ± 11 in the non-QSP-group (p = 0.7). However, in the non-QSP group, 3 out of 8 patients required conversion to THA, in comparison to no patients in the QSP group. However, this study was not powered to test the ability of the fixation method used to maintain the degree of reduction achieved in surgery; further study is thus needed to test for this. However, the ability to achieve an improved fracture reduction in elderly patients with a SQPF was found to be significantly improved (p = 0.02) with the use of a suprapectineal QSP. As a result of the improved reduction in the QSP-group there is a significant reduction in conversion to THA (p = 0.01) compared to the non-QSP group.
      It is our impression that the pre-contoured shape of a suprapectineal anatomical QSP can be used in some instances as a reduction tool, allowing the surgeon to utilize the medial buttress effect of the surgical plate when applying it, spreading the force over the quadrilateral surface and indirectly correcting the femoral head position. The use of an intrapelvic approach may also give a more direct visualization and a mechanical advantage when addressing fractures of the quadrilateral plate and fractures with medial dome impaction.
      ColeJD,BolhofnerBR.AcetabularfracturefixationviaamodifiedStoppalimited
      Intrapelvic approach. Description of operative technique and preliminary treatment results.
      • Sagi H.C.
      • Afsari A.
      • Dziadosz D.
      The anterior intra-pelvic (modified Rives-Stoppa) approach for fixation of acetabular fractures.
      • Chen K.
      • Yang F.
      • Yao S.
      • Xiong Z.
      • Sun T.
      • Guo X.
      Biomechanical comparison of different fixation techniques for typical acetabular fractures in the elderly: the role of special quadrilateral surface buttress plates [published online ahead of print, 2020 mar 23].
      • Chesser T.J.
      • Eardley W.
      • Mattin A.
      • Lindh A.M.
      • Acharya M.
      • Ward A.J.
      The modified ilioinguinal and anterior intrapelvic approaches for acetabular fracture fixation: indications, quality of reduction, and early outcome.
      .
      This study has several limitations as a result of its retrospective design and small cohort number, related to the recent introduction of the QSP at our centre. Selection biases exist as the treating surgeon decided on the type of treatment offered to the patients at the time of the injury (ORIF Vs. acute THA) and the surgical approach. This study includes the first elderly patients in this centre beginning from July 2015 that were selected for a QSP. As a result, the fracture reduction and patient outcome may have been affected by the development of the surgical intrapelvic approach together with the learning curve of the technique of applying the plate and the equipment available to aid in plate placement. However, we would suggest any improvement in fracture reduction and decrease in conversion to THA would only have been improved with further experience. There was a shorter follow up time of the QSP group (1.9 ± 1.2 years) compared to the non-QSP group (5.6 ± 4.0 years), due to the fact this technique was more recently introduced. However, the mean conversion to THA after ORIF in the non-QSP group was on average less than the follow up time that has been observed in the QSP group at 1.6 ± 2.1 years. Another limitation is the possible lack of study power as there appears to be reduced conversion to a THA in the QSP-group when comparing patients with a desirable fracture reduction in the non-QSP group, a larger study may have shown a significance difference.

      5. Conclusion

      Elderly acetabulum fractures have a high incidence (approaching 40%) of SQPF. Anatomic or imperfect fracture reduction is associated with a reduction in conversion to THA. If an appropriate reduction is achieved there appears to be no difference in conversion to THA regardless of the fixation method used. However, all conversions to THA in cases with appropriate reductions occurred in cases that had not used the QSP and thus the lack of statistical significance may be secondary to the study’s lack of power. A suprapectineal QSP should be considered in patients with a SQPF as they are both reliable and reproducible with a significantly improved chance of obtaining a desirable fracture reduction and hence a lower conversion to THA.

      5.1 Acknowledgments

      None.

      Funding statement

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      Declaration of competing interest

      No authors have any conflicts of interest to declare relevant to this study.

      References

        • Rinne P.P.
        • Laitinen M.K.
        • Huttunen T.
        • Kannus P.
        • Mattila V.M.
        The incidence and trauma mechanisms of acetabular fractures: a nationwide study in Finland between 1997 and 2014.
        Injury. 2017 Oct; 48: 2157-2161https://doi.org/10.1016/j.injury.2017.08.003
        • Melhem E.
        • Riouallon G.
        • Habboubi K.
        • Gabbas M.
        • Jouffroy P.
        Epidemiology of pelvic and acetabular fractures in France.
        Orthop Traumatol Surg Res. 2020 Feb 1; S1877–0568: 30001-30003
        • Firoozabadi R.
        • Cross W.W.
        • Krieg J.C.
        • Routt M.L.C.
        Acetabular fractures in the senior population- epidemiology, mortality and treatments.
        Arch Bone Jt Surg. 2017 Mar; 5: 96-102
        • Papadakos N.
        • Pearce R.
        • Bircher M.D.
        Low energy fractures of the acetabulum.
        Ann R Coll Surg Engl. 2014 May; 96: 297-301
        • Ferguson T.A.
        • Patel R.
        • Bhandari M.
        • Matta J.M.
        Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study.
        J Bone Joint Surg Br. 2010; 92: 250-257https://doi.org/10.1302/0301-620X.92B2.22488
        • Mears D.C.
        Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone.
        J Am Acad Orthop Surg. 1999; 7: 128-141
        • White G.
        • Kanakaris N.K.
        • Faour O.
        • Valverde J.A.
        • Martin M.A.
        • Giannoudis P.V.
        Quadrilateral plate fractures of the acetabulum: an update.
        Injury. 2013; 44: 159-167https://doi.org/10.1016/j.injury.2012.10.010
        • Laflamme G.Y.
        • Hebert-Davies J.
        • Rouleau D.
        • Benoit B.
        • Leduc S.
        Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate.
        Injury. 2011; 42: 1130-1134https://doi.org/10.1016/j.injury.2010.11.060
        • Butterwick D.
        • Papp S.
        • Gofton W.
        • Liew A.
        • Beaulé P.E.
        Acetabular fractures in the elderly: evaluation and management.
        J Bone Joint Surg Am. 2015; 97: 758-768https://doi.org/10.2106/JBJS.N.01037
        • Letournel E.
        Acetabulum fractures: classification and management.
        J Orthop Trauma. 2019; 33: S1-S2https://doi.org/10.1097/BOT.0000000000001424
        • LaflammeGY DelisleJ.
        • LeducS UzelPA.
        Isolated quadrilateral plate fracture: an unusual acetabular fracture.
        Canadian J. Surg. J. Canadien Chirurgie. 2009; 52: E217-E219
        • Qureshi A.A.
        • Archdeacon M.T.
        • Jenkins M.A.
        • Infante A.
        • DiPasquale T.
        • Bolhofner B.R.
        Infrapectineal plating for acetabular fractures: a technical adjunct to internal fixation.
        J Orthop Trauma. 2004; 18: 175-178
        • White G.
        • Kanakaris N.K.
        • Faour O.
        • Valverde J.A.
        • Martin M.A.
        • Giannoudis P.V.
        Quadrilateral plate fractures of the acetabulum: an update.
        Injury. 2013; 44: 159-167https://doi.org/10.1016/j.injury.2012.10.010
        • Hutt J.R.
        • Ortega-Briones A.
        • Daurka J.S.
        • Bircher M.D.
        • Rickman M.S.
        The ongoing relevance of acetabular fracture classification.
        Bone Joint Lett J. 2015; 97-B: 1139-1143https://doi.org/10.1302/0301-620X.97B8.33653
        • Tile M.
        • Helfet D.
        • Kellam J.
        Fractures of the Pelvis and Acetabulum.
        third ed. Lippincott Williams & Wilkins, Baltimore2003
      1. Sanders E, Finless A, Adamczyk A, et al. Outcome Following Open Reduction Internal Fixation (ORIF) of Acetabular Fractures in the Elderly– Comparison to ORIF-THA. COA, June 2020, Halifax, Nova Scotia

        • Mears D.C.
        Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone.
        J Am Acad Orthop Surg. 1999; 7: 128-141
        • Kammerlander C.
        • Pfeufer D.
        • Lisitano L.A.
        • Mehaffey S.
        • Böcker W.
        • Neuerburg C.
        Inability of older adult patients with hip fracture to maintain postoperative weight-bearing restrictions.
        J Bone Joint Surg Am. 2018; 100: 936-941https://doi.org/10.2106/JBJS.17.01222
        • Salama W.
        • Mousa S.
        • Khalefa A.
        • et al.
        Simultaneous open reduction and internal fixation and total hip arthroplasty for the treatment of osteoporotic acetabular fractures.
        Int Orthop. 2017 Jan; 41: 181-189
        • De Bellis U.G.
        • Legnani C.
        • Calori G.M.
        Acute total hip replacement for acetabular fractures: a systematic review of the literature.
        Injury. 2014 Feb; 45: 356-361
        • McMahon S.E.
        • Diamond O.J.
        • Cusick L.A.
        Coned hemipelvis reconstruction for osteoporotic acetabular fractures in frail elderly patients.
        Bone Joint Lett J. 2020; 102-B: 155-161https://doi.org/10.1302/0301-620X.102B2.BJJ-2019-0883.R2
        • Mears D.C.
        Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone.
        J Am Acad Orthop Surg. 1999; 7: 128-141
        • Starr A.
        • Borer D.
        • Reinert C.
        Technical aspects of limited open reduction and percutaneous screw fixation of fractures of the acetabulum.
        Operat Tech Orthop. 2001; 11: 218-226https://doi.org/10.1016/S1048-6666(01)80008-2
        • Karim M.A.
        • Abdelazeem A.H.
        • Youness M.
        • El Nahal W.A.
        Fixation of quadrilateral plate fractures of the acetabulum using the buttress screw: a novel technique.
        Injury. 2017; 48: 1813-1818https://doi.org/10.1016/j.injury.2017.05.028
        • Kistler B.J.
        • Smithson I.R.
        • Cooper S.A.
        • et al.
        Are quadrilateral surface buttress plates comparable to traditional forms of transverse acetabular fracture fixation? [published correction appears in Clin Orthop Relat Res. 2015 Jan;473(1):402.
        Clin Orthop Relat Res. 2014; 472: 3353-3361https://doi.org/10.1007/s11999-014-3800-x
        • ColeJD,BolhofnerBR.AcetabularfracturefixationviaamodifiedStoppalimited
        Intrapelvic approach. Description of operative technique and preliminary treatment results.
        Clin Orthop Relat Res. 1994 Aug; 305: 112-123
        • Sagi H.C.
        • Afsari A.
        • Dziadosz D.
        The anterior intra-pelvic (modified Rives-Stoppa) approach for fixation of acetabular fractures.
        J Orthop Trauma. 2010 May; 24: 263-270
        • Chen K.
        • Yang F.
        • Yao S.
        • Xiong Z.
        • Sun T.
        • Guo X.
        Biomechanical comparison of different fixation techniques for typical acetabular fractures in the elderly: the role of special quadrilateral surface buttress plates [published online ahead of print, 2020 mar 23].
        J Bone Joint Surg Am. 2020; https://doi.org/10.2106/JBJS.19.01027
        • Zhang R.
        • Yin Y.
        • Li S.
        • et al.
        Fixation of displaced acetabular fractures with an anatomic quadrilateral surface plate through the stoppa approach.
        Orthopedics. 2019; 42: e180-e186https://doi.org/10.3928/01477447-20181227-03
        • Nikolopoulos F.V.
        • Tzoras N.T.
        The advantages of stoppa approach-ilioinguinal modification, for surgical treatment of the acetabulum fractures with the traditional plate and the new anatomical suprapectineal plate system.
        J Orthop Case Rep. 2019; 10: 78-81https://doi.org/10.13107/jocr.2019.v10.i01.1646
        • Chen K.
        • Yang F.
        • Yao S.
        • Xiong Z.
        • Sun T.
        • Guo X.
        Biomechanical comparison of different fixation techniques for typical acetabular fractures in the elderly: the role of special quadrilateral surface buttress plates [published online ahead of print, 2020 mar 23].
        J Bone Joint Surg Am. 2020; https://doi.org/10.2106/JBJS.19.01027
        • Kistler B.J.
        • Smithson I.R.
        • Cooper S.A.
        • et al.
        Are quadrilateral surface buttress plates comparable to traditional forms of transverse acetabular fracture fixation? [published correction appears in Clin Orthop Relat Res. 2015 Jan;473(1):402].
        Clin Orthop Relat Res. 2014; 472: 3353-3361https://doi.org/10.1007/s11999-014-3800-x
        • Anglen J.O.
        • Burd T.A.
        • Hendricks K.J.
        • Harrison P.
        The "Gull Sign": a harbinger of failure for internal fixation of geriatric acetabular fractures.
        J Orthop Trauma. 2003; 17: 625-634https://doi.org/10.1097/00005131-200310000-00005
        • Matta J.M.
        • Merrit P.O.
        Displaced acetabular fractures.
        Clin Orthop. 1988; 230: 83-97
        • Tile M.
        • Helfet D.
        • Kellam J.
        Fractures of the Pelvis and Acetabulum.
        third ed. Lippincott Williams & Wilkins, Baltimore2003
      2. Sanders E, Finless A, Adamczyk A, et al. Outcome Following Open Reduction Internal Fixation (ORIF) of Acetabular Fractures in the Elderly– Comparison to ORIF-THA. COA, June 2020, Halifax, Nova Scotia

        • Kistler B.J.
        • Smithson I.R.
        • Cooper S.A.
        • et al.
        Are quadrilateral surface buttress plates comparable to traditional forms of transverse acetabular fracture fixation? [published correction appears in Clin Orthop Relat Res. 2015 Jan;473(1):402].
        Clin Orthop Relat Res. 2014; 472: 3353-3361https://doi.org/10.1007/s11999-014-3800-x
        • Chesser T.J.
        • Eardley W.
        • Mattin A.
        • Lindh A.M.
        • Acharya M.
        • Ward A.J.
        The modified ilioinguinal and anterior intrapelvic approaches for acetabular fracture fixation: indications, quality of reduction, and early outcome.
        J Orthop Trauma. 2015; 29: S25-S28https://doi.org/10.1097/BOT.0000000000000268