| Acetabular fractures account for about 3.73%of all fractures in the body,of which posterior wall(PW)fractures are the most common.Although the diagnosis of acetabular PW fractures is clear,the efficacy of clinical treatment is often not ideal,which is the hotspot and difficulty in the field of orthopaedic trauma.According to the difference of injury mechanisms,the PW fragments can be divided into two types:push-type and pull-type.This study consists of three parts of basic and clinical research.The first part is to explore the morphological distinctions of PW fragments in different complex acetabular fractures using 3D software and fracture mapping technique.The second part is to evaluate the therapeutic effect of nonfixation for pull-type PW fragment after anterior surgical procedures in both-column acetabular fractures.And the last part is to analyze the risk factors and construct the nomogram prediction model for conversion to total hip arthroplasty(THA)after operation for acetabular fractures with push-type PW involvement.The aim of the study was to provide reference and assistance for the minimally invasive treatment of acetabular PW fractures.Part one.Morphological characteristics of the posterior wall associated with complex acetabular fractures:a radiological study using 3D software and fracture mapping techniqueObjectives:The aim of the study was to compare the distinction of the PW fragments in different complex acetabular fractures using 3D software and fracture mapping technique,which can provide some surgical strategies for clinical treatment of PW with different injury mechanisms.Methods:One hundred and fourteen patients with complex acetabular fracture associated with PW were retrospective recruited.All patients were divided into two groups according to the injury mechanism of the PW:Group A(both column and PW)and Group B(including posterior column and PW;T shape and PW;transverse and PW).Fracture mapping was generated on the intra-and extra-surface of a standard template.The radiological parameters including spatial displacement,articular surface area,articular range,marginal impaction and multi-fragments of the two groups were compared.Results:45 cases in Group A and 69 cases in Group B were included in the study.The spatial displacement,intra/extra-articular surface area,start and end point in Group A were 10.9 mm(IQR,8.4-15.2),8.2±2.6 cm~2,17.9±5.3 cm~2,0.8°(IQR,-6.0-16.2)and 107.5°(IQR,97.2-116.9),respectively.The results in Group B were 30.4 mm(IQR,16.8-48.7),4.1±2.0 cm~2,10.6±4.4 cm~2,29.5°(IQR,19.2-38.0)and 117.5°(IQR,98.2-127.2),respectively.No marginal impaction was found in Group A and 18 patients(26%)in Group B.There were 3(7%)and 36(52%)multi-fragments in Groups A and B,respectively.All the differences between two groups were significant(P<0.05).The fracture map in Group A showed an“L”shaped pattern and a“cusp”on the ilium,and the PW was located at 1/5 to 1/4 of the postero-superior part of the acetabulum.The fracture maps in Group B were scattered and lacked consistency,and the PWs were confined to 1/10 to 1/8 of the posterior acetabulum.Part two Is plating fixation through the Kocher-Langenbeck approach for associated pull-type posterior wall fragment indispensable in both-column acetabular fractures?Objectives:The purpose of this study was to compare reduction quality,clinical outcomes and complications of nonfixation for PW fragment and plating via the Kocher-Langenbeck(KL)approach after anterior surgical procedures in both-column acetabular fractures.Methods:Forty-nine Patients with both-column acetabular fractures associated with PW fixed via Iliac fossa and Stoppa approaches at our Level I Trauma Center were retrospectively recruited into this study and were divided into two groups:Nonfix group(nonfixation for PW)and KL group(PW plating through the KL approach).Intraoperative blood loss,operation duration,reduction quality,fracture healing and relevant complications of patients were reviewed.Merle d Aubigné-Postel scores were used for assessing functional outcome.Results:26 cases in Nonfix group and 23 cases in KL group were included in the study.There were no statistically significant differences in all patients demographics characteristics(P>0.05).The mean blood loss of group Nonfix and KL were 784.62±302.91 ml and 1056.52±487.88 ml,respectively(P=0.022).The average operation times were 174.81±35.59min in Nonfix group and 219.57±73.22 min in KL group(P=0.012).The mean hospital stay durations were(18.54±6.42)days and(21.17±7.32)days in groups Nonfix and KL,respectively,(P=0.186).All fractures healed well with no significant difference in union time between the two groups(P=0.210).The rates of satisfactory reduction were 84.62%(22/26)in Nonfix group and 86.96%(20/23)in KL group(P=1.000).The mean Merle d Aubigné-Postel scores were 15.62±2.28 in Nonfix group and 16.17±2.19 in KL group(P=0.388).The complication rates were 7.69%(2/26)in Nonfix group and 34.78%(8/23)in KL group(P=0.046).Part three.Analysis of risk factors and construction of nomogram prediction model for conversion to total hip arthroplasty after operation of acetabular push-type posterior wall fracturesObjectives:The aims of the study were(1)to determine the incidence of conversion to THA after operation of acetabular push-type PW fractures,(2)to identify independent risk factors for conversion to THA,and(3)to create a nomogram prediction model that calculates an individual’s probability for conversion to THA.Methods:One hundred and ninety-five patients(195 hips)with acetabular fractures involving the PW were retrospectively recruited into the study and divided into two groups,THA or No THA.The demographic data,perioperative information and imaging characteristics of patients in the two groups were recorded.Multivariable regression analysis was performed after univariate analysis to identify independent risk factors for conversion to THA.Based on the positive results,a nomogram prediction model was constructed.The concordance index(C-index),area under the receiver operating characteristic curve(AUC),calibration curve and decision curve analysis(DCA)were used to evaluate the accuracy and application value of the nomogram.Internal validation was assessed using the bootstrap validation.Results:The incidence of conversion to THA was 15.4%,70%of which occurred within two years after primary surgery.Age>39.5 years,body mass index(BMI),time to surgery,posterior dislocation and femoral head injury were identified as independent risk factors for conversion to THA after primary surgery.In addition,the C-index and the bootstrap value of the developed nomogram was 0.84(95%CI:0.77-0.91)and 0.81,respectively,and the AUC value was 0.840,suggesting high accuracy and good performance of the nomogram prediction model.Calibration curve showed good consistency between the actual observation and the predicted probability,while the DCA indicated that the nomogram had good clinical value.Conclusions:1.Quantitative measurements and fracture mapping represented the differences in morphological characteristics of PWs associated with complex acetabular fractures.Therefore,the treatment protocols and fixation strategies should also be different.2.For both-column acetabular fractures associated with pull-type PW fragment,although fixation of PW was not performed after anterior surgical procedures,satisfactory outcomes could also be obtained.However,nonfixation was a less invasive choice with a lower complication rate.3.Age>39.5 years,increased BMI,longer time to surgery,posterior dislocation and femoral head injury were identified as independent risk factors for conversion to THA after operation of acetabular push-type PW fractures.For those high-risk patients in the nomogram,doctors can consider other alternative interventions,involving primary THA,to minimize the negative effects of the secondary surgery. |
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