Open reduction and internal fixation of quadrilateral plate fractures in the elderly: association between initial fracture pattern and outcomes

Wu et al. BMC Musculoskeletal Disorders (2021) 22:122 https://doi.org/10.1186/s12891-021-04002-4 RESEARCH ARTICLE Open Access Open reduction and internal fixation of quadrilateral plate fractures in the elderly: association between initial fracture pattern and outcomes Haiyang Wu1†, Qipeng Shao1†, Ranran Shang2, Chengjing Song3, Ximing Liu1 and Xianhua Cai1* Abstract Background: Acetabular fractures with medial displacement of the quadrilateral plate (QLP) are common in the elderly. The presence of QLP fractures greatly increase the surgical difficulty of acetabular fractures. This study aims to evaluate the clinical radiological outcomes of open reduction and internal fixation (ORIF) in QLP fractures in elderly patients and to investigate factors potentially affecting the result. Methods: We conducted a retrospective study. A series of 37 consecutive patients with acetabular fracture involving the QLP aged 60 years and older who received ORIF between January 2010 and May 2019 were included. QLP fractures were classified according to Walid’s classification system. Radiological outcomes were evaluated using Matta criteria and functional outcomes were assessed using the modified Merle d’Aubigné score. The relationships between Walid’s classification and radiological or functional outcomes were analyzed. Results: According to Walid’s classification, 18, 13, 6 were classified as QLP1, QLP2 and QLP3, respectively. The average follow-up was 35.5 ± 10.7 months. We obtained anatomic reduction in 48.6 % (18/37) of cases, imperfect reduction in 40.5 % (15/37) of cases, and poor reduction in 10.8 % (4/37) of cases. Excellent-good functional scores were found in 83.7 % (modified Merle d’Aubigné). There were no cases of screw entering the hip, pull-out and loosening or implant failure during the follow-up. Walid’s classification was positively correlated with radiological outcomes of reduction (r = 0.661; P < 0.001), and functional outcomes (r = 0.478; P = 0.003). Unsatisfactory reduction was demonstrated a correlation with the development of post-traumatic arthritis (r =-0.410; P = 0.012). Conclusions: ORIF may be suggested for quadrilateral plate fractures in the elderly. Walid’s classification system is associated with the reduction quality and functional recovery. Keywords: Acetabulum, Fracture fixation, Internal, Elderly, Classification Background Acetabular fractures are relatively uncommon yet serious injuries which make up about 3–8 % of all fractures. * Correspondence: † Haiyang Wu and Qipeng Shao contributed equally to this work. 1 Department of Orthopaedic Surgery, General Hospital of Central Theater Command, Wuhan Clinical Medicine College of Southern Medical University, 430070 Wuhan, China Full list of author information is available at the end of the article Epidemiological investigations have shown that acetabular fractures have a bimodal distribution with respect to age that has modes at 30–40 and 70–90 years [1]. As the population ages, the incidence of osteopenic acetabular fractures resulting from low energy injuries is also increasing. Open reduction and internal fixation (ORIF) remain the preferred treatment for displaced acetabular fractures [2, 3]. However, controversies still exist © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Wu et al. BMC Musculoskeletal Disorders (2021) 22:122 regarding the optimal treatment of these fractures in older people [4, 5]. And surgical treatment represents a great challenge for orthopedic surgeons because of the decreased physiological compensatory capacity and the severe osteoporosis of the elderly [6]. Acetabular fractures in elderly patients frequently involve the quadrilateral plate (QLP), a deep and thin anatomical structure constituting the medial wall of the acetabulum. Isolated QLP fractures are rare and always associated with the anterior or posterior column fractures. Injuries resulting from the force along the femoral neck can lead to comminuted fractures of the QLP and even central dislocation of the femoral head. The QLP does not play a crucial role in the weight-bearing of the hip and is not key structure of biomechanical functionality. However, previous studies showed that a separate quadrilateral-plate component and/or central dislocation of the femoral head might adversely affect the outcomes [1, 7]. Bastian et al. [8] reported that nearly two thirds of the patients in complex fracture morphologies with medial displacement of QLP required an additional approach in addition to the modified Stoppa approach, which indicated that QLP fractures increased the complexity and difficulty of acetabular fractures surgery. The technical difficulty of ORIF of this area is predominantly due to the complicated anatomy, deep location and narrow surgical field. This study aims to evaluate the clinical radiological outcomes of ORIF in QLP fractures in older people and to investigate factors potentially affecting the result. Materials and Methods Ethical approval was obtained from the ethical committee of the hospital. Between January 2010 and May 2019, Fig. 1 Study flow chart Page 2 of 8 patients with acetabular fractures were identified from the trauma database at our level I trauma center. Inclusion criteria consisted of all types of acetabular fractures involving the QLP, treated with Dynamic Anterior PlateScrew system for Quadrilateral plate (DAPSQ), age older than 60 years at the time of injury, unilateral acetabular fracture, a minimum of 1-year postoperative follow up. The exclusion criteria were open or pathologic fractures, bilateral acetabular injuries, pre-existing ipsilateral hip diseases, or femoral head fracture. The flow chart of our retrospective study was illustrated in Fig. 1. A total of 37 patients with QLP fractures were included in our study eventually. Radiographs and medical records were collected by two investigators who were not implicated in the initial intervention. 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