Quadrilateral plate classification program of acetabular fractures based on three-column classification: a three-dimensional fracture mapping study

Wang et al. Journal of Orthopaedic Surgery and Research https://doi.org/10.1186/s13018-024-04783-z (2024) 19:298 Journal of Orthopaedic Surgery and Research RESEARCH ARTICLE Open Access Quadrilateral plate classification program of acetabular fractures based on three-column classification: a three-dimensional fracture mapping study Ruihan Wang1,2†, Songtao Jiang3†, Wei Wang2, Yingqiu Yang4, Lei Zhang4,5,6* and Guoyou Wang4,5,6* Abstract Background A new classification system for acetabular fractures has been proposed in recent years, which is called the 3-column classification. However, this system does not provide information regarding quadrilateral plate fractures. To address this issue, we utilized three-dimensional (3D) fracture line mapping and heat map to analyze the link between the 3-column classification and quadrilateral plate fractures. Methods We collected CT scan data from 177 patients who had been diagnosed with acetabular fractures. Additionally, we utilized a CT scan of a healthy adult to generate a standard acetabular model. We utilized the collected CT data of the fracture to create a 3D model and subsequently reduced it. We then matched each acetabular fracture model with the standard acetabular model and mapped all of the fracture lines to the standard model. 3D fracture lines and heat maps were created by overlapping all fracture lines. Fracture characteristics were then summarized using these maps. Results This study analyzed a total of 221 acetabular fractures. The most frequently observed fracture type, based on the three-column classification, was A1.2, which corresponds to fractures of the anterior column. In contrast, the least common type of fracture was A4, which represents fractures of the central wall. It was noted that quadrilateral plate fractures were frequently observed in fractures classified as type B and C according to the three-column classification. Conclusions Among the three-column classification, the QLP fractures are commonly observed in type B and C. It is important to carefully identify these fractures during the diagnostic process. Therefore, based on the threecolumn classification, we have amalgamated quadrilateral plate fractures and formulated a classification program for acetabular fractures. † Ruihan Wang, Songtao Jiang, and Wei Wang contributed equally to this work and should be considered co-first authors. *Correspondence: Lei Zhang Guoyou Wang Full list of author information is available at the end of the article © The Author(s) 2024. 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. 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Journal of Orthopaedic Surgery and Research (2024) 19:298 Page 2 of 10 Keywords Acetabular fracture, Three-column classification, Quadrilateral plate, Fracture mapping, Fracture lines, Heat map Introduction Due to the aging population, the occurrence of hip fractures has risen quickly. From 1980 until 2007, the occurrence of hip fractures in older individuals increased by 2.4 times. Within these hip anterior fractures, quadrilateral plate (QLP) fractures account for a high percentage at 50.8% [1]. These fractures are known for their high incidence and disability and cause a significant burden on patients and society [2]. The QLP, a crucial component of the acetabulum and located at the bottom of its bowl, is conventionally seen as the medial surface of the acetabulum and bears the majority of the articular surface [3]. However, the traditional Judet-Letournel classification system does not clearly define the QLP fracture. The Cairo University Hospitals (CUH) classification system is a frequently used method for QLP fracture classification [4]. However, it has not been integrated with the “column” fracture theory, which has resulted in some limitations. In addition, other defects have been proven in the JudetLetournel classification system [5, 6]. It defines fractures of the anterior columns as discontinuities of the iliopectineal line based on the 2-column concept and defines fractures of the posterior columns as discontinuities of the ilioischial line [7, 8]. However, fractures that affect both iliopectineal and ilioischial lines, such as transverse, T-type, and transverse plus posterior wall fractures, do not fall under the classification of bothcolumn fractures [6, 8–10]. Based on the shortcomings of the above Judet-Letournel classification system, Zhang et al. [11] proposed the “3-column” theory for acetabular fractures in 2019. According to the growth period of the hemipelvis, the three-column classification of the acetabulum involves the ilium branch forming the roof, the pubis branch forming the front column, and the ischium branch forming the back column [11]. The 3-column classification provides a clearer and more inclusive way of categorizing acetabular fractures, solving the issue of conceptual confusion. It also has high credibility and repeatability, making it easier for orthopedic surgeons to understand and apply to diagnosis and treatment. However, whether the three-column classification can be combined with the CUH classification to further increase the application of this classification remains unknown. The virtual computed tomography (CT) modeling software generates three-dimensional (3D) fracture models, which facilitates the analysis of the fracture appearance in a more comprehensive way. By integrating 3D fracture line mapping with a heat map based on the CT data, more information can be obtained regarding fracture patterns and morphology [12]. Therefore, we plan to observe the acetabular and QLP fractures using 3D fracture line mapping and heat maps with the 3-column classification. This study aims to examine the link between the 3-column classification system and the QLP fracture by analyzing 3D fracture line mapping and heat map. This study hopes to advance the diagnosis and treatment of patients with acetabular fractures by optimizing the classification system. Materials and methods Specim (...truncated)