The ongoing relevance of acetabular fracture classification

Abstract

The most widely used classification system for acetabular fractures was developed by Judet, Judet and Letournel over 50 years ago primarily to aid surgical planning. As population demographics and injury mechanisms have altered over time, the fracture patterns also appear to be changing. We conducted a retrospective review of the imaging of 100 patients with a mean age of 54.9 years (19 to 94) and a male to female ratio of 69:31 seen between 2010 and 2013 with acetabular fractures in order to determine whether the current spectrum of injury patterns can be reliably classified using the original system. Three consultant pelvic and acetabular surgeons and one senior fellow analysed anonymous imaging. Inter-observer agreement for the classification of fractures that fitted into defined categories was substantial, (κ = 0.65, 95% confidence interval (CI) 0.51 to 0.76) with improvement to near perfect on inclusion of CT imaging (κ = 0.80, 95% CI 0.69 to 0.91). However, a high proportion of injuries (46%) were felt to be unclassifiable by more than one surgeon; there was moderate agreement on which these were (κ = 0.42 95% CI 0.31 to 0.54). Further review of the unclassifiable fractures in this cohort of 100 patients showed that they tended to occur in an older population (mean age 59.1 years; 22 to 94 vs 47.2 years; 19 to 94; p = 0.003) and within this group, there was a recurring pattern of anterior column and quadrilateral plate involvement, with or without an incomplete posterior element injury.

A New, Easy, Fast, and Reliable Method to Correctly Classify Acetabular Fractures According to the Letournel System

“…It is interesting to consider the repeatability of the method. In several previous studies that have evaluated other methods, the intraobserver coefficient was never higher than 0.74 (Table VII) 6 , 8 , 14 , 27 - 30 . In the present study, the intraobserver coefficient was never lower than 0.89 when the app was used, regardless of the experience of the examiners.…”

Acetabular Fractures in the Elderly: Midterm Outcomes of Column Stabilisation and Primary Arthroplasty

“…Not only are today's patients older, but the fractures seen in the current orthopaedic climate are often different to those seen 50 years ago, when the current classification system of Letournel was devised. Underlying bone quality is different, and activities have changed in the elderly, resulting in the generation of a different set of fracture patterns with a predominance of anterior column damage combined with often incomplete posterior fractures [ 26 ]. As such, it is not unreasonable to assume that we may need different solutions to the problem in addition to those that were popularised in the past.…”

Core curriculum illustration: posterior column acetabular fracture

“…The injury is most often the result of motor vehicle collisions or fall from heights greater than 10 feet, although acetabular fractures of multiple types are becoming more common in the elderly fall population [2].…”

“…While there is continued discussion in the literature as to whether this system is capable of classifying The Judet-Letournel fracture classification system is the most widely utilized classification in the current practice. For this case, when classifying a fracture as an isolated posterior column injury, be sure to check for complex fracture patterns, such as a comminuted posterior wall fracture or an anterior column component all fracture types, it currently remains the most widely utilized classification system worldwide [2]. Using this system as the basis for our final classification, the radiographic findings of a posterior column acetabular fracture include disruption of the ilioischial line on radiographs and isolated posterior column involvement on CT.…”