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The Quadrilateral Plate in Acetabular Fracture Surgery: When and How Should It Be Addressed
In this episode, Michael David Stover, MD, professor of Orthopaedic Surgery at Northwestern Medicine, discusses his findings regarding fractures involving the quadrilateral plate (QP), recently published in the Journal of the American Academy of Orthopaedic Surgeons. Dr. Stover shares key takeaways from his study, including types of fractures that affect the QP, and what surgical approaches and fixation techniques should be considered when addressing them.
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Learn more about Michael Stover, MD
Michael Stover, MD
Dr. Michael Stover is a graduate of University of Iowa College of Medicine, University Hospitals of Cleveland, Case Western Reserve University, residency, and fellowship trained in orthopaedic trauma at Carolinas Medical Center in Charlotte, N.C.Learn more about Michael Stover, MD
Transcription:
Melanie Cole (Host): Welcome to Better Edge a Northwestern Medicine podcast for physicians. I'm Melanie Cole and today we're discussing the Quadrilateral Plate in Acetabular Fracture Surgery, when and how it should be addressed. Joining me is Dr. Michael Stover. He's a Professor of Orthopedic Surgery at Northwestern Medicine. Dr. Stover, it's a pleasure to have you join us today. Tell us a little bit about the quadrilateral plate and the types of fractures that might affect it.
Michael Stover, MD (Guest): The basis of our paper was to address exactly that. So, to discuss the quadrilateral plate and when it is involved with fractures and when it should be addressed. So, there's been a lot of talk lately about the importance of the quadrilateral plate and approaches had been developed in order to better visualize and secure the quadrilateral plate.
It was our feeling that this has not necessarily been a good focus for acetabular fracture surgery and that the quadrilateral plate has been a part of most fractures for a very long time. It's just that it has more recently been more prevalent due to the higher incidence of fractures in elderly patients.
Host: Thank you for that explanation. So speak more, expand a little bit about your published findings in the Journal of the American Academy of Orthopedic Surgeons regarding those fractures. And tell us a little bit about the background of your work.
Dr. Stover: Well, it's a review paper. So, the findings are mainly a discussion of already published work. The importance of the quadrilateral surface is in evaluation of the reduction of fractures that involve the columns of the acetabulum or in allowing us to secure and hold portions of the joint back into place. The higher incidence of the fractures in the elderly population, has driven people to want a better way to access the quadrilateral surface and secure that with the surgical fixation that we use. So, that recently has driven people more towards a intra pelvic approach to that surface of the acetabulum, where they can have better direct visualization for manipulation, and then direct fixation of that fracture fragment.
Host: So then when should fractures involving that area be addressed? What are some of the indications for stabilization, as you're speaking about being able to get to that area? Why is this so important for better outcomes?
Dr. Stover: In a large number of patients, that area can just be used to assess the fractures of the columns as I already discussed. In and of itself, the quadrilateral surface fragment or fracture line does not need to be separately addressed. In patients that have a fracture of only the quadrilateral surface, that probably does not lend to instability of the joint. And that instability of the joint is what leads to arthritis later on. And therefore it does not need to be addressed. If there is a fracture of that surface or the quadrilateral surface or plate that is displaced, and along with it comes a piece of the joint, then instability can occur. And that is when those fracture lines need to be addressed. Now, when they're a portion of a column fracture, the assessment of the reduction can tell you how the column has been reduced. And if that's adequate. If they're separate pieces, they can help guide reduction of the columns. Or if it's a separate piece with an associated impaction fracture or an impacted part of the joint next to it, the surface fragment can be utilized for access into the joint to push this joint piece back into position. And then the surface fragment or the quadrilateral plate can be put back into position and help contain or help hold that impacted fragment into position until healing.
Host: That's fascinating, Dr. Stover. So, do you have any other technical considerations you'd like other providers to know about? Surgical approaches and fixation techniques for those fractures?
Dr. Stover: The one thing that I would stress is that using just the intrapelvic approach may not be adequate for the exposure and then the subsequent fixation of all fractures to allow for anatomic restoration of the joint, which is your goal. So, the utilization of either a more extensive lateral window, to the internal iliac fossa or the pelvis and acetabulum would be indicated in a lot of fractures that involve higher anterior column fractures or anterior posterior hemitransverse, or both column fractures or utilizing standard traditional ilioinguinal approach with the middle window. And then using the medial window as an intrapelvic approach that will expand your visualization and reduction maneuvers through a expansion of a more traditional approach to the acetabular fracture.
Host: Have any other fixation techniques shown to be superior in terms of outcomes, Doctor?
Dr. Stover: No, they haven't. In fact, just using traditional approaches with screws across the fracture lines, to help secure the columns and also to help secure areas of the quadrilateral surface; the screws had been shown to be at least as good or better than even plate fixation. But one thing that hasn't necessarily been studied well, is if that fracture fragment is an individual fragment that doesn't attach to a column, that is put back to hold a piece of the joint in place that is probably benefited by a more direct fixation of the quadrilateral surface plate, which can be done with a plate and screw fixation directly onto that. And I think that is probably the biggest benefit of the intrapelvic approach is that you're allowed to place plates and screws below the pelvic brim or the infrapectineal area of the acetabulum to help support those specific fragments.
Host: Dr. Stover, this is such an interesting topic. So, can you tell us how the collective work of many orthopedic surgeons has resulted in numerous effective methods for approaching, reducing, and stabilizing the quadrilateral plate? And how did this all come together as you expand just a little bit on how your study happened.
Dr. Stover: Again, the focus recently has been on the quadrilateral surface and how the assessment of reduction in that area can help guide the repositioning of all the fractures around the acetabulum or the hip joint. The impetus of the study was to say, yes, that is an important part of it, but it is not the only thing to assess. And I think that the studies that have been done have shown that you can get as close or even better with utilizing the intrapelvic approach with certain fracture types. But I just wanted to be certain that people understood that should not be the sole focus. What has happened is that there's been a change or a shift in how people repair fractures, especially ones that involve the anterior portions of the acetabulum, where there's been real shift towards the utilization of the intrapelvic approach. But then there's also been an evolution of trying to put together all of these factors of the approaches, all these different factors for fixation in order to better the outcomes for the reduction and therefore the long-term outcome of the joint for the patient.
Host: Excellent information. Do you have any final thoughts you'd like to share, any big takeaways for other surgeons and providers?
Dr. Stover: Yeah, I think that just finding somebody who has a real interest in taking care of patients with these problems is important. And our continued work is to try to provide the best outcomes for patients, are in the studies that we've done, in the papers that we've written and the patients that we've operated on. And I think that for surgeons that are doing the acetabular fracture surgery is to still maintain the goal of perfection and putting everything back into place so that we can better the outcomes of patients, regardless of what the approach that they use. And not just focusing on certain portions of the fractures and their reduction in order to just help hold it in place and not necessarily focus on a perfect reduction.
Host: Thank you so much, Dr. Stover, just an interesting episode. Thank you again for sharing your expertise. And to refer your patient or for more information, head on over to our website breakthroughsforphysicians.nm.org/ortho to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians.
I'm Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): Welcome to Better Edge a Northwestern Medicine podcast for physicians. I'm Melanie Cole and today we're discussing the Quadrilateral Plate in Acetabular Fracture Surgery, when and how it should be addressed. Joining me is Dr. Michael Stover. He's a Professor of Orthopedic Surgery at Northwestern Medicine. Dr. Stover, it's a pleasure to have you join us today. Tell us a little bit about the quadrilateral plate and the types of fractures that might affect it.
Michael Stover, MD (Guest): The basis of our paper was to address exactly that. So, to discuss the quadrilateral plate and when it is involved with fractures and when it should be addressed. So, there's been a lot of talk lately about the importance of the quadrilateral plate and approaches had been developed in order to better visualize and secure the quadrilateral plate.
It was our feeling that this has not necessarily been a good focus for acetabular fracture surgery and that the quadrilateral plate has been a part of most fractures for a very long time. It's just that it has more recently been more prevalent due to the higher incidence of fractures in elderly patients.
Host: Thank you for that explanation. So speak more, expand a little bit about your published findings in the Journal of the American Academy of Orthopedic Surgeons regarding those fractures. And tell us a little bit about the background of your work.
Dr. Stover: Well, it's a review paper. So, the findings are mainly a discussion of already published work. The importance of the quadrilateral surface is in evaluation of the reduction of fractures that involve the columns of the acetabulum or in allowing us to secure and hold portions of the joint back into place. The higher incidence of the fractures in the elderly population, has driven people to want a better way to access the quadrilateral surface and secure that with the surgical fixation that we use. So, that recently has driven people more towards a intra pelvic approach to that surface of the acetabulum, where they can have better direct visualization for manipulation, and then direct fixation of that fracture fragment.
Host: So then when should fractures involving that area be addressed? What are some of the indications for stabilization, as you're speaking about being able to get to that area? Why is this so important for better outcomes?
Dr. Stover: In a large number of patients, that area can just be used to assess the fractures of the columns as I already discussed. In and of itself, the quadrilateral surface fragment or fracture line does not need to be separately addressed. In patients that have a fracture of only the quadrilateral surface, that probably does not lend to instability of the joint. And that instability of the joint is what leads to arthritis later on. And therefore it does not need to be addressed. If there is a fracture of that surface or the quadrilateral surface or plate that is displaced, and along with it comes a piece of the joint, then instability can occur. And that is when those fracture lines need to be addressed. Now, when they're a portion of a column fracture, the assessment of the reduction can tell you how the column has been reduced. And if that's adequate. If they're separate pieces, they can help guide reduction of the columns. Or if it's a separate piece with an associated impaction fracture or an impacted part of the joint next to it, the surface fragment can be utilized for access into the joint to push this joint piece back into position. And then the surface fragment or the quadrilateral plate can be put back into position and help contain or help hold that impacted fragment into position until healing.
Host: That's fascinating, Dr. Stover. So, do you have any other technical considerations you'd like other providers to know about? Surgical approaches and fixation techniques for those fractures?
Dr. Stover: The one thing that I would stress is that using just the intrapelvic approach may not be adequate for the exposure and then the subsequent fixation of all fractures to allow for anatomic restoration of the joint, which is your goal. So, the utilization of either a more extensive lateral window, to the internal iliac fossa or the pelvis and acetabulum would be indicated in a lot of fractures that involve higher anterior column fractures or anterior posterior hemitransverse, or both column fractures or utilizing standard traditional ilioinguinal approach with the middle window. And then using the medial window as an intrapelvic approach that will expand your visualization and reduction maneuvers through a expansion of a more traditional approach to the acetabular fracture.
Host: Have any other fixation techniques shown to be superior in terms of outcomes, Doctor?
Dr. Stover: No, they haven't. In fact, just using traditional approaches with screws across the fracture lines, to help secure the columns and also to help secure areas of the quadrilateral surface; the screws had been shown to be at least as good or better than even plate fixation. But one thing that hasn't necessarily been studied well, is if that fracture fragment is an individual fragment that doesn't attach to a column, that is put back to hold a piece of the joint in place that is probably benefited by a more direct fixation of the quadrilateral surface plate, which can be done with a plate and screw fixation directly onto that. And I think that is probably the biggest benefit of the intrapelvic approach is that you're allowed to place plates and screws below the pelvic brim or the infrapectineal area of the acetabulum to help support those specific fragments.
Host: Dr. Stover, this is such an interesting topic. So, can you tell us how the collective work of many orthopedic surgeons has resulted in numerous effective methods for approaching, reducing, and stabilizing the quadrilateral plate? And how did this all come together as you expand just a little bit on how your study happened.
Dr. Stover: Again, the focus recently has been on the quadrilateral surface and how the assessment of reduction in that area can help guide the repositioning of all the fractures around the acetabulum or the hip joint. The impetus of the study was to say, yes, that is an important part of it, but it is not the only thing to assess. And I think that the studies that have been done have shown that you can get as close or even better with utilizing the intrapelvic approach with certain fracture types. But I just wanted to be certain that people understood that should not be the sole focus. What has happened is that there's been a change or a shift in how people repair fractures, especially ones that involve the anterior portions of the acetabulum, where there's been real shift towards the utilization of the intrapelvic approach. But then there's also been an evolution of trying to put together all of these factors of the approaches, all these different factors for fixation in order to better the outcomes for the reduction and therefore the long-term outcome of the joint for the patient.
Host: Excellent information. Do you have any final thoughts you'd like to share, any big takeaways for other surgeons and providers?
Dr. Stover: Yeah, I think that just finding somebody who has a real interest in taking care of patients with these problems is important. And our continued work is to try to provide the best outcomes for patients, are in the studies that we've done, in the papers that we've written and the patients that we've operated on. And I think that for surgeons that are doing the acetabular fracture surgery is to still maintain the goal of perfection and putting everything back into place so that we can better the outcomes of patients, regardless of what the approach that they use. And not just focusing on certain portions of the fractures and their reduction in order to just help hold it in place and not necessarily focus on a perfect reduction.
Host: Thank you so much, Dr. Stover, just an interesting episode. Thank you again for sharing your expertise. And to refer your patient or for more information, head on over to our website breakthroughsforphysicians.nm.org/ortho to get connected with one of our providers. And that concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians.
I'm Melanie Cole. Thanks so much for listening.