The use of a T-plate as "spring plates" for small comminuted posterior wall fragments.
ABSTRACT In the treatment of posterior wall fractures of the acetabulum, a modified distal radius T-plate can be substituted for one third tubular spring plates for fixation of thin, small, or comminuted posterior wall fragments. This technique is described as well as a case series of 33 patients with various posterior wall acetabular fractures.
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ABSTRACT: Reproducible simple fractures and osteotomies of the posterior wall of the acetabulum were created in twenty paired hemipelves from fresh human cadavera. Comminution was created with an additional fracture line that was either parallel (concentric comminution) or perpendicular (transverse comminution) to the posterior rim of the acetabulum. Under simulated weight-bearing, the stiffness of fixation of the transversely comminuted fractures that had been achieved with use of a reconstruction plate and screws was significantly higher than that achieved with fixation with screws alone (p < 0.05). The load to failure of the fixation of transversely comminuted fractures treated with a reconstruction plate and screws was also significantly higher than that of fixation of such fractures with screws alone (p = 0.05). The load to failure of the fixation of concentrically comminuted fractures was significantly higher when a reconstruction plate and accessory spring plates had been used than when a reconstruction plate alone had been employed (p < 0.05).The Journal of Bone and Joint Surgery 10/1994; 76(10):1457-63. · 3.23 Impact Factor
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ABSTRACT: The indications for open reduction and internal fixation of posterior wall acetabular fractures associated with a clinically stable hip joint are unclear. In previous work a large posterior wall defect (27% articular surface area) resulted in significant alteration of load transmission across the hip; specifically, there was a transition from evenly distributed loading along the acetabular articular surface to loading concentrated mainly in the superior portion of the articular surface during simulated single leg stance. However, the majority of posterior wall fractures involve a smaller amount of the articular surface. Posterior wall acetabular fractures not associated with instability of the hip are commonly treated nonoperatively. This practice does not account for the size of the posterior wall fracture. To study the biomechanical consequences of variably sized articular defects, a laboratory experiment was conducted evaluating three progressively larger posterior wall defects of the acetabulum during simulated single leg stance using superlow Fuji prescale film (Itochu International, New York): (a) 1/3 articular surface width through a 50 degrees arc along the posterior wall of the acetabulum, (b) 2/3, and (c) 3/3 articular width defects through the same 50 degrees arc along the posterior wall of the acetabulum. In the intact acetabulum, 48% of the total articular contact was located in the superior acetabulum. Twenty-eight percent of articular contact was in the anterior wall region of the acetabulum and 24% in the posterior wall region. After the 1/3 width posterior wall defect, 64% of the articular contact was located in the superior acetabulum (p = 0.0011). The 2/3 width posterior wall defect resulted in 71% of articular contact area being located in the superior acetabulum (p = 0.0006). After the 3/3 width posterior wall defect, 77% of articular contact was located in the superior acetabulum, significantly greater than the intact condition (p < 0.0001) and 1/3 width defect (p = 0.0222). The total absolute contact areas for all defect conditions were significantly less than the intact conditions. The results of this study reconfirm the observation that posterior wall fractures of the acetabulum significantly alter the articular contact characteristics in the hip during single leg stance. The relationship between defect size and changes in joint contact showed that the smallest defect resulted in the greatest alteration in joint contact areas, whereas larger defects resulted in minor increments of change in contact area. This finding is of concern because the clinical practice of managing acetabular fractures nonoperatively if the hip joint is stable is based on the supposition that the joint retains enough integrity to function without undue risk of late posttraumatic osteoarthritis. A better understanding of the natural history of stable posterior wall acetabular fractures is needed to ascertain whether some of these fractures merit operative repair.Journal of Orthopaedic Trauma 02/1996; 10(6):395-402. · 1.75 Impact Factor
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ABSTRACT: The spring plate, a modified one third tubular plate, can be a viable and durable option for fixation of periarticular acetabular fractures. The use of the spring plate in acetabular fractures is demonstrated.Journal of Orthopaedic Trauma 04/2004; 18(3):179-81. · 1.75 Impact Factor
The Use of a T-Plate as ‘‘Spring Plates’’ for Small
Comminuted Posterior Wall Fragments
Bruce H. Ziran, MD,* Jill E. Little, BA,† and Ramsey C. Kinney, MD, PhD*
Summary: In the treatment of posterior wall fractures of the
acetabulum, a modified distal radius T-plate can be substituted for one
third tubular spring plates for fixation of thin, small, or comminuted
posterior wall fragments. This technique is described as well as a case
series of 33 patients with various posterior wall acetabular fractures.
Key Words: acetabular fracture, posterior wall, internal fixation,
(J Orthop Trauma 2011;25:574–576)
In certain acetabular fracture patterns, the posterior wall
fragment can be very thin or quite small (less than 5 mm) and
cannot be adequately secured with an overlying 3.5-mm
reconstruction plate. In such cases, the use of a spring plate has
been advocated, which is usually made from a one third
tubular plate that is contoured to provide a compressive force
on the small fragment over which a standard 3.5-mm
reconstruction plate is applied.1,2The joint reactive force
vector across the hip is 2.35 times body weight with the
posterior wall bearing 24% of this load.3The small spring
plates serve to distribute force over the small fracture segments
and also help avoid intra-articular penetration of screws that
may have been used to secure such fragments close to the
articular surface. In the eventof greater comminution or longer
rim fragments, multiple one third tubular plates have been
used. Because the one third tubular plate has a relatively thin
profile and width, multiple plates are needed for extended
fragments or comminution.
In the present report, we propose a technical modifica-
tion whereby the contact area for a spring plate can be
increased easily andwithout havingto resort tomultiple plates.
Using a distal radial T-plate in the same manner as the spring
plate, the area of contact nearest the articular surface is
broadened. A standard overlying 3.5-mm reconstruction plate
can be used as with one third tubular plates. We report on the
technique and our small case series of 33 patients.
This technique is indicated in acetabular fractures with
a small posterior wall fragment that requires stabilization and
cannot be entirely contained with the standard 3.5-mm
reconstruction plate. The T-plate chosen can be either a standard
T-plate orangleT-plate.Theplate can besized by removalofthe
proximal end (Fig. 1). The distal ‘‘T’’ portion can be slightly
bent and the remainder of the plate gently curved to match the
contour of the posterior wall. The plate will initially be convex,
but when the fixation of the stem to the bone is performed, the
platewill naturally flatten and provide the ‘‘spring’’ effect, in the
same manner that occurs with one third tubular plates (Fig. 2).
The plates should be independently attached to the pelvis with
a screw before having an overlying reconstruction plate applied.
Additional fixation, especially in the case of extensive
comminution, can be achieved by removal of the distal portion
of the T-plate to create multiple prongs to aid in securing the
fragments (Fig. 3A).
Like any pronged spring plate, care should be taken to
ensure that the prongs are not beyond the osseous edge of the
bone into the labrum or femoral head, which would result in
abrasive wear. Other potential complications associated with
spring plates in general include overcontouring leading to
inadequate buttressing of the wall fragments as well as errors
in sizing the plate that can result in extension into the greater
sciatic notch and irritation of the rotators and sciatic nerve.
Correct placement of the reconstruction plate is also important
to avoid excessive loading of the thinner spring plate.
During the time period of 2003 to 2008, we performed
the previously described technique on 33 patients ranging
from 18 to 79 years of age who required this type of plate
because of very thin, small, or comminuted posterior wall
fragments (Table1). We did not havea control group using one
third tubular plates for comparison. All fractures had
a posterior wall element, but the overall fracture patterns
included simple posterior wall, extended posterior wall,
superior posterior wall, posterior wall with posterior column,
transverse posterior wall, and T-type with posterior wall. The
mechanisms of injury were motor vehicle crash, motorcycle
Accepted for publication August 23, 2010.
From the *Department of Orthopaedics, Atlanta Medical Center, Atlanta, GA;
and †St. Elizabeth Health Center, Youngstown, OH.
No funds were received in support of this work.
No benefits in any form have been or will be received from a commercial party
related directly or indirectly to the subject of the manuscript.
B. H. Ziran is a paid consultant for Stryker, Synthes, Medtronic and has equity
position with Tekartis.
Reprints: Bruce H. Ziran, MD, Director of Orthopaedic Trauma, Atlanta
Medical Center, Orthopaedic Residency Program, 303 Parkway Drive NE,
Atlanta, GA 30312 (e-mail: email@example.com).
Copyright ? 2011 by Lippincott Williams & Wilkins
574|www.jorthotrauma.comJ Orthop Trauma?Volume 25, Number 9, September 2011
crash, and falls. Patients were followed until healing with
a mean follow-up of approximately 3 years (range, 0.5–5
years). Examples of postoperative results are shown in Figure
3A–C. One patient of 33 (3%) had fixation failure using this
method. In the patient with failure, he was a significant
substance abuser of a gas inhalant and was reported to be
walking and crawling on his comminuted posterior wall in the
early postoperative period.4He also failed his proximal
FIGURE 1. A standard or angled distal radius T-plate is gently
curved to match the contour of the posterior wall and then
bent along the stem to produce the ‘‘spring’’ pressure. The
plate can be sized to the correct length by scoring the proximal
end of the plate (A) followed by deformation of the end plate
(B) until failure and separation of the piece (C).
FIGURE 2. Pelvic model with simulated posterior wall fracture
demonstrating the use of the modified T-plate in conjunction
with an overlying reconstruction plate. (A) The T-plate
maximizes contact area over the small posterior wall fragment.
(B) The T-plate is low profile, even with an additional overlying
q 2011 Lippincott Williams & Wilkins
J Orthop Trauma?Volume 25, Number 9, September 2011 T-Plate Fixation for Fractures of the Acetabulum
humeral fracture fixations. He developed heterotopic bone and
expressed no desire to stop his substance abuse. He was
subsequently treated with multiple resection arthroplasties and
felt satisfied for his level of activity.
Spring plates have been a valuable tool for the
stabilization of small fragments of posterior wall fractures.1,2
Although this study does not directly compare our technique
with the use of one third tubular spring plates, the need for
more than one plate entails more time, potentially more
dissection, additional hardware, and may complicate the
contouring of the overlying 3.5-mm reconstruction plate.
Using a single plate with an extended contact area on the small
fragments may be more convenient and more practical than
multiple one third tubular plates. Because this technique has
not been previously described, we present our experience and
feel it is a reasonable adjunct for stabilization of posterior wall
fragments. We reinforce the tenets that they should only be
used with an overlying 3.5-mm reconstruction plate and
should have independent fixation to the posterior bone to limit
the chance of migration.
1. Goulet JA, Rouleau JP, Mason DJ, et al. Comminuted fractures of the
posterior wall of the acetabulum. A biomechanical evaluation of fixation
methods. J Bone Joint Surg Am. 1994;76:1457–1463.
2. Richter H, Hutson JJ, Zych G. The use of spring plates in the internal
fixation of acetabular fractures. J Orthop Trauma. 2004;18:179–181.
3. Olson SA, Bay BK, Pollak AN, et al. The effect of variable size posterior
wall acetabular fractures on contact characteristics of the hip joint. J Orthop
4. Little J, Hileman B, Ziran BH. Inhalant abuse of 1,1-difluoroethane (DFE)
leading to heterotopic ossification: a case report. Patient Saf Surg. 2008;
FIGURE 3. (A) Postoperative internal oblique plain radiograph of the pelvis illustrating a modification of the T-plate technique to
form multiple prongs. Postoperative anteroposterior (A) and internal oblique (B) plain radiographs of the pelvis demonstrating
fixation of a posterior wall fracture of the acetabulum with a T-plate and overlying reconstruction plate.
TABLE 1. Case Demographics and Summary
43 years (range, 18–79 years)
14 Standard posterior wall
9 Transverse posterior wall
3 Superior posterior wall
2 Extended posterior wall
2 Posterior wall with posterior column
1 T-type with posterior wall
723 mL (range, 200–1500 mL)
117 minutes (range, 45–210 minutes)
Mechanism of injury
Average blood loss
Average operative time
MVC/MCC, motor vehicle crash/motorcycle crash.
576|www.jorthotrauma.comq 2011 Lippincott Williams & Wilkins
Ziran et al
J Orthop Trauma?Volume 25, Number 9, September 2011