Characteristics and Clinical Significance of Dome Impaction in Acetabular Fractures

Characteristics and Clinical Significance of Dome Impaction in Acetabular Fractures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Characteristics and Clinical Significance of Dome Impaction in Acetabular Fractures Pengfei Wang, Chen Fei, Zhi Li, Binfei Zhang, Kun Yang, Yuxuan Cong, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-146669/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective This study aimed to explore the characteristics of acetabular dome impaction fractures(ADIF) and evaluate the clinical outcomes. Methods Twenty-two ADIF treated by single surgeon were analyzed. The location and size of impaction was measured through Mimics. Patients’ demographic, characteristic data, surgical data and clinical outcomes were collected. The quality of reduction was assessed using criteria described by Matta. Functional outcomes were evaluated using modified Merle d’Aubigné score and SF-36. Results 40.91% of the ADIF located at the posterosuperior quadrant,36.36% of the ADIF located at anterosuperior quadrant, 22.73% of the ADIF involved both areas. The average impacted size was 467.24±308.25mm 2 . The average percent of the impacted was 17.18±8.94%（impaction size/ lunar surfaces）. At the final follow-up, the rate of excellent and good outcome per Matta’s radiographic grading was 77.27%. The modified Merle d’Aubigné score graded as excellent in 5(22.73%), good in 10(45.45%), fair in 5(22.73%), and poor in 2(9.09%). The mean score of SF-36 was 76.76±20.18. Avascular necrosis (AVN) developed in two patients. Heterotopic ossification(HO) developed in one patient. Sciatic nerve injury developed in one patient. Arthritis developed in one patient. Conclusions  The ADIF can locate at the posterosuperior quadrant, the anterosuperior quadrant or involved both areas. Understanding the characteristics of the dome impaction can aid surgeons during reduction and fixation. Meanwhile, good to excellent outcomes and a high degree of patient satisfaction can be achieved in majority of the patients. Orthopedic Surgery acetabular fracture dome impaction computed tomography outcome Figures Figure 1 Figure 2 Introduction Traditionally, acetabular fractures have been associated with high energy trauma in younger patients. However, with the increasing prevalence of osteoporosis amongst an ageing population, low energy acetabular fractures in the elderly are likely to become ever more predominant[8]. The ADIF which was usually called the gull-wing sign is frequently encountered in the elderly population with poor bone quality. The gull-wing sign was first described in 1965 by Berkebile et al.[1]It describes the appearance of a posterior fracture-dislocation of the hip on the lateral view. The posteriorly displaced fragment of the acetabulum combines with the rest of the acetabulum to create a double curved shadow which resembles the silhouette of a flying seagull[21]. An influential articles described that the notorious gull-wing sign is a medially displaced fracture of the acetabular roof where the medially displaced fragment of the acetabulum and the lateral part together also form a seagull outline on a plain AP radiograph[12]. Traditionally, the fracture including this characteristic represents a less reliable outcome from fixation alone.[5; 12] This fracture pattern was defined by Theodoros H. Tosounidis as an anterior column fracture without involvement of the pelvic brim according to the 2-column concept, which was contradictory to the description of the Judet-Letournel classification superomedial impaction of the anterior dome is a risk factor for poor outcome in elderly patients[12; 22]. However，all the study described the ADIF and evaluated the clinical outcomes of the gull-wing sign or ADIF only in the plain X-ray[8; 10; 24]. Thus, the exact location, the characteristics and the outcomes are controversial[10; 15; 24]. Meanwhile, the location of dome impaction determined the ability of the surgeon to access and reduce the fragment under direct visualization during surgery. To the best of our knowledge, current study is the first one to explore characteristics of the lesion based on the CT[24]. The purpose of this article is to explore the characteristics of ADIF and evaluate the clinical outcomes based on the CT scan and 3D reconstruction. Materials And Methods We retrospectively analyzed a series of 228 consecutive patients treated by a single surgeon(ZY) from Jan 2014 and Jan 2018. Inclusion criteria were as follows: (1) age >18 years; (2) acetabular dome impaction fractures (3) complete clinical data and imaging information, including X-ray and CT data. Exclusion criteria included: (1) incomplete clinical information; (2) poor quality of X-ray and CT data. Demographic information such as gender, age, mechanism of injury, associated injuries, fracture classification, surgical related data was recorded. According to the Letournel-Judet classification, the fractures were classified into five elementary patterns and five associated patterns by the senior orthopaedic traumatologists (YZ and KZ). Meanwhile, the dome impaction was identified by them through the AP view of the pelvis. If the agreement was not achieved, the third senior surgeon (XW, 20-year experience in pelvic and acetabular surgery) was consulted. All measurements were performed by two orthopedists at intervals of two weeks. The radiographic and functional outcomes were evaluated by two orthopaedic traumatologists (XW and HW) who were not involved in the surgeries. The quality of the reduction was graded as anatomical (0-1mm displacement), imperfect (2-3mm displacement), or poor (more than 3mm displacement) based on Matta’s criteria[19]. The clinical outcomes were evaluated using the modified Merle d’Aubigné score [19]. The patients were categorized as excellent (18 points), good (15–17 points), fair (13–14 points), or poor (<13 points). At final follow-up, the radiographs were utilized to evaluate the heterotopic ossification (HO) (Brooker classification[3]), osteoarthritis (Kellgren-Lawrence classification[14]) and avascular necrosis (AVN)(Ficat/Arlet classification[9]) Location and measurement The data of computer tomography were obtained in the Digital Imaging and Communications in Medicine (DICOM) format from our radiology database and then imported into the MIMICS19.0 (Materialise, Belgium). The pelvic position was corrected to the standard lateral decubitus. The bilateral femoral head was removed from the 3D-CT reconstruction. Acetabular abduction angle and anteversion angle were eliminated through controlling the rotation of the pelvis before measurement. The acetabulum was divided into 4 quadrants by the midperpendicular of the acetabular notch and their bisector across the acetabulum. The dome impaction fragment was located by selecting all axial and coronal computed tomography sections[2; 13]. The 3D reconstruction was converted by 3-Matic 12.0（materialise, Belgium）.The area of acetabular dome impaction was located. The normal size of acetabulum, the normal size of the lunar surface, the impacted size and percent of the impaction area were measured. When measuring the normal size of acetabulum and normal size of acetabular lunar surface, a mirror of the uninjured, contralateral acetabulum was used. Results Demographic characteristics Twenty-two patients were included in the study and had an average age of 58.91± 13.68 years (range; 30–85), with 14 males and 8 female participants. Average follow-up was 28±4.5 months. Patient characteristics, fracture pattern and mechanism of injury are shown in Table 1 . Associated injuries included 1 upper extremity, 3 lower extremities, 2 chest injuries,1 minor head injury and 1 abdominal injury. There were no open fractures. Three combined pelvic injuries were classified according to Tile’s classification (1 type B2 and 2 type C). 7 patients with femoral head cartilage injury. Measurement of the acetabular dome impaction 45.45% ADIF are located at the posterosuperior quadrant. 40.91% ADIF are located at the anterosuperior quadrant. The remaining (13.64%) ADIF involved both areas. The details are shown in Table 2 and Table 3. Clinical imagine and functional outcomes Most involving both columns fractures (18 patients,81.82%) were managed through single Ilioinguinal approach (11patients) or Stoppa approach (7 patients) in our study. Additional injuries to the pelvis were treated with either plates or screws. Surgical related data are in Table 1 . At final follow-up, according to the reduction categories described by Matta[19], we achieved anatomical reduction in 10 patients (45.45%), imperfect reduction in 7 patients (31.82%), and poor reduction in 5 patients (22.73%). According to the Merle d’Aubigné score, 5 patients (22.73%) were rated excellent, 10 patients (45.45%) were rated good, 5 patients (22.73%) were rated fair and 2 patients (9.09%) rated poor. The average score of SF-36 was 76.76±20.18. Deep venous thrombosis (DVT) was screened in 12 patients (54.55%) during hospitalization. One sciatic nerve injury was observed preoperatively. One patient developed mild heterotopic ossification (Brookers’type II). Significant AVN was seen in 2 patients and required subsequent revision surgery with a total hip arthroplasty. Two patients developed mild osteoarthritis (Kellgren-Lawrence classification I-II). Discussion Characteristics of Acetabular Dome Impaction Fractures Treatment of an ADIF poses a difficult challenge for the orthopaedic traumatologist. Several authors have recently reported clinical outcomes involve the acetabular dome impaction[4; 6; 10; 16; 23; 25]. Jeffrey O. Anglen[12] found the ADIF which was called the ‘gull sign’, was 100% predictive of failure of reduction and/or fixation. In their study, they considered that it was difficult to reduce and fix the gull sign because of the superoanteromedial location of the fragment and its displacement into the cancellous [12] . It is difficult or impossible to get any bone graft or hardware applied in a manner to reliably support the fragment. The previous study was controversial on the location of the dome impaction. Most of the study identified the location was in the anteromedial area of the acetabulum[24]. Some authors identified that the impaction part involved the posteromedial portion of the roof[8; 17; 20]. But none of the previous study explored the morphological characteristics[24]. In the current study, based on the CT scan, we founded that the 45.45% of the ADIF was located more posterosuperior which was different from the previous study. The location of the ADIF might influence the approach and then manipulate and the implant placement. From current morphological study, most of the dome impaction located at the posterosuperior quadrant. The average impaction size was 467.24±308.25, almost occupied 17% of the normal size of the lunar surface, which needs more wildly debrided toward to the posterior and lateral. Usually, anterior based approach is used in all cases and the location/configuration of the fracture dictate the exact reduction maneuvers and fixation techniques. Previous study reported that the dome impaction is important to success and can generally be accomplished through use of the lateral two windows of the ilioinguinal approach[25]. This circumstance might lead to it difficult to maneuve get the perfect reduction and stable fixation. Clinical significance of Acetabular Dome Impaction Fractures Several study had reported that the clinical outcomes and imagine results of ADIF were poor[11; 12]. The best predictor of success for acetabular fractures is the quality of the reduction according to Matta [19] . However, the perfection of the reduction was difficult to achieved especially in associated acetabular fracture in elderly patients. We recommend that the indirect reduction techniques are generally not ideal for ADIF. 45.45% of the ADIF located in the posteromedial, the area was covered up by the anterior cortex, which may influence the direct reduction. The accesses to the dome impaction were usually through opening the anterior wall fracture segment, the true pelvic fracture line or making a cortical window in the anterior wall [25] . When reduction was performed, the surgeon should pay more attention to debride the ADIF fragments more posteriorly and exposure the periphery. Fracture fragments and hematoma are then subsequently cleaned from fracture lines, frequently by use of long pituitary rongeurs and elevators. Usually, a small curved elevator or mosquito forceps was used for the reduction. The femoral head was used as the template. The reduction maneuvers should be more anterior/posterior which depended on the location of the ADIF Then, the bone defect was filled through the anterior column /wall fracture window with allograft or shaped autograft which was harvested from the iliac spine [25] . We prefer to address dome impaction and then proceed with the definitive reduction of the infrapectineal buttress plate [26] . Screws may be placed independently or through the buttress plate. After investigated in 15 Level-1 trauma centers, Manson TT reported that the fractures with dome impaction were significantly more likely to be treated initially with THA [18] . However, in a larger study, Carroll et al. found no association between the gull sign and the need for subsequent arthroplasty, stating that the failure rate was largely related to the overall quality of the reduction and fixation [7] . Based on our previous study, the primary ORIF can receive good clinical and imagine outcomes[25]. In this study, the quality of reduction within 3mm was achieved in 77.27% patients which were similar to the previous study[10; 25]. The excellent and good rate per modified Merle d’Aubigne score was 68.18%, which was lower than previous study [25] .We infer that might attribute to the younger patients in Zhuang’s previous study [25] . In addition, THA is more expensive than ORIF, according to our medical insurance system, many patients cannot afford it. 2 patients were performed revision surgery with THA due to avascular necrosis. One patient (4.55%) had grade II arthritic changes as described by Brookers[3] and was complaining of intermittent moderate pain requiring occasional oral non-steroidal anti-inflammatory medication. Limitations This study has several limitations due to its retrospective single-center design and non-comparative study. The number of patients in the study is not high but this is secondary to the relatively low incidence of complex acetabular fractures. Although this is the first study mentioned the ADIF morphological characteristics in CT, the relatively limited number of patients with this procedure further limits this study’s generalizability. This study also had relatively short length of follow-up to evaluate progression of arthritis. Conclusion The ADIF can locate at the posterosuperior quadrant, the anteriorsuperior quadrant or both of these two areas. Understanding the characteristics of the dome impaction can aid surgeons during reduction and fixation. Meanwhile, good to excellent outcomes and a high degree of patient satisfaction can be achieved in majority of the patients. Abbreviations ADIF :acetabular dome impaction fractures; AVN :Avascular necrosis; HO :Heterotopic ossification; AP: anterior-posterior; CT: computed tomography; DICOM:Digital Imaging and Communications in Medicine; DVT:deep venous thrombosis; THA: total hip arthroplasty. Declarations Acknowledgements None Funding This work was supported by the Social Development Foundation of Shaanxi Province (grant no. 2017SF-050). Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to personal reasons, but are available from the corresponding author on reasonable request. Authors contributions Pengfei Wang carried out the study, and drafted the manuscript. Chen Fei measured the data. Zhi Li, Hu Wang, Xing Wei, Yahui Fu, collected the data.Binfei Zhang and Yuxuan Cong helped to finish the statistics. Kun Zhang and Yan Zhuang designed the study. All authors read and approved the final manuscript. Ethical review committee statement This study was approved by the Ethics Committee and Institutional Review Board of Honghui hospital. The informed consent forms were obtained from the patients prior to study participation. Consent for publication Written informed consent was obtained from individual participants. Competing interests The authors declare that they have no competing interests References 1 Berkebile, Robert D. Fischer, Delbert A, Leroy Faber KJ (1965) The Gull-Wing sign. Radiology, 84:937-939 2 BR M, DA A, H I (2009) Computed tomography as a predictor of hip stability status in posterior wall fractures of the acetabulum. 23(1):7-15 3 Brooker AF, Bowerman JW, Robinson RA, Riley LH, Jr. (1973) Ectopic ossification following total hip replacement. Incidence and a method of classification. The Journal of bone and joint surgery. American volume, 55(8):1629-1632 4 Casstevens C, Archdeacon MT, d'Heurle A, Finnan R (2014) Intrapelvic reduction and buttress screw stabilization of dome impaction of the acetabulum: a technical trick. Journal of orthopaedic trauma, 28(6):e133-137 5 Chotai N, Arshad H, Bates P (2018) Radiographic anatomy and imaging of the acetabulum. Orthopaedics and Trauma, 32(2):102-109 6 E G, JR C, E C (2012) Fractures of the acetabulum in elderly patients: an update. Injury:S33-41 7 Eben A. Carroll M, Florian G. Huber M, Ariel T. Goldman M, et al. (2010) Treatment of Acetabular Fractures in an Older Population. Journal of orthopaedic trauma, 24:637–644 8 Ferguson TA, Patel R, Bhandari M, Matta JM (2010) Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study. The Journal of bone and joint surgery. British volume, 92(2):250-257 9 Ficat RP (1985) Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. The Journal of bone and joint surgery. British volume, 67(1):3-9 10 G-Yves Laflamme M, FRCSC, Jonah Hebert-Davies M (2014) Direct Reduction Technique for Superomedial Dome Impaction in Geriatric Acetabular Fractures. Journal of orthopaedic trauma, 28:e39–e43 11 GJ H (2010) Acetabular fractures: the role of arthroplasty. Orthopedics, 33(9):645 12 Jeffrey O. Anglen M, Timothy A. Burd M, Kelly J. Hendricks M, Paula Harrison R (2003) The “Gull Sign”A Harbinger of Failure for Internal Fixation of Geriatric Acetabular Fractures. Journal of orthopaedic trauma, 17:625–634 13 JM R, BR M (2011) Can computed tomography predict hip stability in posterior wall acetabular fractures? Clinical orthopaedics related research, 469(7):2035-2041 14 Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Annals of the rheumatic diseases, 16(4):494-502 15 Laflamme GY, Hebert-Davies J, Rouleau D, Benoit B, Leduc S (2011) Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate. Injury, 42(10):1130-1134 16 Li YL, Tang YY (2014) Displaced acetabular fractures in the elderly: results after open reduction and internal fixation. Injury, 45(12):1908-1913 17 Manson TT (2020) Acetabular Fractures in Older Patients Assessment and Management. Springer Switzerland 18 Manson TT, Reider L, O'Toole RV, et al. (2016) Variation in Treatment of Displaced Geriatric Acetabular Fractures Among 15 Level-I Trauma Centers. Journal of orthopaedic trauma, 30(9):457-462 19 Matta JM (1996) Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. The Journal of bone and joint surgery. American volume, 78(11):1632-1645 20 Paul E. Beaulé M, FRCSC;, David B. Griffin M, Joel M. Matta M (2004) The Levine Anterior Approach for Total Hip Replacement as the Treatment for an Acute Acetabular Fracture. Journal of orthopaedic trauma, 18:623–629 21 Ridley WE, Xiang H, Han J, Ridley LJ (2018) Gull-wing sign: Acetabular fracture. Journal of Medical Imaging and Radiation Oncology, 62:142-142 22 Saterbak AM, Marsh JL, Nepola JV, Brandser EA, Turbett T (2000) Clinical failure after posterior wall acetabular fractures: the influence of initial fracture patterns. Journal of orthopaedic trauma, 14(4):230-237 23 Scolaro JA, Routt ML, Jr. (2013) Reduction of osteoarticular acetabular dome impaction through an independent iliac cortical window. Injury, 44(12):1959-1964 24 Tosounidis TH, Stengel D, Giannoudis PV (2016) Anteromedial dome impaction in acetabular fractures: Issues and controversies. Injury, 47(8):1605-1607 25 Zhuang Y, Lei JL, Wei X, Lu DG, Zhang K (2015) Surgical treatment of acetabulum top compression fracture with sea gull sign. Orthopaedic surgery, 7(2):146-154 26 Zhuang Y, Zhang K, Wang H, et al. (2017) A short buttress plate fixation of posterior column through single ilioinguinal approach for complex acetabular fractures. International orthopaedics, 41(1):165-171 Tables Table 1 Patient demographics data, characteristics and surgical related data Variable N=22 Mean age (years) 58.91±13.68 Sex (n, %) M F 14（63.63%） 8（36.37%） Mechanism of injury MVA fall from standing height fall from height (=3m) 5（22.7%） 6（27.3%） 7（31.8%） 4（18.2%） acetabular fracture type (Letournel) anterior column+anterior wall posterior column+posterior wall transverse anterior column+posterior hemitransvers both column T-type indeterminate fracture transverse+posterior wall isolate quadrilateral surface 1(4.55%) 1(4.55%) 1(4.55%) 13(59.09%) 2(9.10%) 1(4.55%) 3(13.64%) 2(9.10%) 1(4.55%) associated injury pelvic injury upper extremity lower extremity chest injury head injury abdominal injury multi-injury femoral head injury 3(13.64%) 1(4.55%) 3(13.64%) 2(9.10%) 1(4.55%) 1(4.55%) 3(13.64%) 7(31.81%) approach IL Stoppa KL 11(50%) 7(31.82%) 4(18.18%) operation time(minutes) 226.59±48.34 blood loss(ml) 1122.73±482.98 bone graft autograft allograft 15(68.2%) 7(31.8%) follow-up(months) 28±4.5 Tornetta and Matta Radiographic grades anatomical (0–1 mm displacement) imperfect (2–3 mm displacement) poor (more than 3 mm displacement) 10(45.45%) 7(31.82%) 5(22.73%) modified Merle d’Aubigné score excellent (18 points) good (15–17 points) fair (13–14 points) poor (<13 points) 5(22.73%) 10(45.45%) 5(22.73%) 2(9.09%) SF-36 76.76±20.18 Complication None DVT sciatic nerve injury HO arthritis AVN 10(45.45%) 12(54.54%) 1(4.55%) 1(4.55%) 2(9.09%) 2(9.09%) Note: MVA: motor vehicle accident, IL: Ilioinguinal, KL: Kocher–Langenbeck, DVT: deep venous thrombosis, HO: heterotopic ossification, AVN: avascular necrosis Table 2 Location of the acetabular dome impaction Location N=22 9-12 o’clock 12-3 o’clock 9-3 o’clock 10(45.45%) 9(40.91%) 3(13.64%) Table 3 Characteristics of the acetabular dome impaction Characteristics N Minimum Maximum Mean S.D normal size of acetabulum (contralateral) 22 3300.00 4662.00 4010.86 449.74 normal size of lunar surface 22 2124.00 3637.00 2749.46 371.73 impaction size 22 80.00 1100.00 467.24 308.25 percent of the impaction area (%) 22 3.13 36.94 17.18 8.94 Note ：percent of the impaction= impaction size/ lunar surface Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-146669","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":8124614,"identity":"486d3194-4efb-4d8e-a184-444864cfa7cc","order_by":0,"name":"Pengfei Wang","email":"","orcid":"","institution":"Xi'an Honghui Hospital,Xi'an Jiaotong University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Pengfei","middleName":"","lastName":"Wang","suffix":""},{"id":8124615,"identity":"21a9c5dc-bc0e-4350-b296-eb472ea76db3","order_by":1,"name":"Chen Fei","email":"","orcid":"","institution":"Xi'an Honghui Hospital,Xi'an Jiaotong University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Chen","middleName":"","lastName":"Fei","suffix":""},{"id":8124616,"identity":"edab0a4a-cf56-4542-867a-191bd0de1da4","order_by":2,"name":"Zhi Li","email":"","orcid":"","institution":"Xi'an Honghui Hospital，Xi'an Jiaotong University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Zhi","middleName":"","lastName":"Li","suffix":""},{"id":8124617,"identity":"7e367539-aaf1-4f83-9e59-fc00fde3621c","order_by":3,"name":"Binfei Zhang","email":"","orcid":"","institution":"Xi'an Honghui Hispital,Xi'an Jiaotong University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Binfei","middleName":"","lastName":"Zhang","suffix":""},{"id":8124618,"identity":"09bc0703-8218-4b9a-a169-6ea00e30a71a","order_by":4,"name":"Kun Yang","email":"","orcid":"","institution":"Xi'an Honghui Hospital，Xi'an Jiaotong University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Kun","middleName":"","lastName":"Yang","suffix":""},{"id":8124619,"identity":"f27fd091-23e3-4cba-912e-e2bfe2c7772b","order_by":5,"name":"Yuxuan Cong","email":"","orcid":"","institution":"Xi'an Honghui Hospital,Xi'an Jiaotong University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Yuxuan","middleName":"","lastName":"Cong","suffix":""},{"id":8124620,"identity":"5652b8c0-5b12-45d8-848c-cf1843faf32d","order_by":6,"name":"Hu Wang","email":"","orcid":"","institution":"Xi'an Honghui Hospital,Xi'an Jiaotong University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Hu","middleName":"","lastName":"Wang","suffix":""},{"id":8124621,"identity":"f749867f-18c9-4a6e-9abf-6c065266bd6c","order_by":7,"name":"Xing Wei","email":"","orcid":"","institution":"Xi'an Honghui Hospital,Xi'an Jiaotong University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Xing","middleName":"","lastName":"Wei","suffix":""},{"id":8124622,"identity":"0824dce1-0eab-4a25-992c-3b72ab75b1af","order_by":8,"name":"Yahui Fu","email":"","orcid":"","institution":"Xi'an Honghui Hospital,Xi'an Jiaotong University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Yahui","middleName":"","lastName":"Fu","suffix":""},{"id":8124623,"identity":"a78909dc-bfaa-481c-8d90-4ed7f92db1ca","order_by":9,"name":"Yan Zhuang","email":"","orcid":"","institution":"Xi'an Honghui Hospital,Xi'an Jiaotong University Health Science Center","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Zhuang","suffix":""},{"id":8124624,"identity":"a30b1cd5-3dae-4154-ac01-f8b87c986411","order_by":10,"name":"Kun Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYBACNv7+7x8+VNgwszHzf3yQUFFDWAufxAEzxhln0tj52RuMDR6cOUZYixxDghkzb9thfsmeA2aSD1uYiXAYw4G0x0At0gY3EtIqEhvYGPjbuxPwa2FuOG4451y6MVDLsRuJO2QYJM6c3UDAloMNEm/KrJMNbiS23Ug8w8ZgIJFLSEsygwQPG3P9hhvJbAWJbczEaEljk+Rpc2aW7DnGxkCcFokzzIbAQGbmZ+9hlkg4c4yHoF/k+3sYH0Cikofx44+KGjn+9l78WjAAD2nKR8EoGAWjYBRgBQAcOEmvPODIXQAAAABJRU5ErkJggg==","orcid":"","institution":"Xi'an Honghui Hospital,Xi'an Jiaotong University","correspondingAuthor":true,"prefix":"","firstName":"Kun","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2021-01-13 11:44:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-146669/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-146669/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":5013279,"identity":"f96739ce-3b9e-464f-ba17-2f8b7a77975c","added_by":"auto","created_at":"2021-01-15 23:47:32","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":895104,"visible":true,"origin":"","legend":"A 74-year-old female presented with acetabular fractures. Preoperative radiographs [AP view and Judet views pictured] showed right anterior column +hemi-transverse fractures (A-C). Gull wing sign can be clearly seen from the AP view. (D) Acetabular dome impaction can be found from the coronal view of CT scan. (E-H) Postoperative radiographs, CT scan showed the reduction was well. (I-K) Post-operative radiographs at 30 months after surgery. (L) The range of motion at 22 months follow up.","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-146669/v1/eada268909ee1dc7e230d980.jpg"},{"id":5013309,"identity":"0f37819c-7502-42b9-b862-410b5ed3102b","added_by":"auto","created_at":"2021-01-15 23:50:32","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":550421,"visible":true,"origin":"","legend":"(A) Location of the acetabular dome impaction. (B) the area of the impaction fragment (orange) was 146.95mm2. (C) normal size of acetabulum (contralateral side) was 4575.62mm2 (D)normal size of lunar surface (contralateral side) was 2684.14mm2. ","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-146669/v1/ec67abf7fe5a2a898cd481e1.jpg"},{"id":13648246,"identity":"35a27616-e3ee-4cf7-aa6a-17732c6e2b43","added_by":"auto","created_at":"2021-09-17 09:31:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":565587,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-146669/v1/4bcdd208-1af0-4448-b181-16016b37f2da.pdf"}],"financialInterests":"","formattedTitle":"Characteristics and Clinical Significance of Dome Impaction in Acetabular Fractures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTraditionally, acetabular fractures have been associated with high energy trauma in younger patients. However, with the increasing prevalence of osteoporosis amongst an ageing population, low energy acetabular fractures in the elderly are likely to become ever more predominant[8]. The ADIF which was usually called the gull-wing sign is frequently encountered in the elderly population with poor bone quality. The gull-wing sign was first described in 1965 by Berkebile et al.[1]It describes the appearance of a posterior fracture-dislocation of the hip on the lateral view. The posteriorly displaced fragment of the acetabulum combines with the rest of the acetabulum to create a double curved shadow which resembles the silhouette of a flying seagull[21]. An influential articles described that the notorious gull-wing sign is a medially displaced fracture of the acetabular roof where the medially displaced fragment of the acetabulum and the lateral part together also form a seagull outline on a plain AP radiograph[12]. Traditionally, the fracture including this characteristic represents a less reliable outcome from fixation alone.[5; 12] This fracture pattern was defined by Theodoros H. Tosounidis as an anterior column fracture without involvement of the pelvic brim according to the 2-column concept, which was contradictory to the description of the Judet-Letournel classification superomedial impaction of the anterior dome is a risk factor for poor outcome in elderly patients[12; 22].\u003c/p\u003e\n\u003cp\u003eHowever，all the study described the ADIF and evaluated the clinical outcomes of the gull-wing sign or ADIF only in the plain X-ray[8; 10; 24]. Thus, the exact location, the characteristics and the outcomes are controversial[10; 15; 24]. Meanwhile, the location of dome impaction determined the ability of the surgeon to access and reduce the fragment under direct visualization during surgery. To the best of our knowledge, current study is the first one to explore characteristics of the lesion based on the CT[24]. The purpose of this article is to explore the characteristics of ADIF and evaluate the clinical outcomes based on the CT scan and 3D reconstruction.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003eWe retrospectively analyzed a series of 228 consecutive patients treated by a single surgeon(ZY) from Jan 2014 and Jan 2018. Inclusion criteria were as follows: (1) age \u0026gt;18 years; (2) acetabular dome impaction fractures (3) complete clinical data and imaging information, including X-ray and CT data. Exclusion criteria included: (1) incomplete clinical information; (2) poor quality of X-ray and CT data. Demographic information such as gender, age, mechanism of injury, associated injuries, fracture classification, surgical related data was recorded. According to the Letournel-Judet classification, the fractures were classified into five elementary patterns and five associated patterns by the senior orthopaedic traumatologists (YZ and KZ). Meanwhile, the dome impaction was identified by them through the AP view of the pelvis. If the agreement was not achieved, the third senior surgeon (XW, 20-year experience in pelvic and acetabular surgery) was consulted. All measurements were performed by two orthopedists at intervals of two weeks. The radiographic and functional outcomes were evaluated by two orthopaedic traumatologists (XW and HW) who were not involved in the surgeries. The quality of the reduction was graded as anatomical (0-1mm displacement), imperfect (2-3mm displacement), or poor (more than 3mm displacement) based on Matta\u0026rsquo;s criteria[19]. The clinical outcomes were evaluated using the modified Merle d\u0026rsquo;Aubign\u0026eacute; score [19]. The patients were categorized as excellent (18 points), good (15\u0026ndash;17 points), fair (13\u0026ndash;14 points), or poor (\u0026lt;13 points). At final follow-up, the radiographs were utilized to evaluate the heterotopic ossification (HO) (Brooker classification[3]), osteoarthritis (Kellgren-Lawrence classification[14]) and avascular necrosis (AVN)(Ficat/Arlet classification[9])\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLocation and measurement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data of computer tomography were obtained in the Digital Imaging and Communications in Medicine (DICOM) format from our radiology database and then imported into the MIMICS19.0 (Materialise, Belgium). The pelvic position was corrected to the standard lateral decubitus. The bilateral femoral head was removed from the 3D-CT reconstruction. Acetabular\u0026nbsp;abduction angle and anteversion\u0026nbsp;angle were eliminated through controlling the rotation of the pelvis before measurement. The acetabulum was divided into 4 quadrants by the midperpendicular of the acetabular notch and their bisector across the acetabulum. The dome impaction fragment was located by selecting all axial and coronal computed tomography sections[2; 13]. The 3D reconstruction was converted by 3-Matic 12.0（materialise, Belgium）.The area of acetabular dome impaction was located. The normal size of acetabulum, the normal size of the lunar surface, the impacted size and percent of the impaction area were measured. When measuring the normal size of acetabulum and normal size of acetabular lunar surface, a mirror of the uninjured, contralateral acetabulum was used.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eDemographic characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTwenty-two patients were included in the study and had an average age of 58.91\u0026plusmn; 13.68 years (range; 30\u0026ndash;85), with 14 males and 8 female participants. Average follow-up was 28\u0026plusmn;4.5 months. Patient characteristics, fracture pattern and mechanism of injury are shown in \u003cstrong\u003eTable 1\u003c/strong\u003e. Associated injuries included 1 upper extremity, 3 lower extremities, 2 chest injuries,1 minor head injury and 1 abdominal injury. There were no open fractures. Three combined pelvic injuries were classified according to Tile\u0026rsquo;s classification (1 type B2 and 2 type C). 7 patients with femoral head cartilage injury.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMeasurement of the acetabular dome impaction\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e45.45% ADIF are located at the posterosuperior quadrant. 40.91% ADIF are located at the anterosuperior quadrant. The remaining (13.64%) ADIF involved both areas. The details are shown in \u003cstrong\u003eTable 2 and Table 3.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical imagine and functional outcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost involving both columns fractures (18 patients,81.82%) were managed through single Ilioinguinal approach (11patients) or Stoppa approach (7 patients) in our study. Additional injuries to the pelvis were treated with either plates or screws. Surgical related data are in \u003cstrong\u003eTable 1\u003c/strong\u003e. At final follow-up, according to the reduction categories described by Matta[19], we achieved anatomical reduction in 10 patients (45.45%), imperfect reduction in 7 patients (31.82%), and poor reduction in 5 patients (22.73%). According to the Merle d\u0026rsquo;Aubign\u0026eacute; score, 5 patients (22.73%) were rated excellent, 10 patients (45.45%) were rated good, 5 patients (22.73%) were rated fair and 2 patients (9.09%) rated poor. The average score of SF-36 was 76.76\u0026plusmn;20.18. Deep venous thrombosis (DVT) was screened in 12 patients (54.55%) during hospitalization. One sciatic nerve injury was observed preoperatively. One patient developed mild heterotopic ossification (Brookers\u0026rsquo;type II). Significant AVN was seen in 2 patients and required subsequent revision surgery with a total hip arthroplasty. Two patients developed mild osteoarthritis (Kellgren-Lawrence classification I-II).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCharacteristics of Acetabular Dome Impaction Fractures\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTreatment of an ADIF poses a difficult challenge for the orthopaedic traumatologist. Several authors have recently reported clinical outcomes involve the acetabular dome impaction[4; 6; 10; 16; 23; 25]. Jeffrey O. Anglen[12] found the ADIF which was called the \u0026lsquo;gull sign\u0026rsquo;, was 100% predictive of failure of reduction and/or fixation. In their study, they considered that it was difficult to reduce and fix the gull sign because of the superoanteromedial location of the fragment and its displacement into the cancellous\u003csup\u003e[12]\u003c/sup\u003e. It is difficult or impossible to get any bone graft or hardware applied in a manner to reliably support the fragment. The previous study was controversial on the location of the dome impaction. Most of the study identified the location was in the anteromedial area of the acetabulum[24]. Some authors identified that the impaction part involved the posteromedial portion of the roof[8; 17; 20]. But none of the previous study explored the morphological characteristics[24]. In the current study, based on the CT scan, we founded that the 45.45% of the ADIF was located more posterosuperior which was different from the previous study. The location of the ADIF might influence the approach and then manipulate and the implant placement. From current morphological study, most of the dome impaction located at the posterosuperior quadrant. The average impaction size was 467.24\u0026plusmn;308.25, almost occupied 17% of the normal size of the lunar surface, which needs more wildly debrided toward to the posterior and lateral. Usually, anterior based approach is used in all cases and the location/configuration of the fracture dictate the exact reduction maneuvers and fixation techniques. Previous study reported that the dome impaction is important to success and can generally be accomplished through use of the lateral two windows of the ilioinguinal approach[25]. This circumstance might lead to it difficult to maneuve get the perfect reduction and stable fixation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical significance of Acetabular Dome Impaction Fractures\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral study had reported that the clinical outcomes and imagine results of ADIF were poor[11; 12]. The best predictor of success for acetabular fractures is the quality of the reduction according to Matta\u003csup\u003e[19]\u003c/sup\u003e. However, the perfection of the reduction was difficult to achieved especially in associated acetabular fracture in elderly patients. We recommend that the indirect reduction techniques are generally not ideal for ADIF. 45.45% of the ADIF located in the posteromedial, the area was covered up by the anterior cortex, which may influence the direct reduction. The accesses to the dome impaction were usually through opening the anterior wall fracture segment, the true pelvic fracture line or making a cortical window in the anterior wall\u003csup\u003e[25]\u003c/sup\u003e. When reduction was performed, the surgeon should pay more attention to debride the ADIF fragments more posteriorly and exposure the periphery. Fracture fragments and hematoma are then subsequently cleaned from fracture lines, frequently by use of long pituitary rongeurs and elevators. Usually, a small curved elevator or mosquito forceps was used for the reduction. The femoral head was used as the template. The reduction maneuvers should be more anterior/posterior which depended on the location of the ADIF Then, the bone defect was filled through the anterior column /wall fracture window with allograft or shaped autograft which was harvested from the iliac spine\u003csup\u003e[25]\u003c/sup\u003e. We prefer to address dome impaction and then proceed with the definitive reduction of the infrapectineal buttress plate\u003csup\u003e[26]\u003c/sup\u003e. Screws may be placed independently or through the buttress plate.\u003c/p\u003e\n\u003cp\u003eAfter investigated in 15 Level-1 trauma centers, Manson TT reported that the fractures with dome impaction were significantly more likely to be treated initially with THA\u003csup\u003e[18]\u003c/sup\u003e. However, in a larger study, Carroll et al. found no association between the gull sign and the need for subsequent arthroplasty, stating that the failure rate was largely related to the overall quality of the reduction and fixation\u003csup\u003e[7]\u003c/sup\u003e. Based on our previous study, the primary ORIF can receive good clinical and imagine outcomes[25]. In this study, the quality of reduction within 3mm was achieved in 77.27% patients which were similar to the previous study[10; 25]. The excellent and good rate per modified Merle d\u0026rsquo;Aubigne score was 68.18%, which was lower than previous study\u003csup\u003e[25]\u003c/sup\u003e.We infer that might attribute to the younger patients in Zhuang\u0026rsquo;s previous study\u003csup\u003e[25]\u003c/sup\u003e. In addition, THA is more expensive than ORIF, according to our medical insurance system, many patients cannot afford it. 2 patients were performed revision surgery with THA due to avascular necrosis. One patient (4.55%) had grade II arthritic changes as described by Brookers[3] and was complaining of intermittent moderate pain requiring occasional oral non-steroidal anti-inflammatory medication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLimitations\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations due to its retrospective single-center design and non-comparative study. The number of patients in the study is not high but this is secondary to the relatively low incidence of complex acetabular fractures. Although this is the first study mentioned the ADIF morphological characteristics in CT, the relatively limited number of patients with this procedure further limits this study\u0026rsquo;s generalizability. This study also had relatively short length of follow-up to evaluate progression of arthritis.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe ADIF can locate at the posterosuperior quadrant, the anteriorsuperior quadrant or both of these two areas. Understanding the characteristics of the dome impaction can aid surgeons during reduction and fixation. Meanwhile, good to excellent outcomes and a high degree of patient satisfaction can be achieved in majority of the patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADIF :acetabular dome impaction fractures; AVN :Avascular necrosis; HO :Heterotopic ossification; AP: anterior-posterior; CT: computed tomography; DICOM:Digital Imaging and Communications in Medicine; DVT:deep venous thrombosis; THA: total hip arthroplasty.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e This work was supported by the Social Development Foundation of Shaanxi Province (grant no. 2017SF-050).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e The datasets generated and/or analyzed during the current study are not publicly available due to personal reasons, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions \u003c/strong\u003ePengfei Wang carried out the study, and drafted the manuscript. Chen Fei measured the data. Zhi Li, Hu Wang, Xing Wei, Yahui Fu, collected the data.Binfei Zhang and Yuxuan Cong helped to finish the statistics. Kun Zhang and Yan Zhuang designed the study. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical review committee statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee and Institutional Review Board of Honghui hospital. The informed consent forms were obtained from the patients prior to study participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e Written informed consent was obtained from individual participants.\u003cbr /\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e The authors declare that they have no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e1 Berkebile, Robert D. Fischer, Delbert A, Leroy Faber KJ (1965) The Gull-Wing sign. Radiology, 84:937-939\u003c/p\u003e\n\u003cp\u003e2 BR M, DA A, H I (2009) Computed tomography as a predictor of hip stability status in posterior wall fractures of the acetabulum. 23(1):7-15\u003c/p\u003e\n\u003cp\u003e3 Brooker AF, Bowerman JW, Robinson RA, Riley LH, Jr. (1973) Ectopic ossification following total hip replacement. Incidence and a method of classification. The Journal of bone and joint surgery. American volume, 55(8):1629-1632\u003c/p\u003e\n\u003cp\u003e4 Casstevens C, Archdeacon MT, d'Heurle A, Finnan R (2014) Intrapelvic reduction and buttress screw stabilization of dome impaction of the acetabulum: a technical trick. Journal of orthopaedic trauma, 28(6):e133-137\u003c/p\u003e\n\u003cp\u003e5 Chotai N, Arshad H, Bates P (2018) Radiographic anatomy and imaging of the acetabulum. Orthopaedics and Trauma, 32(2):102-109\u003c/p\u003e\n\u003cp\u003e6 E G, JR C, E C (2012) Fractures of the acetabulum in elderly patients: an update. Injury:S33-41\u003c/p\u003e\n\u003cp\u003e7 Eben A. Carroll M, Florian G. Huber M, Ariel T. Goldman M, et al. (2010) Treatment of Acetabular Fractures in an Older Population. Journal of orthopaedic trauma, 24:637\u0026ndash;644\u003c/p\u003e\n\u003cp\u003e8 Ferguson TA, Patel R, Bhandari M, Matta JM (2010) Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study. The Journal of bone and joint surgery. British volume, 92(2):250-257\u003c/p\u003e\n\u003cp\u003e9 Ficat RP (1985) Idiopathic bone necrosis of the femoral head. Early diagnosis and treatment. The Journal of bone and joint surgery. British volume, 67(1):3-9\u003c/p\u003e\n\u003cp\u003e10 G-Yves Laflamme M, FRCSC, Jonah Hebert-Davies M (2014) Direct Reduction Technique for Superomedial Dome Impaction in Geriatric Acetabular Fractures. Journal of orthopaedic trauma, 28:e39\u0026ndash;e43\u003c/p\u003e\n\u003cp\u003e11 GJ H (2010) Acetabular fractures: the role of arthroplasty. Orthopedics, 33(9):645\u003c/p\u003e\n\u003cp\u003e12 Jeffrey O. Anglen M, Timothy A. Burd M, Kelly J. Hendricks M, Paula Harrison R (2003) The \u0026ldquo;Gull Sign\u0026rdquo;A Harbinger of Failure for Internal Fixation of Geriatric Acetabular Fractures. Journal of orthopaedic trauma, 17:625\u0026ndash;634\u003c/p\u003e\n\u003cp\u003e13 JM R, BR M (2011) Can computed tomography predict hip stability in posterior wall acetabular fractures? Clinical orthopaedics related research, 469(7):2035-2041\u003c/p\u003e\n\u003cp\u003e14 Kellgren JH, Lawrence JS (1957) Radiological assessment of osteo-arthrosis. Annals of the rheumatic diseases, 16(4):494-502\u003c/p\u003e\n\u003cp\u003e15 Laflamme GY, Hebert-Davies J, Rouleau D, Benoit B, Leduc S (2011) Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate. Injury, 42(10):1130-1134\u003c/p\u003e\n\u003cp\u003e16 Li YL, Tang YY (2014) Displaced acetabular fractures in the elderly: results after open reduction and internal fixation. Injury, 45(12):1908-1913\u003c/p\u003e\n\u003cp\u003e17 Manson TT (2020) Acetabular Fractures in Older Patients Assessment and Management. Springer Switzerland\u003c/p\u003e\n\u003cp\u003e18 Manson TT, Reider L, O'Toole RV, et al. (2016) Variation in Treatment of Displaced Geriatric Acetabular Fractures Among 15 Level-I Trauma Centers. Journal of orthopaedic trauma, 30(9):457-462\u003c/p\u003e\n\u003cp\u003e19 Matta JM (1996) Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. The Journal of bone and joint surgery. American volume, 78(11):1632-1645\u003c/p\u003e\n\u003cp\u003e20 Paul E. Beaul\u0026eacute; M, FRCSC;, David B. Griffin M, Joel M. Matta M (2004) The Levine Anterior Approach for Total Hip Replacement as the Treatment for an Acute Acetabular Fracture. Journal of orthopaedic trauma, 18:623\u0026ndash;629\u003c/p\u003e\n\u003cp\u003e21 Ridley WE, Xiang H, Han J, Ridley LJ (2018) Gull-wing sign: Acetabular fracture. Journal of Medical Imaging and Radiation Oncology, 62:142-142\u003c/p\u003e\n\u003cp\u003e22 Saterbak AM, Marsh JL, Nepola JV, Brandser EA, Turbett T (2000) Clinical failure after posterior wall acetabular fractures: the influence of initial fracture patterns. Journal of orthopaedic trauma, 14(4):230-237\u003c/p\u003e\n\u003cp\u003e23 Scolaro JA, Routt ML, Jr. (2013) Reduction of osteoarticular acetabular dome impaction through an independent iliac cortical window. Injury, 44(12):1959-1964\u003c/p\u003e\n\u003cp\u003e24 Tosounidis TH, Stengel D, Giannoudis PV (2016) Anteromedial dome impaction in acetabular fractures: Issues and controversies. Injury, 47(8):1605-1607\u003c/p\u003e\n\u003cp\u003e25 Zhuang Y, Lei JL, Wei X, Lu DG, Zhang K (2015) Surgical treatment of acetabulum top compression fracture with sea gull sign. Orthopaedic surgery, 7(2):146-154\u003c/p\u003e\n\u003cp\u003e26 Zhuang Y, Zhang K, Wang H, et al. (2017) A short buttress plate fixation of posterior column through single ilioinguinal approach for complex acetabular fractures. International orthopaedics, 41(1):165-171\u003c/p\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1 \u003c/strong\u003e\u003cstrong\u003ePatient demographics data, characteristics and \u003c/strong\u003e\u003cstrong\u003esurgical related data\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003eN=22\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003eMean age (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003e58.91\u0026plusmn;13.68\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003eSex (n, %)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; M\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; F\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e14（63.63%）\u003c/p\u003e\n\u003cp\u003e8（36.37%）\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003eMechanism of injury\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; MVA\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; fall from standing height\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; fall from height (\u0026lt;3m)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; fall from height (\u0026gt;=3m)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5（22.7%）\u003c/p\u003e\n\u003cp\u003e6（27.3%）\u003c/p\u003e\n\u003cp\u003e7（31.8%）\u003c/p\u003e\n\u003cp\u003e4（18.2%）\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003eacetabular fracture type (Letournel)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eanterior column+anterior wall\u003c/p\u003e\n\u003cp\u003eposterior column+posterior wall\u003c/p\u003e\n\u003cp\u003etransverse\u003c/p\u003e\n\u003cp\u003eanterior column+posterior hemitransvers\u003c/p\u003e\n\u003cp\u003eboth column\u003c/p\u003e\n\u003cp\u003eT-type\u003c/p\u003e\n\u003cp\u003eindeterminate fracture\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; transverse+posterior wall\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; isolate quadrilateral surface\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1(4.55%)\u003c/p\u003e\n\u003cp\u003e1(4.55%)\u003c/p\u003e\n\u003cp\u003e1(4.55%)\u003c/p\u003e\n\u003cp\u003e13(59.09%)\u003c/p\u003e\n\u003cp\u003e2(9.10%)\u003c/p\u003e\n\u003cp\u003e1(4.55%)\u003c/p\u003e\n\u003cp\u003e3(13.64%)\u003c/p\u003e\n\u003cp\u003e2(9.10%)\u003c/p\u003e\n\u003cp\u003e1(4.55%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003eassociated injury\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; pelvic injury\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; upper extremity\u003c/p\u003e\n\u003cp\u003elower extremity\u003c/p\u003e\n\u003cp\u003echest injury\u003c/p\u003e\n\u003cp\u003ehead injury\u003c/p\u003e\n\u003cp\u003eabdominal injury\u003c/p\u003e\n\u003cp\u003emulti-injury\u003c/p\u003e\n\u003cp\u003efemoral head injury\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3(13.64%)\u003c/p\u003e\n\u003cp\u003e1(4.55%)\u003c/p\u003e\n\u003cp\u003e3(13.64%)\u003c/p\u003e\n\u003cp\u003e2(9.10%)\u003c/p\u003e\n\u003cp\u003e1(4.55%)\u003c/p\u003e\n\u003cp\u003e1(4.55%)\u003c/p\u003e\n\u003cp\u003e3(13.64%)\u003c/p\u003e\n\u003cp\u003e7(31.81%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003ctable style=\"width: 584px;\" border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003eapproach\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; IL\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; Stoppa\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; KL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e11(50%)\u003c/p\u003e\n\u003cp\u003e7(31.82%)\u003c/p\u003e\n\u003cp\u003e4(18.18%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003eoperation time(minutes)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003e226.59\u0026plusmn;48.34\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003eblood loss(ml)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003e1122.73\u0026plusmn;482.98\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003ebone graft\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; autograft\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; allograft\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e15(68.2%)\u003c/p\u003e\n\u003cp\u003e7(31.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003efollow-up(months)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003e28\u0026plusmn;4.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003eTornetta and Matta Radiographic grades\u003c/p\u003e\n\u003cp\u003eanatomical (0\u0026ndash;1 mm displacement)\u003c/p\u003e\n\u003cp\u003eimperfect (2\u0026ndash;3 mm displacement)\u003c/p\u003e\n\u003cp\u003epoor (more than 3 mm displacement)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e10(45.45%)\u003c/p\u003e\n\u003cp\u003e7(31.82%)\u003c/p\u003e\n\u003cp\u003e5(22.73%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003emodified Merle d\u0026rsquo;Aubign\u0026eacute; score excellent (18 points)\u003c/p\u003e\n\u003cp\u003egood (15\u0026ndash;17 points)\u003c/p\u003e\n\u003cp\u003efair (13\u0026ndash;14 points)\u003c/p\u003e\n\u003cp\u003epoor (\u0026lt;13 points)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5(22.73%)\u003c/p\u003e\n\u003cp\u003e10(45.45%)\u003c/p\u003e\n\u003cp\u003e5(22.73%)\u003c/p\u003e\n\u003cp\u003e2(9.09%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003eSF-36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003e76.76\u0026plusmn;20.18\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003eComplication\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003eDVT\u003c/p\u003e\n\u003cp\u003esciatic nerve injury\u003c/p\u003e\n\u003cp\u003eHO\u003c/p\u003e\n\u003cp\u003earthritis\u003c/p\u003e\n\u003cp\u003eAVN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 284px;\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e10(45.45%)\u003c/p\u003e\n\u003cp\u003e12(54.54%)\u003c/p\u003e\n\u003cp\u003e1(4.55%)\u003c/p\u003e\n\u003cp\u003e1(4.55%)\u003c/p\u003e\n\u003cp\u003e2(9.09%)\u003c/p\u003e\n\u003cp\u003e2(9.09%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: MVA: motor vehicle accident, IL: Ilioinguinal, KL: Kocher\u0026ndash;Langenbeck, DVT: deep venous thrombosis, HO: heterotopic ossification, AVN: avascular necrosis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Location of the acetabular dome impaction\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003eLocation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003eN=22\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003e9-12 o\u0026rsquo;clock\u003c/p\u003e\n\u003cp\u003e12-3 o\u0026rsquo;clock\u003c/p\u003e\n\u003cp\u003e9-3 o\u0026rsquo;clock\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"284\"\u003e\n\u003cp\u003e10(45.45%)\u003c/p\u003e\n\u003cp\u003e9(40.91%)\u003c/p\u003e\n\u003cp\u003e3(13.64%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3 Characteristics of the acetabular dome impaction\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"187\"\u003e\n\u003cp\u003eCharacteristics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003eMinimum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003eMaximum\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003eMean\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003eS.D\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"187\"\u003e\n\u003cp\u003enormal size of acetabulum (contralateral)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e3300.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e4662.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e4010.86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e449.74\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"187\"\u003e\n\u003cp\u003enormal size of lunar surface\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e2124.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e3637.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e2749.46\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e371.73\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"187\"\u003e\n\u003cp\u003eimpaction size\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e80.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e1100.00\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e467.24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e308.25\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"187\"\u003e\n\u003cp\u003epercent of the impaction area (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"44\"\u003e\n\u003cp\u003e22\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e3.13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"95\"\u003e\n\u003cp\u003e36.94\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"76\"\u003e\n\u003cp\u003e17.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"94\"\u003e\n\u003cp\u003e8.94\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote ：percent of the impaction= impaction size/ lunar surface\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"acetabular fracture, dome impaction, computed tomography, outcome","lastPublishedDoi":"10.21203/rs.3.rs-146669/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-146669/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective\u003c/p\u003e\u003cp\u003eThis study aimed to explore the characteristics of acetabular dome impaction fractures(ADIF) and evaluate the clinical outcomes. \u003c/p\u003e\u003cp\u003eMethods\u003c/p\u003e\u003cp\u003eTwenty-two ADIF treated by single surgeon were analyzed. The location and size of impaction was measured through Mimics. Patients’ demographic,\u0026nbsp;characteristic data, surgical data and clinical outcomes were collected. The quality of reduction was assessed using criteria described by Matta. Functional outcomes were evaluated using modified Merle d’Aubigné score and SF-36.\u003c/p\u003e\u003cp\u003eResults\u003c/p\u003e\u003cp\u003e40.91% of the ADIF located at the posterosuperior quadrant,36.36% of the ADIF located at anterosuperior quadrant, 22.73% of the ADIF involved both areas. The average impacted size was 467.24±308.25mm\u003csup\u003e2\u003c/sup\u003e. The average percent of the impacted was 17.18±8.94%（impaction size/ lunar surfaces）. At the final follow-up, the rate of excellent and good outcome per Matta’s radiographic grading was 77.27%. The modified Merle d’Aubigné score graded as excellent in 5(22.73%), good in 10(45.45%), fair in 5(22.73%), and poor in 2(9.09%). The mean score of SF-36 was 76.76±20.18. Avascular necrosis (AVN) developed in two patients. Heterotopic ossification(HO) developed in one patient. Sciatic nerve injury developed in one patient. Arthritis developed in one patient. \u003c/p\u003e\u003cp\u003eConclusions\u003c/p\u003e\u003cp\u003e\u003cspan class=\"ql-cursor\"\u003e\u003c/span\u003eThe ADIF can locate at the posterosuperior quadrant, the anterosuperior quadrant or involved both areas. Understanding the characteristics of the dome impaction can aid surgeons during reduction and fixation. Meanwhile, good to excellent outcomes and a high degree of patient satisfaction can be achieved in majority of the patients.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Characteristics and Clinical Significance of Dome Impaction in Acetabular Fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-01-15 23:47:31","doi":"10.21203/rs.3.rs-146669/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"50bfc31a-8b3d-43ac-b0c5-64ca02f3ed5e","owner":[],"postedDate":"January 15th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":1904289,"name":"Orthopedic Surgery"}],"tags":[],"updatedAt":"2021-02-10T18:39:49+00:00","versionOfRecord":[],"versionCreatedAt":"2021-01-15 23:47:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-146669","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-146669","identity":"rs-146669","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}