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The Relevance of the Judet and Letournel Acetabular Fracture Classification System in the Modern Era

A Review

Butler, Bennet A., MD; Lawton, Cort D., MD; Hashmi, Sohaib Z., MD; Stover, Michael D., MD

Journal of Orthopaedic Trauma: February 2019 - Volume 33 - Issue - p S3–S7
doi: 10.1097/BOT.0000000000001401
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Summary: The Judet and Letournel acetabular fracture classification system, based on the idea of bicolumnar support of the acetabulum, was first described in a landmark article published in the 1960s. It has stood the test of time and continues to be the preferred method for describing acetabular fractures for the majority of orthopaedic trauma surgeons. Still, there have been attempts to modify or replace Letournel system since its introduction for a variety of reasons, chief among them a perceived inability of the classification system to account for a number of transitional fracture patterns and injury modifiers that may affect surgical decision making and patient outcomes. In this review, we present the literature related to the Judet and Letournel acetabular fracture classification system, over 50 years after its first formal description. We summarize its strengths, weaknesses, and its place in our current understanding of acetabular fractures and their recommended management.

Department of Orthopaedic Surgery, Northwestern Memorial Hospital, Chicago, IL.

Reprints: Bennet A. Butler, MD, Northwestern University, 676 North Saint Clair, Suite 1350, Chicago, IL 60611 (e-mail: Bennet-butler@northwestern.edu).

The authors report no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jorthotrauma.com).

Accepted November 07, 2018

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INTRODUCTION

Dr. Robert Judet and his protégé, Dr. Emile Letournel, were prominent French surgeons who practiced and taught orthopaedic trauma surgery in the latter decades of the 20th century.1 Their seminal work on the radiology of the innominate bone along with their vast clinical experience led to one of their most widely known contributions to orthopaedics, the acetabular fracture classification system which bears their names.2 This classification system, based on the idea of bicolumnar support of the acetabulum, was first described in a landmark article published in the 1960s.3 It has stood the test of time and continues to be the preferred method for describing acetabular fractures for the majority of surgeons.3–5 The Judet and Letournel classification system divides acetabular fractures into 5 elementary and 5 associated patterns based on their radiographic appearance and prevalence, with the understanding that transitional patterns exist.3 Its relative simplicity can mask its tremendous effectiveness for predicting the appropriate surgical approach for a wide variety of fracture patterns.6

Despite the long, successful history of the Judet and Letournel classification system, there have been attempts to modify or replace it in the years since its development. The authors of these attempts have cited numerous reasons for these efforts. Commonly, the difficulty of mastering the classification system is seen as a major weakness.7–9 In addition, there are studies which have found as many as 35% of fractures do not fit in any of the classified patterns described.10 This may be especially true for low-energy fractures encountered in elderly patients, which often exhibit substantial quadrilateral surface involvement.10–13 Furthermore, the Judet and Letournel classification system does not account for a variety of injury characteristics that have been shown to affect fracture management and patient outcomes, such as marginal impaction, loose bodies, and femoral head involvement.14–16

In this review, we present the literature related to the Judet and Letournel acetabular fracture classification system, over 50 years after its first formal description. We aim to summarize its strengths, weaknesses, and its place in our current understanding of acetabular fractures and their recommended management.

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Reliability

Substantial attention has been paid to the diagnostic reliability of the Judet and Letournel classification system. For experienced acetabular fracture surgeons, the classification system is highly reliable using plain radiographs [specifically, a combination of anteroposterior (AP), obturator oblique, and iliac oblique views of the pelvis] alone. Beaule et al found that the intraobserver and interobserver kappa values for orthopaedic trauma surgeons trained by Dr. Letournel was 0.8 and 0.7, respectively, representing substantial to near-perfect agreement.17 In the same study, similar intraobserver and interobserver kappa (κ) values were obtained for orthopaedic trauma surgeons with significant acetabular fracture experience. These results were reproduced by others, including Hufner, who found that experienced acetabular fracture surgeons correctly classified acetabular fractures 83% of the time with the addition of computed tomography (CT) images (see Supplemental Digital Content Table 1, http://links.lww.com/JOT/A608).7,18

For general orthopaedic surgeons and musculoskeletal radiologists, the reliability of the Judet and Letournel system has been shown to be somewhat diminished but remains fairly high. In the same study cited above by Beaule et al, general orthopaedic surgeons had intraobserver and interobserver κ values of 0.64 and 0.51, indicating moderate to substantial agreement.17 Clarke-Jenssen et al found an interobserver κ of 0.46 for general orthopaedic surgeons, and Ohashi et al found an interobserver κ of 0.42 among musculoskeletal radiologists.9,19 Similar values have been obtained by numerous other authors when testing orthopaedic surgeons without significant acetabular fracture management experience.20–24 Notably, Visutipol et al8 found moderate intraobserver agreement but poor interobserver agreement in this population (κ = 0.24).

The difficulty of mastering Judet and Letournel system is most apparent when surgeons in training are asked to classify acetabular fractures. Hufner et al7 found that residents successfully classified acetabular fractures correctly only 11% of the time using plain radiographs alone (in this and all other studies included here, plain radiographs consist of AP, obturator oblique, and iliac oblique views of the pelvis). Meanwhile, Petrisor et al21 reported an intraclass correlation coefficient of −0.14 for residents using the Letournel classification system, representing poor agreement. Other studies, however, have found residents to be somewhat more successful in classifying acetabular fractures; Ly et al,25 for example, found that residents without any prior preparation correctly classified 50% of fractures. A substantial factor in this wide discrepancy in observations seems to be the degree of resident experience with the classification.25,26 Only one published study has reported on medical student ability to use the Judet and Letournel classification system: with radiographs alone, the students were able to correctly identify just 28% of fractures.18

CT scans can provide assistance to certain groups of practitioners attempting to classify acetabular fractures. Multiple authors have reported improvements in diagnostic accuracy or agreement using CT imaging in addition to or in place of the standard AP and Judet oblique radiographs for treating surgeons, residents, and musculoskeletal radiologists.9,19,20,27–29 Others have found no improvement with the routine addition of CT imaging, especially for experienced acetabular surgeons.8,17,30 More advanced CT image manipulation has shown promise for improving acetabular fracture diagnosis, including CT-generated Judet oblique radiographs, 3D pelvic reconstructions, segmentation software for color coding fracture fragments on CT, and even the generation of 3D printed models.18,26,31–34

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Mastery

Because the Judet and Letournel classification system has a prolonged learning curve, many authors have described educational tools or techniques to assist residents and less experienced attending surgeons with fracture classification. In addition to providing advanced imaging, image modification, and modeling, as noted above, multiple authors have developed algorithms for correctly using the Letournel classification system.22,23,25,35,36 These algorithms focus less experienced practitioners onto specific features of the plain radiographs and have shown promise for quickly improving their ability to classify acetabular fractures.

Prevezas et al and Patel et al, using a method developed by Brandser and Marsh, independently reported improvements in the ability of general orthopaedic surgeons to diagnose acetabular fractures after being taught an algorithmic approach.22,23,35 Ly et al were able to show similar improvements in a population of orthopaedic residents who had been given their algorithm, which was based on the previous work of Saterbak et al.25,36 Before implementation of the algorithm, residents diagnosed 50% of acetabular fractures correctly; after being provided with the algorithm for one time use, they diagnosed 59% of fractures correctly. Improvements were seen for all levels of resident education.

The educational value of algorithms for classifying acetabular fractures is supported by Hanley et al,37 who used eye-tracking technology to show that residents, as compared with more experienced practitioners, had increased eye movements and fixation points when reading acetabular plain radiographs. This finding suggests a disorganized approach to diagnosis, which can theoretically be streamlined and systematized by a successful algorithm. To match the high levels of accuracy obtained by experienced acetabular fracture surgeons, however, it is likely that learners would eventually need to move past algorithmic thinking and achieve a more complete understanding of the fracture patterns and their radiographic appearance.

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Inclusivity

Although the Letournel classification system has historically been thought of as flexible and highly inclusive, unclassifiable fracture patterns have been reported.38–48 Letournel himself acknowledged that there were a wide variety of transitional patterns, which lie in the gray area between 2 established classification categories.4,5

Large epidemiological studies have found varying rates of apparently unclassifiable fractures.13,38–40 On the lower end were series published by Boudissa et al and Ochs et al, in which ∼1% of fractures were unclassifiable.13,38 Separate series by Herman et al and Mauffrey et al, however, found that 9%–20% of acetabular fractures were unclassifiable based on the Letournel system.39,40 Hutt et al10 had 3 orthopaedic surgeons classify acetabular fractures using a series of AP and Judet oblique radiographs and CT scans; 63% of these fractures determined to be unclassifiable by at least 1 surgeon. The unclassifiable fractures in the Hutt et al study were primarily anterior column fractures with quadrilateral plate involvement or incomplete fractures. This is similar to the series by Herman et al,40 where the majority of unclassifiable fractures were either anterior column fractures with quadrilateral plate involvement or dual column patterns (anterior column plus posterior hemitransverse, T-type, or both column fractures) with posterior wall involvement. It is possible that these patterns will become more common as the demographics of patients presenting with acetabular fractures changes; elderly patients are more likely to present with anteriorly based fracture patterns than patients in the general population, and comminution is frequently encountered in patients with poor bone quality.11,12

Small case series or case reports have highlighted other patterns that may not be classifiable based on the Judet and Letournel system. These include isolated quadrilateral plate injuries and anterior or inferior rim fractures without columnar involvement.41–45 Some authors have reported iliac fractures with transverse components but no inferior fracture lines as unclassifiable variants of either both column or anterior column/posterior hemitransverse fractures.46–48 In addition, the Judet and Letournel system does not account for a number of important injury modifiers that may affect management decisions. These include marginal impaction, intraarticular loose bodies, femoral head injuries, or combined acetabular fracture/pelvic ring injuries.14–16,49–51 The classification system also fails to account for newer approaches that have been developed and proliferated since the time of Letournel, including the anterior intrapelvic approach, surgical hip dislocations, and the pararectus approach.52–56 Furthermore, the Judet and Letournel system does not include information regarding roof arcs, posterior wall size, or articular displacement, all of which are important from a decision-making standpoint.57–59

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Other Classification Systems

The earliest published acetabular fracture classification system, to our knowledge, was proposed by Rowe, and divided fractures into undisplaced, inner wall, posterior, and superior/burst patterns.60 This was supplanted shortly after its introduction by the Judet and Letournel system. Tile presented a different classification system, which built upon and expanded Judet and Letournel's work.61 His classification system split fractures into type A partial articular (including posterior wall and single column fractures), type B complete articular (including transverse, T-type, and anterior column/posterior hemitransverse fractures), and type C both column fractures, including those with sacroiliac joint involvement. Within each group are further subdivisions allowing for associated patterns and further specifying fracture line location. A similar, but more broadly divided classification system was developed by Harris et al based on CT imaging.62–64 This classification separated injuries into wall fractures, single column fractures, 2 column fractures, and both column injuries. Neither of these classifications has been reported to have improved utility in the determination of surgical approach or patient outcomes.

More recently, Herman et al40 developed a classification system based on displacement vector and structures fractured with the goal of predicting surgical approach and improving inclusivity as compared with the Judet and Letournel system. It divides fractures into posterior displacement, superomedial displacement, and combined displacement groups. Within these groups are further subdivisions based on which structures are fractured. According to the authors' evaluation of radiographs, this new classification system encompassed over 99% of fractures, as opposed to the Judet and Letournel system, which encompassed just under 80% of fractures. Furthermore, the new classification system was able to correctly predict surgical approach for the majority of fractures, especially those which the authors felt were amenable to an intrapelvic approach.

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DISCUSSION

Since its introduction in the 1960s, the Judet and Letournel acetabular fracture classification system has been widely adopted by orthopaedic surgeons, and orthopaedic traumatologists in particular.3–5 It has a long and successful track record for determining the appropriate surgical approach for fracture treatment.6 From a prognostic perspective, there are certain fracture patterns in the classification that are associated with worse outcomes.6,65

Despite its successes, some authors have been critical of Judet and Letournel system. As noted above, it can be a difficult classification system to master.8,21 Although this might suggest some degree of unwieldiness, it is more likely that the difficult learning curve is attributable to the challenging nature of acetabular fractures rather than anything inherent to the classification system. For surgeons who have extensive experience with acetabular fractures, this classification system has a high intraobserver and interobserver reliability using the 3 standard plain radiographs.17 The addition of CT imaging can further improve the reliability of fracture classification and can provide prognostically important details about the injury pattern which plain radiographs might not be able to detect (such as marginal impaction, loose bodies, and femoral head impaction injuries).9,14–16,19,20,27–29

There have been numerous studies reporting disappointingly high rates of unclassifiable fractures using the Letournel system.10,39,40 The majority of these fractures, however, are either anterior column fractures with quadrilateral plate involvement, incomplete fractures, or patterns with associated posterior wall fractures that are not specifically categorized.10,40 For these patterns, the fact that they are not classifiable in a technical sense does not invalidate Judet and Letournel classification system. These fractures are analogous to fracture patterns defined by the classification system, and many can be managed similarly. The same is true for the rare unclassifiable fracture patterns noted in the case reports above, which can typically be dealt with similarly to the defined pattern they most resemble.41–48 Many of these so-called unclassifiable fractures were described or predicted by Letournel himself, who acknowledged that a wide range of transitional patterns existed.4,5

Proposed alternatives to Judet and Letournel fracture classification system have their own shortcomings. Broader classification systems will have trouble meaningfully differentiating fractures and determining management or predicting outcomes. For those surgeons who do not need a detailed understanding of fracture treatment, however, such classifications (eg, the first level of the Tile classification) may serve as a reliable way to grossly differentiate patterns. However, more complex classification systems will suffer from limited clinical applicability and low interobserver and intraobserver diagnostic reliability. This has been observed with the AO classifications for articular fractures, where the intraobserver and interobserver reliability is degraded by progressive increases in classification complexity.66,67

The recent classification system proposed by Herman is an interesting departure from traditional systems.40 It is our opinion, though, that the inclusion of displacement vector as a primary fracture pattern differentiator may be misleading. For example, although the superomedial group would frequently call for anterior intrapelvic approach as proposed by the authors, there are a number of patterns included in this group, such as transtectal transverse fractures, for which some surgeons would choose a different approach. In addition, the presence of a posterior wall fracture in combination with a bicolumnar fracture pattern does not necessarily indicate a combined displacement vector, as the new classification system suggests. In our experience, the posterior wall component of these injuries is a bending wedge fracture, which occurs during superomedial displacement of the femoral head. Often it remains minimally displaced with the acetabular labrum intact and can be managed through an anterior approach with directed intrapelvic to extrapelvic interfragmentary screw fixation.68,69

Currently, Judet and Letournel classification system remains the gold standard for acetabular fractures. Rather than modifying Judet and Letournel system to make it easier to master, efforts should be focused on improving our teaching methods. Already, methods for teaching the classification system using advanced imaging, 3D models, and algorithms have shown promise for quickly developing competence among trainees, and recent graduates.18,22,23,25,26,31–36 New educational techniques, possibly including an integrated curriculum using a number of the teaching tools noted above, would be of substantial value in residency or fellowship training.

Nevertheless, low-energy fractures in the elderly, which tend to be qualitatively different than those fractures encountered in younger patients, may require reevaluation and additional subclassifications within the existing system.10–13 It is our expectation that, modified or not, the Judet and Letournel system will continue to guide future acetabular fracture surgeons with regard to the determination of the appropriate surgical approach for fracture treatment and overall patient management decision making.

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Keywords:

Judet; Letournel; acetabulum; acetabular fracture; classification; classification system

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