Early open reduction and internal fixation of the disrupted pelvic ring

A minimally invasive stabilizing system for dorsal pelvic ring injuries

BACKGROUND

Open reduction and stabilization of dorsal pelvic ring injuries is accompanied by a high rate of soft tissue complications. Minimally invasive techniques have the potential to decrease soft tissue trauma, but the risk of iatrogenic nerve and vessel damage through the reduced surgical exposure should be considered. We treated these injuries using a transiliac internal fixator (TIFI) in a minimally invasive technique characterized by implantation of a pedicle screw and rod system, bridging the sacroiliac joints and the sacral area.

QUESTIONS/PURPOSES

We asked whether (1) we could achieve anatomic restoration with the device, (2) specific complications were associated with this minimally invasive approach (particularly enhanced intraoperative blood loss, soft tissue complications, and iatrogenic neurovascular damage), and (3) function 3 years after trauma was comparable to that of established methods.

METHODS

We retrospectively reviewed 67 patients with dorsal pelvic injuries during a 7-year period. We evaluated the (1) reduction by grading the maximal displacement measured with three radiographic views, (2) the complications during the observation period, and (3) the function with a validated questionnaire (Pelvic Outcome Score) in all but five patients at least 3 years after trauma (mean, 37 months; range, 36-42 months).

RESULTS

At last followup we observed a secondary fracture displacement greater than 5 mm in one patient. The intraoperative blood loss was less than 50 mL in all patients. No neurovascular lesions occurred owing to implantation. Four patients had wound infections, one had loosening of a single pedicle screw, and one had an iatrogenic screw malpositioning. Thirty-five of the 62 patients achieved Pelvic Outcome Scores of either a maximum score or 6 of 7 points.

CONCLUSION

Our observations suggest TIFI is a reasonable alternative to other established fixation devices for injuries of the dorsal pelvic ring with minor risks of major blood loss or iatrogenic neurovascular damage.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Open reduction and internal fixation of a traumatic diastasis of the pubic symphysis: one-year radiological and functional outcomes

The aim of this study was to review the number of patients operated on for traumatic disruption of the pubic symphysis who developed radiological signs of movement of the anterior pelvic metalwork during the first post-operative year, and to determine whether this had clinical implications. A consecutive series of 49 patients undergoing internal fixation of a traumatic diastasis of the pubic symphysis were studied. All underwent anterior fixation of the diastasis, which was frequently combined with posterior pelvic fixation. The fractures were divided into groups using the Young and Burgess classification for pelvic ring fractures. The different combinations of anterior and posterior fixation adopted to stabilise the fractures and the type of movement of the metalwork which was observed were analysed and related to functional outcome during the first post-operative year. In 15 patients the radiographs showed movement of the anterior metalwork, with broken or mobile screws or plates, and in six there were signs of a recurrent diastasis. In this group, four patients required revision surgery; three with anterior fixation and one with removal of anterior pelvic metalwork; the remaining 11 functioned as well as the rest of the study group. We conclude that radiological signs of movement in the anterior pelvic metalwork, albeit common, are not in themselves an indication for revision surgery.

Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity

BACKGROUND

Although the benefits of acute stabilization of long bone fractures are recognized, the role of early fixation of unstable pelvis and acetabular fractures is not well-defined. The purpose of this study was to review complications and hospital course of patients treated surgically for pelvis and acetabulum fractures. We hypothesized that early definitive fixation would reduce morbidity and decrease length of stay.

METHODS

Six hundred forty-five patients were treated surgically at a level I trauma center for unstable fractures of the pelvic ring (n = 251), acetabulum (n = 359), or both (n = 40). Mean age was 40.5 years, and mean Injury Severity Score (ISS) was 25.6 (range 9-66). They were retrospectively reviewed to determine complications including acute respiratory distress syndrome (ARDS), pneumonia, deep vein thrombosis, pulmonary embolism, multiple organ failure (MOF), infections, and reperations.

RESULTS

Definitive fixation was within 24 hours of injury in 233 patients (early, mean 13.4 hours) and >24 hours in 412 (late, mean 99.2 hours). Twenty-nine patients (12.4%) had complications after early fixation versus 81 (19.7%) after late, p = 0.006. Length of stay and intensive care unit days were 10.7 days versus 11.6 days (p = 0.26) and 8.1 days versus 9.9 days (p = 0.03) for early and late groups, respectively. With ISS >18 (n = 165 early [ISS 32.7]; n = 253 late [ISS 33.1]), early fixation resulted in fewer pulmonary complications (12.7% versus 25%, p = 0.0002), less ARDS (4.8% versus 12.6%, p = 0.019), and less MOF (1.8% versus 4.3%, p = 0.40). Rates of complications, pulmonary complications, deep vein thrombosis, and MOF were no different for patients with pelvis versus acetabulum fractures. In patients receiving ≥ 10U packed red blood cells (n = 41 early, n = 56 late) early fixation led to fewer pulmonary complications (24% versus 55%, p = 0.002), less ARDS (12% versus 25%, p = 0.09), and MOF (7.3% versus 14%, p = 0.23). Two hundred ten patients had some chest injury (32.6%). Chest injury with Abbreviated Injury Scores ≥ 3 was present in 46 (19.7%) of early and 78 (18.9%) of late patients (p = 0.44) and was associated with pulmonary complications in 26.1% versus 35.9%; ARDS in 15.2% versus 23.1%; and MOF in 6.5% versus 6.4%, respectively (all p > 0.20). However, chest injury with Abbreviated Injury Scores ≥ 3 was independently associated with more complications including ARDS (20.2% versus 3.3%, p < 0.0001), other pulmonary complications (32.3% versus 10.4%, p < 0.0001), and MOF (6.5% versus 1.2%, p = 0.0016), regardless of timing of fixation.

CONCLUSIONS

Early fixation of unstable pelvis and acetabular fractures in multiply injured patients reduces morbidity and length of intensive care unit stay, which may decrease treatment costs. Further study to ascertain the effects of associated systemic injuries and the utility of physiologic and laboratory parameters during resuscitation may delineate recommendations for optimal surgical timing in specific patient groups.

Pelvic fracture: the last 50 years

The past 50 years have been a time of rapid progress in the control of mortality and morbidity of pelvic fracture. Early understanding of the anatomic features of the fracture and the potential for major, life-threatening arterial hemorrhage in a small proportion of patients led to multidisciplinary approaches designed to control hemorrhage and temporarily stabilize the fracture. Progress in the diagnosis and management of lower urinary tract injuries has resulted in maintenance of urinary continence and sexual function in a large proportion of patients with pelvic fracture-associated urinary tract injury. Finally, definitive open reduction and fixation of the fracture has led to permanent pelvic stability and pain-free walking in most patients. With successful combination of these approaches, survival and return to a satisfactory level of function is now the rule rather than the exception for patients with severe pelvic fracture.

Quantification of the upper and second sacral segment safe zones in normal and dysmorphic sacra

OBJECTIVES

To quantify the obliquity and dimensions of the upper and second sacral segment iliosacral screw safe zones and to determine the differences between normal and dysmorphic sacral morphology.

DESIGN

Retrospective cohort.

SETTING

University Level I trauma center.

PATIENTS/PARTICIPANTS

Fifty patients with pelvic computed tomography scans.

INTERVENTION

All sacra were characterized as normal or dysmorphic based on plain pelvic radiographs and previously described criteria. Multiple computed tomography scan reconstructions were viewed and manipulated simultaneously with 6 degrees of freedom to allow for custom visualization in any plane.

MAIN OUTCOME MEASUREMENTS

In each patient, a unique reconstruction plane was created perpendicular to the safe zone axis. The narrowest safe zone cross-sectional area was measured. Next, on simulated pelvic outlet and inlet views, safe zone obliquity and width were measured. Finally, the space available for a transverse screw was assessed. Measurements were performed for both upper and second sacral segment. Values for normal and dysmorphic safe zones were compared.

RESULTS

Sacral dysmorphism was identified in 22 patients. In these sacra, the upper sacral segment safe zone cross-section was 36% smaller than in normal sacra (P < 0.001). No transverse screws could be placed, but accommodating for the caudal to cranial obliquity (30° versus 21° in normals, P < 0.001) and posterior to anterior obliquity (15% versus 4% in normals, P < 0.001) of the safe zone, an iliosacral screw at least 75 mm in length could be placed safely in 91% of patients. A transverse screw could be placed in 75% of normal sacra. In the second segment safe zone, the cross-sectional area was more than twice as large in dysmorphic sacra compared to normals (220 mm versus 109 mm, P < 0.001). The obliquity was not different on either the inlet or outlet views between groups. A transverse screw could be placed at this level in 95% of those with dysmorphic sacra and in only 50% of normal sacra.

CONCLUSIONS

Sacral dysmorphism occurred in 44% of patients in this consecutive series. Many anatomic differences were consistently found between the two morphologies with clinical relevance to iliosacral screw placement. Specifically, the dysmorphic upper sacral segment safe zone is significantly smaller and more obliquely oriented but is still large enough to accommodate an iliosacral screw in nearly all patients. The second sacral segment safe zone is approximately transversely oriented in both sacral types but is more than twice as large in dysmorphic sacra. This segment may be a primary fixation opportunity in patients with sacral dysmorphism.

2D-fluoroscopic navigated percutaneous screw fixation of pelvic ring injuries--a case series

BACKGROUND

Screw fixation of pelvic ring fractures is a common, but demanding procedure and navigation techniques were introduced to increase the precision of screw placement. The purpose of this case series was the evaluation of screw misplacement rate and functional outcome of percutaneous screw fixation of pelvic ring disruptions using a 2D navigation system.

METHODS

Between August 2004 and December 2007, 44 of 442 patients with pelvic injuries were included for closed reduction and percutaneous screw fixation of disrupted pelvic ring lesions using an optoelectronic 2D-fluoroscopic based navigation system. Operating and fluoroscopy time were measured, as well as peri- and postoperative complications documented. Screw position was assessed by postoperative CT scans. Quality of live was evaluated by SF 36-questionnaire in 40 of 44 patients at mean follow up 15.5 +/- 1.2 month.

RESULTS

56 iliosacral- and 29 ramus pubic-screws were inserted (mean operation time per screw 62 +/- 4 minutes, mean fluoroscopy time per screw 123 +/- 12 seconds). In post-operative CT-scans the screw position was assessed and graded as follows: I. secure positioning, completely in the cancellous bone (80%); II. secure positioning, but contacting cortical bone structures (14%); III. malplaced positioning, penetrating the cortical bone (6%). The malplacements predominantly occurred in bilateral overlapping screw fixation. No wound infection or iatrogenic neurovascular damage were observed. Four re-operations were performed, two of them due to implant-misplacement and two of them due to implant-failure.

CONCLUSION

2D-fluoroscopic navigation is a safe tool providing high accuracy of percutaneous screw placement for pelvic ring fractures, but in cases of a bilateral iliosacral screw fixation an increased risk for screw misplacement was observed. If additional ramus pubic screw fixations are performed, the retrograde inserted screws have to pass the iliopubic eminence to prevent an axial screw loosening.

Acute definitive internal fixation of pelvic ring fractures in polytrauma patients: a feasible option

BACKGROUND

Staged surgery is recommended for the management of multiple injuries-associated high-energy pelvic ring fractures (acute temporary skeletal stabilization is followed by definitive internal fixation [ORIF]). Acute definitive internal fixation is a controversial topic. The purpose of this study was to evaluate the safety and efficiency of acute pelvic ORIF by comparing its short-term outcomes with those who had staged surgery.

METHODS

A 43-month retrospective review of the prospective pelvic fracture database of a level-1 trauma center was performed. Consecutive high-energy trauma patients who sustained a fracture that was suitable for minimally invasive internal fixation (iliosacral screw fixation and symphyseal plating) were included. Patients were categorized as acute ORIF (<24 hours) or staged late ORIF (>24 hours). Demographics, Injury Severity Score, pelvic Abbreviated Injury Score, first 24-hour transfusions, physiologic parameters, time to operating room (OR), angiography requirement, length of stay (LOS), and mortality were recorded. Data are presented as mean +/- SD or percentages. Statistical significance was determined at p < 0.05 based on univariate analysis.

RESULTS

Forty-five patients met inclusion criteria, 18 patients had acute definitive ORIF (5.5 hours to OR) and 27 had late definitive ORIF (5 days to OR). Acute and late ORIF patients had comparable demographics (age: 48 +/- 22 years vs. 40 +/- 14 years, gender: 82% vs. 79% men) and injury severity (Injury Severity Score: 30 +/- 18 vs. 24.5 +/- 13, pelvic Abbreviated Injury Score: 3.7 +/- 1 vs. 3.4 +/- 1.1). Initial shock parameters were significantly worse in the acute ORIF group (systolic blood pressure, 69.7 +/- 17 mm Hg vs. 108 +/- 21 mm Hg; BD, -7.4 +/- 4 vs. -4.9 +/- 2 mEq/L, lactate 6.67 +/- 7 mmol/L vs. 2.51 +/- 1.3 mmol/L). Angiography was used in 18% (3/18) vs. 21% (6 of 27) of the cases. All early ORIF patients survived and one (3%) of the late ORIF patients died. There was a trend to shorter hospital LOS (25 +/- 24 days vs. 37 +/- 32 days) and a decreased 24-hour red cell transfusion rate (4.7 +/- 5 U vs. 6.6 +/- 4 U) in the early ORIF group. The intensive care unit admission rate (12 of 18 vs. 15 of 27) and LOS was comparable (2.9 +/- 2.5 days vs. 3.7 +/- 3.6 days).

CONCLUSION

Acute ORIF of unstable pelvic ring fractures within 6 hours could be safely performed even in severely shocked patients with multiple injuries. The procedure did not lead to increased rates of transfusion, mortality, intensive care unit LOS, or overall LOS. Furthermore, all these parameters showed a trend toward benefit compared with a staged approach.

The impact of open reduction internal fixation on acute pain management in unstable pelvic ring injuries

BACKGROUND

The management of unstable pelvic ring injuries is complex. Displacement is a clear indication for surgical intervention. However, reduction of acute pain after stabilization may have substantial clinical benefits and affect management decisions. The purpose of this study was to determine the impact of operative fixation of unstable pelvic ring injuries in diminishing acute pain.

METHODS

During a 33-month period, 70 patients with isolated pelvic ring injuries were managed at a Level-1 trauma center and retrospectively reviewed. On the basis of clinical and radiographic instability, 38 patients were managed surgically and formed the study group. Pain was assessed using visual analog scales and narcotic consumption during the index hospitalization.

RESULTS

In the operative group, visual analog scale scores decreased 48% after fixation from 4.71 +/- 1.8 preoperatively to 2.85 +/- 0.8 postoperatively (p < 0.001). Concomitantly, narcotic requirements decreased 25% from 2.26 mg morphine per hour preoperatively to 1.71 mg morphine per hour postoperatively (p = 0.024). The mean total length of hospital stay was 5.6 days (SD, 1.2 days), and the postoperative length of hospital stay was 4.7 days (SD, 1.2 days).

CONCLUSIONS

Operative reduction and fixation of unstable pelvic ring injuries significantly decreases acute pain. This has substantial physiologic benefits, particularly by improving mobilization, and should be an additional factor when determining surgical indication and timing.

Treatment of posterior pelvic ring injuries with minimally invasive percutaneous plate osteosynthesis

From January 2004 to July 2007, 21 patients with injuries at the posterior pelvic ring were treated with locking compression plate osteosynthesis through a minimally invasive approach and followed up for a mean of 12.2 months. Preoperative and postoperative radiography was conducted to assess the reduction and union. The mean operation time was 60 minutes (range: 40-80). Intraoperative blood loss was 50-150 ml. All patients achieved union at the final follow-up. The overall radiological results were excellent or good in 17 patients (85%). The functional outcome was excellent or good in 18 patients (90%). There was no iatrogenic nerve injury, deep infection or failure of fixation. We believe that fixation with a locking compression plate is an effective method for the treatment of injuries of the posterior pelvic ring in view of its convenience, minimal traumatic invasion and lower morbidity.

Outcome and complications of posterior transiliac plating for vertically unstable sacral fractures

Vertically unstable sacral fractures often make it difficult to achieve rigid fixation and there is no consensus on the optimal fixation technique for these injuries. The purpose of this study was to evaluate complication rate and short-term outcome of vertically unstable sacral fractures treated by posterior transiliac plate fixation. We performed a retrospective review of prospectively collected data of patients who underwent posterior transiliac plating for sacral fractures at two institutions. All patients were treated with the standard posterior approach using a 4.5-mm reconstruction plate and followed for at least 12 months. Patients' demographics, Majeed functional questionnaire surveys, and radiographic outcomes were collected. There were 19 patients with a mean age of 37.5-years. The mean follow-up was 26.3 months. The most frequent mechanism of injury was a fall from a height. According to the AO/OTA classification, there were 10 C1, 6 C2, and 3 C3, which were classified as 2 Denis I, 20 Denis II, and 2 Denis III, including 5 bilateral sacral fractures. Neurological deficit at the initial examination was recorded in 10 patients. The mean ISS was 20.7 and the mean timing of the internal fixation was 6.4 days. Anterior internal fixation of pelvic ring was added in eight patients. A Morel-Lavallee lesion was identified in 5 patients during the operation. Reductions were graded as nine excellent, seven good, and three fair according to the method of Tornetta. There were two postoperative surgical wound infections, both occurring in patients with a Morel-Lavallee lesion. All the sacral fractures united eventually and no implant failure occurred, though there were two patients with a small loss of reduction (<5mm) over the follow-up period. A total of 18 patients completed the functional assessment with a mean score of 78.5 points. Posterior plate fixation of vertically unstable sacral fractures is effective in maintaining fracture reduction even in the presence of significant posterior comminution. We caution its use in the presence of a known Morel-Lavallee lesion, as this may increase the wound complication and infection risk.

[Bony sacroiliac corridor. A virtual volume model for the accurate insertion of transarticular screws]

BACKGROUND

Minimally invasive sacroiliac (SI) screw fixation carries a high risk for implant malposition. Only idealised shape conceptions of the safe bony corridor exist.

METHODS

Two SI corridor models were generated based on a 3D CT reconstruction of a human pelvis. Therefore two penetration depths of the screws into the sacrum were defined.

RESULTS

By inserting screws into the centre of the first sacral body an osseous volume of 121 cm3 and an iliac entrance area of 53 cm2 were utilizable. Screw positioning beyond the opposite sacral isthmus leads to a reduction of the bony volume to 72 cm3 (60%) and a decrease of the iliac screw entrance to 20 cm2 (38%).

CONCLUSION

The computed realistic 3D models provide exact references to confining bone structures for safe screw positions. The implementation of a software algorithm for fully automated calculation of such volumes based on fluoroscopic or CT images could enhance the performance of computer-assisted navigation systems.

Management of lower limb fractures in polytrauma patients with delayed referral in a mass disaster. The role of the Ilizarov method in conversion osteosynthesis

Polytrauma cases in mass disasters present several challenges to the orthopaedic surgeon. Delayed referral, multisystem involvement and the requirement to manage coexisting injuries by interhospital transfer often make infection an inevitable risk. 28 patients with polytrauma were studied after being referred after being recovered from the debris of their homes in the Kashmir earthquake. All patients were referred more than 24h after sustaining their injuries. The lower limb fractures were fixed by external fixators in all these cases before interhospital transfer for the management of their co existing injuries. Return referral to the orthopaedic facility occurred after an average of 25 days. All cases were converted to Ilizarov fixation. The results bear out the fact that the Ilizarov method may be well suited for conversion osteosynthesis of lower limb fractures in polytrauma cases.

Closed reduction and iliosacral percutaneous fixation of unstable pelvic ring fractures

OBJECTIVE

To report clinical results of patients treated with closed reduction and percutaneous iliosacral screw fixation for unstable pelvic ring fractures.

MATERIALS AND METHODS

Retrospective study using medical records, images and late clinical assessment of all patients treated in our centre with percutaneous iliosacral screw fixation for unstable pelvic ring fractures, with a minimum follow-up of 12 months. Seventy-three patients with a mean age of 40.3 years old (range 14-70 years) were treated between July 1998 and December 2005. Seventy-one patients were included. Fractures types included 10 AO type B and 61 AO type C injuries. Forty-two patients had associated injuries. Mean follow-up was 31 months (12-96). Functional status was assessed using Majeed's grading score for pelvic fractures at final follow-up.

RESULTS

Sixty-nine patients obtained a satisfactory initial reduction. Two patients had transitory postoperative neurological deficit. Five patients presented hardware failure. Fifteen patients developed sacroiliac osteoarthritis during follow-up. Good and excellent functional results were observed in 66 patients at final follow-up. Five patients had bad results, one due to infection of an anterior pelvic plate and the others due to painful refractory sacroiliac osteoarthritis that required a sacroiliac fusion. Sixty-one (86%) patients were able to return to pre-injury occupation.

CONCLUSIONS

Good clinical results with a low and predictable rate of complications can be expected using closed reduction and percutaneous iliosacral screw fixation for unstable pelvic ring fractures.

Comparative radiographic and clinical outcome of two-hole and multi-hole symphyseal plating

OBJECTIVES

To report on the radiographic and clinical outcome of symphyseal plating techniques, with specific attention to the incidence of implant failure, reoperation secondary to implant complication, and ability to maintain reduction of the pelvic ring.

DESIGN

Retrospective chart and radiographic review.

SETTING

Level 1 trauma center.

PATIENTS

A total of 229 skeletally mature patients with traumatic pelvic disruptions associated with pubic symphysis diastasis requiring open reduction internal fixation.

INTERVENTION

Symphyseal plating: (1) group THP, a two-hole plate; (2) group MHP, a multi-hole plate (minimum 2 holes/screws on either side of the symphysis). Patients were analyzed with respect to technique of anterior ring fixation and posterior ring injury pattern and fixation.

MAIN OUTCOME MEASUREMENT

Retrospective review of charts and radiographs immediately after the index procedure to latest follow-up was performed. Analysis included pelvic ring injury, type of anterior and/or posterior fixation, maintenance of postoperative reduction, rate of implant failure, and need for reoperation secondary to implant complication. Additionally, logistic regression analysis was performed to detect correlation between any other variable (posterior injury pattern, presence or absence of posterior fixation, time to surgery) and failure or malunion. Statistical analyses were performed using SPSS software.

RESULTS

A total of 92 complete data sets were available for review. There were 51 patients in group THP and 41 patients in group MHP. When comparing the results of the 2 different methods of anterior fixation (THP versus MHP), the rate of fixation failure was greater in group THP (17 of 51; 33%) than group MHP (5 of 41; 12%). This was statistically significant (P = 0.018). When evaluating the presence of a malunion as a result of these 2 treatment methods, there were more present in the THP group (29 of 51; 57%) than in the MHP group (6 of 41; 15%). Again, this was highly statistically significant (P = 0.001). Although the reoperation rate was slightly higher in the THP group (16%) as compared to the MHP group (12%), this was not statistically significant (P = 0.67). Logistic regression analysis did not reveal any other variables to correlate as a risk factor for failure or malunion in this group of patients.

CONCLUSIONS

In this group of patients, the two-hole symphyseal plating technique group had a higher implant failure rate and, more importantly, a significantly higher rate of pelvic malunion. On the basis of these findings, we recommend multi-hole plating of unstable pubic symphyseal disruptions.

Pelvic ring disruptions: treatment modalities and analysis of outcomes

A systematic review of the English literature over the last 30 years was conducted in order to investigate the correlation of the clinical outcome of different types of pelvic ring injuries to the method of treatment. Three basic therapeutic approaches were analysed: non-operative treatment (group A), stabilisation of anterior pelvis (group B) and internal fixation of posterior pelvis (group C). Of 818 retrieved reports, 27 case series, with 28 groups of patients and 1,641 patients, met our inclusion criteria. The quality of the literature was evaluated using a structured questionnaire. Outcomes of the eligible studies were summarised by the medians of the reported results. Most of the component studies were of fair or poor quality. Certain radiological results (quality of reduction, malunion rates) were significantly better in group C. From the functional point of view only walking capacity was proved to be significantly better in the groups of operative treatment compared to the non-operative group.

[Biomechanical comparison of different stabilisation devices for transforaminal sacral fracture. Is an interlocking device advantageous?]

BACKGROUND

Reliable osteosynthesis for fractures in the different regions of the human pelvis are described in the literature while there is no common and satisfying treatment for unstable sacral fractures. Because of the posterior pelvic rings special anatomic conditions a local plate osteosynthesis seems to be advantageous. In many fields of modern fracture treatment locking implants show superior results. The prototype of a local locking plate osteosynthesis was compared to a common local plate and two sacroiliac screws.

METHODS

The implants were tested using six plastic models of the pelvis and three embalmed human specimens. A Tile C1 fracture was created by disruption of the pubic symphysis and a transforaminal osteotomy. The specimens were exposed to axial loading in an upright single-leg stance with a maximum of 800 N for the plastic models and 200 N for the human specimens. An ultrasonic-based measuring system recorded translations (X, Y, Z) and rotations (alpha, beta, gamma). Parameters such as pattern of motion, translation/rotation, load to failure and remaining dislocation were evaluated.

RESULTS

Concerning most of the evaluated parameters the local plate osteosynthesis was inferior compared with two sacroiliac screws. There were no significant differences between the locking implant and the local plate osteosynthesis. Compared with the two sacroiliac screws the locking implant shows biomechanically equal results but allows greater anterior rotation and remaining dislocation. Because of the lower bone quality, the results from the anatomic specimen tested were not utilisable.

CONCLUSIONS

The locking implant is biomechanically an alternative compared with two sacroiliac screws. Problems occurred due to the preset direction of the locking head screws.

The floating hip: complications and outcomes

BACKGROUND

To perform a descriptive study of the course, treatment decisions, complications, and outcome of patients suffering simultaneous ipsilateral fractures of the femur and pelvis.

METHODS

Medical records and radiographs of 57 patients were reviewed retrospectively.

RESULTS

The average follow-up was 28 months. Fifteen patients (26%) had an acetabular fracture, 17 (30%) had a pelvic ring fracture, and 25 (44%) had both fractures concomitant with the ipsilateral femoral fracture. Eighty percent of acetabular fractures and 55% of pelvic ring fractures were treated surgically. Femur fractures underwent operation in 94% of cases. When multiple operative settings were used, the femur fracture was always fixed at the first operation. Complications included deep venous thrombosis (DVT) (12%), heterotopic ossification (HO) (34%), femoral head avascular necrosis (AVN) (2%), osteoarthritis (OA) (16%), and traumatic sciatic nerve palsy (33%). At least partial nerve palsy resolution occurred in 53% of patients.

CONCLUSIONS

Ipsilateral injuries to the femur and the pelvis or acetabulum ("floating hip") are severe injuries usually caused by high-energy trauma. The acetabulum and pelvic ring are more commonly fractured together than either alone. The femur fracture will most commonly be addressed first, as in 65% of our cases in which both components were addressed at the same setting, and 100% of cases in which they were addressed in separate settings. Delays of surgery were common because of severity of systemic trauma. Surgeons should be aware of the high incidence of sciatic nerve palsy as well as treatment options and potential complications associated with this devastating combination of injuries.

'Damage control orthopaedics' in patients with delayed referral to a tertiary care center: experience from a place where Composite Trauma Centers do not exist

BACKGROUND

Management of orthopaedic injuries in polytrauma cases continues to challenge the orthopaedic traumatologist. Mass disasters compound this challenge further due to delayed referral. Recently there has been increasing evidence showing that damage control surgery has advantages that are absent in the early total care modality. We studied the damage control modality in the management of polytrauma cases with orthopaedic injuries who had been referred to our hospital after more than 24 hours of sustaining their injuries in an earthquake. This study was conducted on 51 cases after reviewing their records and complete management one year after the trauma.

RESULTS

At one year, out of the 62 fractures, 3 were still under treatment, while the others had united. As per the radiological and functional scoring there were 20 excellent, 29 good, 5 fair and 5 poor results. In spite of the delayed referral there was no mortality.

CONCLUSION

In situations of delayed referral in areas where composite trauma centers do not exist the damage control modality provides an acceptable method of treatment in the management of polytrauma cases.

CT-Guided Stabilization for Chronic Sacroiliac Pain: A Preliminary Report

BACKGROUND

We evaluated a percutaneous, computed tomographic, stabilization from S1 to S2, for chronic painful sacroiliac disease. Our hypothesis was that this technique carries low morbidity, and may provide substantial relief of recalcitrant sacroiliac pain.

METHODS

17 patients had CT guided injection with local anesthesia and steroid to confirm the diagnosis. If symptoms recurred, they had a CT guided stabilization using only local anesthesia and conscious sedation. Outcome was evaluated with a visual analog scale. Univariate analysis and Spearman correlations used for analysis.

RESULTS

Pain improved from a mean of 8.3 pre-injection to 3.5 post-injection and remained at 3.3 at final follow up. Four patients had complete relief, 11 patients had significant pain relief, and two patients experienced little to no pain relief. There was a statistically significant difference between pre-injection and post injection pain scores (p < 0.0001), final and pre injection pain scores (p < 0.0001), but not between the post injection and final pain scores (p = 0.8906). A statistically significant correlation (p < 0.02) was found between final pain score and the difference between pre and post injection scores. There were no infections, hardware or technical complications.

CONCLUSIONS

This technique appeared effective in relieving the majority of confirmed sacroiliac pain and appeared to be lasting with few complications. While we did not confirm nor deny an arthrodesis with this technique, it appears that stabilization of the sacroiliac joint may have resulted in enough stability (e.g. alkalosis, mechanical restriction) that it relieved symptoms.

Modified and new approaches for pelvic and acetabular surgery

We analysed outcomes of new operative techniques for open reduction and internal fixation in 120 consecutive patients with fractures of the pelvic ring and 164 patients with acetabular fractures treated between 1989 and 1999. An anterior extraperitoneal approach was performed through a low midline incision to fix the anterior and lateral parts of the pelvis and for central involvement of different types of acetabular fractures. The anterior approach was combined with a lateral incision on the lateral crest for fractures of the iliac wing and with a posterior approach for sacroiliac injuries, or with Kocher-Langenbeck approach for posterior acetabular involvements. The complication rate of the new techniques was low. Heterotopic ossification was rare. The functional recovery was good in 66 of the 81 patients with an unstable C-type pelvic injury, in 18 out of the 20 patients with a lateral compression, B-2-type injury and 13 out of 19 patients with a open book, B-1-injury. Neurological recovery was observed after adequate reduction in those patients suffering from lesions of the sacral plexus. The radiographic result was good in 73, 20 and 17 of the patients groups, respectively. The Harris Hip Score was more than 80 in 75% of the 164 patients with an acetabular fracture. The radiological result was good (residual displacement 0-2mm) in 84%, fair (3-5mm) in 9% and poor (more than 5mm) in 7%. The new methods are less invasive than the basic approaches described in the literature. The whole pelvic ring, as well as all the acetabular fracture combinations may be treated with the combination of approaches used in the present study.

Impact of timing of pelvic fixation on functional outcome

Pelvic fractures are the third most common cause of death in motor vehicle accidents. Recent improvements in mortality can be attributed to the progress made in modern critical care medicine, multidetector CT, ATLS principles, multidisciplinary protocols and early fracture stabilisation. Currently, the timing of pelvic fixation is often based on the haemodynamic status and response of the patient to resuscitation, the fracture pattern, the presence of associated injuries and the immuno-inflammatory status of the patient. The purpose of this review is to focus on the impact of timing of reconstruction of pelvic fractures on the functional outcome of the patients. Thirty seven scientific studies on the outcome of pelvic and acetabular injuries were reviewed. Four on pelvic ring fractures, and one study on pelvic and acetabular fractures met our second inclusion criterion of prospective or retrospective studies investigating the outcome after early or late pelvic and acetabular fixation. These five studies suggested early pelvic and acetabular fixation for optimal outcome but their main difference was the definition of the length in time of that early period. In polytrauma patients, the "damage control orthopaedics" principle should be applied for haemodynamic and skeletal stabilisation (and faecal diversion, if indicated in cases of open fractures of the pelvis). The definitive fixation should be performed after the fourth post-injury day, when the physiological state of the patient is conducive to surgery.

Stumpfe Beckenverletzung

Life-threatening complex pelvic fractures are commonly associated with vast peripelvine soft-tissue injuries and hemorrhage. Correct assessment and classification of the existing pelvic trauma and additional severe injuries present is required for accurate diagnosis and effective therapy. Treatment of the usually multiply injured patient is time-sensitive. The circulatory situation is the benchmark for diagnostic and therapeutic actions. Emergency stabilization of an initially unstable pelvic ring should be done first, followed by an extraperitoneal tamponade, if needed to control bleeding. The positive results of these actions can be measured by hemodynamic parameters. Delayed definitive internal stabilization of the anterior and/or posterior pelvic ring is then performed according to the fracture classification.

Contemporary management of pelvic fractures

BACKGROUND

Pelvic fractures occur when there is high kinetic energy transfer to the patient such as would be expected in motor vehicle crashes, auto-pedestrian collisions, motorcycle crashes, falls, and crush injuries. High-force impact implies an increased risk for associated injuries to accompany the pelvic fracture, as well as significant mortality and morbidity risks. Choosing the optimum course of diagnosis and treatment for these patients can be challenging. The purpose of this review is to supply a contemporary view of the diagnosis and therapy of patients with this important group of injuries.

METHODS

A comprehensive review of the medical literature, focusing on publications produced in the last 10 years, was undertaken. The principal sources were found in surgical, orthopedic, and radiographic journals.

CONCLUSIONS

The central challenge for the clinician evaluating and managing a patient with a pelvic fracture is to determine the most immediate threat to life and control this threat. Treatment approaches will vary depending on whether the main threat arises from pelvic fracture hemorrhage, associated injuries, or both simultaneously. Functional outcomes in the long-term depend on the quality of the rigid fixation of the fracture, as well as associated pelvic neural and visceral injuries.

Damage control orthopedics in patients with multiple injuries is effective, time saving, and safe

BACKGROUND

Although early fracture fixation is expedient in patients with multiple injuries, early total care (ETC) may be associated with posttraumatic systemic complications. This study was conducted to prospectively evaluate the concept of damage control by immediate external fracture fixation (damage control orthopedics [DCO]) and consecutive conversion osteosynthesis with regard to time savings, effectiveness, and safety.

METHODS

In a prospective controlled trial, a cohort of 1,070 patients with an Injury Severity Score (ISS) of 20.7 were admitted to a Level I trauma center over a 3.5-year period. Patients with an ISS > 15, survival of more than 24 hours, and without interhospital transfer were included. In all patients with major fractures requiring immediate stabilization, external fixation was performed (DCO). Conversion was executed at the earliest possible time as a one-stage procedure after stabilization of organ functions. TRISS was calculated for patients requiring DCO (DCO group) and for patients without major fractures (control group). Time spent on particular and all surgical procedures, blood loss, and complications of DCO were compared with data of consecutive conversion osteosyntheses which were considered as hypothetical ETC procedures (h-ETC) in identical patients.

RESULTS

Four hundred nine patients fulfilled the inclusion criteria. Seventy-five (ISS of 37.3) required DCO for 135 fractures, whereas 334 patients (ISS of 30.4) did not require immediate fracture fixation. Mean surgical time was 62 +/- 30 minutes (SEM, 3.5) for DCO. Because of fracture consolidation with external fixation (n = 3) and injury-related death (n = 15), conversion (h-ETC) was performed in 57 patients for 101 fractures. Duration of external fixation averaged 13.7 days (range, 3-46 days). Fifty-five patients (96.5%) required intensive care treatment and 42 patients (73.7%) required mechanical ventilation at the time of conversion. Mean operation time for conversion was 233 +/- 19 minutes (SEM, 18.7) with a value of p < 0.001. Also, blood loss was significantly (p < 0.001) different for DCO (<50 mL) and h-ETC (472 mL; SEM, 63). Pin-track infections were identified in five patients, two patients with acetabular plate osteosynthesis had deep wound infection, and one patient died related to bacterial sepsis with infections of all wound sites. Overall mortality in DCO patients was significantly lower than predicted by TRISS (20% vs. 39.3%), as it was in the 334 patients without immediate fracture fixation (29.5% vs. 24.3%).

CONCLUSION

DCO appears to provide a major reduction of operation time and blood loss in the primary treatment period in severely injured patients compared with h-ETC. In addition, we found that DCO is not associated with an increased rate of procedure-related complications. So far, DCO with early and one-stage conversion seems to be a safe strategy of primary fracture treatment in patients with multiple injuries.

Surgical management of transforaminal sacral fractures

Fourteen patients with transforaminal sacral fractures were treated with posterior iliosacral instrumentation. Patients were assessed in terms of surgical technique and functional results. A subjective functional scoring with a five-point scale was performed at the last follow-up. Activity pain, pain at rest, limping and patient satisfaction were evaluated. By considering symptom and satisfaction scores, subjective functional assessment revealed that ten patients had excellent results, two good and two moderate. There were no patients with poor functional outcome. The surgical technique is not a new concept. Combining sacral bar and pediculo-iliac fixation methods, provides vertical as well as horizontal stability and allows early weight bearing, the methods has many advantages. However, vertical and horizontal stabilities achieved by this technique may require further assessment with comparative biomechanical studies.

Outcome of operatively treated type-C injuries of the pelvic ring

BACKGROUND

Internal fixation has become the preferred treatment for type-C pelvic ring injuries, but controversies persist regarding surgical approach and surgical technique.

PATIENTS

We evaluated 101 consecutive patients with type C1-C3 pelvic ring injuries who had been treated with standardized reduction and internal fixation techniques.

RESULTS

Our findings suggest a correlation between excellent reduction followed by sufficient fixation of the pelvic ring and functional outcome. Unsatisfactory reduction (displacement > 5 mm), failure of fixation, loss of reduction and a permanent lumbosacral plexus injury were the commonest reasons for an unsatisfactory functional result. All 40 patients with an associated lumbosacral plexus injury showed at least some evidence of neurological recovery. 14 underwent complete neurologic recovery. 8 had only sensory deficits and the remaining 18 also had motor deficits at the final followup. Complications were rare, but some of them were severe: loss of reduction in 8%, malunion in 10%, deep wound infection in 2%, and a lesion of the L5 nerve root in 1%.

INTERPRETATION

Our results suggest that special attention should be paid to preoperative planning, reduction of the fracture, decompression of the nerve roots, and fixation of the most severe sacral fractures. Our results seem to favor internal fixation of displaced (> 10 mm) and unstable rami fractures and symphyseal disruptions in conjunction with posterior fixation, to achieve better stability of the whole pelvic ring.

Operative Versorgungsstrategien beim Polytrauma mit Beckenfraktur

OBJECTIVE

In the management of multiply injured patients the question of the optimal time point for surgical treatment of individual injuries still remains open. Especially in severely injured patients with pelvic fractures, this decision differs between rapid surgical interventions in life-threatening situations or time-consuming reconstructive surgery. Besides the "early" operative treatment, i.e., within the first 24 h after trauma, the "late," i.e., definitive or secondary surgical fracture stabilization, exists. The following study represents a review of the current recommendations in the literature concerning the optimal time and fracture management of multiply injured patients with pelvic fracture.

METHODS

Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches), reviewed, and classified into evidence levels (1 to 5 according to the Oxford system).

RESULTS

According to the literature there is consensus on "early" operative stabilization of multiply injured patients with hemodynamically and mechanically unstable pelvic fractures, open pelvic fractures, or complex pelvic trauma. External fixation and the pelvic C-clamp are the methods of choice in emergency situations, whereas currently internal fracture fixation is only proposed in exceptional circumstances. In contrast, the point in time for the secondary definitive fracture stabilization remains controversially discussed. This discussion ranges from the postulation that extensive definitive fracture treatment be avoided during days 2-4 after trauma to the recommendation that definitive internal fixation of pelvic fractures be undertaken early, i.e., within the 1st week after trauma.

CONCLUSION

Basically, the principles of trauma management of multiply injured patients with life-threatening hemorrhage from mechanically unstable pelvic fractures are divided into two main time periods. On the one hand, there is the emergency stabilization of the pelvic ring as the most important goal within the acute period to control the bleeding, at least with extraperitoneal tamponade if necessary. On the other hand, once the hemorrhaging has been stopped, the "late" and definitive internal fracture stabilization of the pelvis should be performed depending on the fracture pattern.

Implant retention and removal after internal fixation of the symphysis pubis

Although internal fixation of diastasis of the symphysis pubis is commonly performed, there are no clear guidelines regarding the indications for removal of these implants. The long-term physiologic effects of retaining these internal fixation devices are not well described. We surveyed the literature to assess the current thinking and recommendations regarding implant retention and removal. Twenty-four case series and two case reports were found, for a total of 482 cases. Complications arose as a result of implant retention in 7.5% of patients, with infection the most common complication. There is no consensus in the literature regarding implant retention and removal after internal fixation of diastasis of the symphysis pubis.

[The minimally invasive stabilization of the dorsal pelvic ring with the transiliacal internal fixator (TIFI)--surgical technique and first clinical findings]

The Trans Iliacal Internal Fixator (TIFI) is a minimally invasive technique for the stabilization of sacro-iliac joint ruptures and fractures lateral to the sacral ala or through the sacral foramen. In this study, 7.0 mm pedicle screws of the Universal-Spine-System (USS, Synthes) were inserted 1-2 cm on the cranial side of the posterior superior iliac spine and parallel to the superior gluteal line. The connecting bar was inserted subfascially and fixed with the locking head pedicle screws to form an fixed-angle construction. In a prospective study 31 patients with vertical shear injuries of the pelvis were treated with the TIFI. There were two wound infections and one loosening of a pedicle screw. None of the screws were incorrectly positioned and no neuro-vascular lesions were caused by the implant. 2 years postoperatively we found 50% good and excellent results for type C pelvic ring injuries. Early findings show that the TIFI is well suited to stabilization of sacro-iliac joint ruptures and fractures of the lateral sacrum. Closed reduction and minimally invasive insertion technique are possible. The implant leads to sufficient biomechanical stability but there is a very low intraoperative risk of neuro-vascular lesion.

Einfluss der Sakrumfraktur auf das funktionelle Langzeitergebnis von Beckenringverletzungen

Initial treatment of pelvic ring fractures with involvement of the iliosacral complex is directed at bleeding control and fixation of the pelvic ring. However, long-term outcome is determined by persisting neurological deficits, malunion of the posterior pelvic ring with low back pain, and urological lesions. Between 1991 and 2000, 173 patients with sacral fractures were treated at our institution. Sacral fractures as part of type B2 ("lateral compression") or type C ("vertical shear") pelvic ring fractures were treated conservatively, if dislocation was less than 1 cm. Fractures with a dislocation of more than 1 cm were treated operatively (n=33, 19%). A total of 112 patients were examined after an average of 4.9 years. Of the 39 patients with primary neurological deficits (35%) only 4 showed complete neurological recovery. Chronic low back pain was rarely observed (n=8, 7%) and only in type C injuries. The low incidence of chronic low back pain justifies conservative treatment of minimally (<1 cm) displaced sacral fractures. Long-term outcome is largely determined by neurological deficits, which persist in 30% of all patients with sacral fractures.

Soft tissue injuries associated with pelvic fractures

Significant soft tissue injuries often occur as part of high-energy injuries to the pelvis. These soft tissue injuries must be recognized and considered when implementing a treatment plan if complications are to be minimized. Vigilance in diagnosing open fractures must be maintained. Patients with these injuries must be managed aggressively, because they are at high risk for complications and death. Closed pelvic and acetabular fractures also may include soft tissue injury that requires special consideration. Careful evaluation and management of the soft tissues aids in determining appropriate techniques for reduction and fixation of the associated fractures.

Computed tomography-guided screw fixation of a sacroiliac joint dislocation fracture: a case report

A 19-year-old woman sustained a vertical shear type pelvic fracture. Sacroiliac fixation using computed tomography (CT)-guided cannulated screws was performed for a left sacroiliac dislocation fracture, and a satisfactory result was obtained over time. Patients who have posterior instability of the lateral compression or vertical shear type do not obtain adequate stability by fixation of the anterior part alone; and they often have persistent residual pain, necessitating internal fixation of the posterior part later. Advantages of CT-guided sacroiliac screw fixation include precise evaluation of the degree of reduction and absence of nerve and vascular damage during the time the screw is inserted into the sacral body. This procedure is a useful, safe method owing to its minimal invasiveness in patients with unstable pelvic fractures that are reducible by manual manipulation or traction.

Functional outcome of open reduction and internal fixation for completely unstable pelvic ring fractures (type C): a report of 40 cases

OBJECTIVES

To evaluate functional outcomes, morbidity and mortality rates, and psychological and psychosomatic status in patients treated for completely unstable pelvic injuries (Tile class C).

DESIGN

Prospective clinical study.

SETTING

University hospital.

PATIENTS/PARTICIPANTS

Forty patients treated with anterior and posterior internal fixation for unstable pelvic ring fractures between January 1992 and August 1999.

INTERVENTION

Open reduction and anterior and posterior internal fixation of the pelvic ring.

MAIN OUTCOME MEASUREMENTS

The data were analyzed as follows: pelvic fracture classification, Tile classification; severity of trauma, Injury Severity Score (ISS); functional outcomes, the Majeed Outcome Scale; psychological and psychosomatic status, Hamilton Depression and Anxiety Rating Score (HDARS).

RESULTS

Preoperatively the average ISS was 29.4 (range 12-66). There was a statistically significant positive correlation between anxiety and ISS (r = 0.536, P < 0.01). Two patients died during the early postoperative period. Two additional patients were lost to follow-up, leaving 36 patients followed for an average of 45 months (range 21-116 months). Deep infections developed in three patients with a posterior pelvic ring injury who had been treated with percutaneous fixation techniques. These were treated successfully with débridement. Nine patients complained of pain of pelvic origin. Nerve deficits recovered completely in four of the seven patients with preoperative neurologic deficiency. Moderate or major depression was diagnosed in sexually dysfunctional patients in the 12th postoperative month according to HDARS (r = -0.559, P < 0.001). At the last visit, there was an inverse correlation between ability to work and depression and anxiety (r = -0.551, r = -0.391). An inverse correlation was found between pain and ability to work (r = 0.597, P < 0.001). Of the 36 patients, 26 returned to their original jobs at the last follow-up visit.

CONCLUSIONS

Morbidity and mortality rates are higher in patients with a completely unstable pelvic ring injury. Emergency department stabilization and reconstruction of the pelvic ring with optimal operative techniques in these patients can reduce morbidity and mortality rates. Anterior and posterior internal fixation results in satisfactory clinical and radiologic outcomes. The affective status of patients is an important aspect that should be considered during the entire care of the patient.

Anatomically correct reduction and fixation of a Tile C-1 type unilateral sacroiliac disruption using a rod and pedicle screw system between the S1 vertebra and the ilium: experimental and clinical case report

We have developed a new surgical technique for the treatment of Tile C-1 type sacroiliac disruption. We tried this procedure first in a cadaveric specimen and then applied it to a clinical case. We used the Texas Scottish Rite Hospital (TSRH) rod and pedicle screw system to insert one screw into the S1 vertebra without using an image intensifier and the other screw into the bone marrow of the ilium from the posterosuperior iliac spine. A straight rod was connected between the two screws by using a manipulator to attempt to reduce and fix the sacroiliac disruption. The combined pubic symphysis diastasis could be simultaneously reduced and fixed by using a plate through another incision, resulting in anatomically correct reconstruction of the pelvic ring. In this procedure, the alignment of the sacroiliac joint can be reversibly and directly changed during reduction and fixation. The sacroiliac joint can be strongly fixed because the screws can be freely inserted into the intact portion of the pelvis and the adjacent lumbar spine, if necessary. Good reduction is obtained because direct compression force is applied to the fracture site. The posterior and anterior procedures can be simultaneously performed under the same lateral position.

Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads

OBJECTIVE

To conduct a biomechanical comparison of a new triangular osteosynthesis and the standard iliosacral screw osteosynthesis for unstable transforaminal sacral fractures in the immediate postoperative situation as well as in the early postoperative weight-bearing period.

DESIGN

Twelve preserved human cadaveric lumbopelvic specimens were cyclicly tested in a single-limb-stance model. A transforaminal sacral fracture combined with ipsilateral superior and inferior pubic rami fractures were created and stabilized. Loads simulating muscle forces and body weight were applied. Fracture site displacement in three dimensions was evaluated using an electromagnetic motion sensor system.

INTERVENTION

Specimens were randomly assigned to either an iliosacral and superior pubic ramus screw fixation or to a triangular osteosynthesis consisting of lumbopelvic stabilization (between L5 pedicle and posterior ilium) combined with iliosacral and superior pubic ramus screw fixation.

MAIN OUTCOME MEASURES

Peak loaded displacement at the fracture site was measured for assessment of initial stability. Macroscopic fracture behavior through 10,000 cycles of loading, simulating the early postoperative weight-bearing period, was classified into type 1 with minimal motion at the fracture site, type 2 with complete displacement of the inferior pubic ramus, or type 3 with catastrophic failure.

RESULTS

The triangular osteosynthesis had a statistically significantly smaller displacement under initial peak loads (mean +/- standard deviation [SD], 0.163 +/- 0.073 cm) and therefore greater initial stability than specimens with the standard iliosacral screw fixation (mean +/- SD, 0.611 +/- 0.453 cm) ( = 0.0104), independent of specimen age or sex. All specimens with the triangular osteosynthesis demonstrated type 1 fracture behavior, whereas iliosacral screw fixation resulted in one type 1, two type 2, and three type 3 fracture behaviors before or at 10,000 cycles of loading.

CONCLUSION

Triangular osteosynthesis for unstable transforaminal sacral fractures provides significantly greater stability than iliosacral screw fixation under in vitro cyclic loading conditions. In vitro cyclic loading, as a limited simulation of early stages of patient mobilization in the postoperative period, allows for a time-dependent evaluation of any fracture fixation system.

Improvement of external fixator performance in type C pelvic ring injuries by plating of the pubic symphysis: an experimental study on 12 external fixators

BACKGROUND

In an earlier study, we introduced a pelvic ring stability criterion for weightbearing stabilization. In a loading test, however, current external fixation systems alone did not meet this criterion. Internal fixation of the dorsal ring can significantly increase stability, but the condition of severely injured patients is often a contraindication for major surgery. The aim of this study is to optimize external pelvic ring fixation without dorsal ring stabilization to allow weightbearing in early mobilization of patients with unstable pelvic ring injuries.

METHODS

The stiffness of external fixation systems alone and in combination with one or two anterior plates was measured by using a pelvic replica with a type C pelvic ring injury. Endpoints were 15 mm of dislocation or tolerance of 560 N.

RESULTS

Addition of one plate at least doubles stiffness, whereas two-plate fixation results in at least a fourfold stiffer configuration. Frame configurations profit more than single-bar systems, and all but one system resist the weightbearing load after double-plating of the pubic symphysis.

CONCLUSION

The choice of double-plate fixation of the anterior ring in addition to external fixation results in weightbearing capacity.

A modification of the retrograde medullary screw for the treatment of bilateral pubic ramus nonunions: a case report

We describe a patient with bilateral pubic ramus nonunions who was treated successfully with a modification of the retrograde medullary screw technique, in which the screw orientation was altered so that it engaged the cancellous bone in the inferior part of the anterior column and the anterior-inferior cortex of the fossa acetabuli. The modification should be one option when the original technique is judged to be difficult to perform.

A level one trauma center's experience with the posterior approach to the pelvis

A retrospective review of the experience at Los Angeles County and University of Southern California Medical Center was conducted as part of a multicenter study to evaluate the true complication rate of the posterior approach to the sacroiliac joint. Between 1995 and 1997, 35 patients underwent 42 approaches, representing all patients who underwent the posterior approach by a single staff surgeon at these medical centers. All patients underwent follow-up > or = 1 year postoperatively. (11%) neurologic complications were found postoperatively, all of which resolved prior to discharge. There was 1 (2.4%) wound complication. There was 1 gluteal flap for closure (open fracture) and 1 secondary wound closure. Five patients had prolonged wound drainage (> 5 days). There were no skin sloughs in the series and only 1 patient developed a deep wound infection. Contrary to reports by advocates of anterior approaches and closed reductions, the posterior approach allows anatomic reduction of posterior lesions with an acceptable complication rate.

CT guided percutaneous fixation of sacroiliac fractures in trauma patients

BACKGROUND

Open reduction and internal fixation of unstable pelvic fractures has been advocated to minimize complications and avoid further injury. We have recently performed CT guided percutaneous fixation of sacroiliac joints as an alternative to open repair.

METHODS

From May 1, 1998 to April 30, 1999, our Level II trauma center admitted 76 patients with pelvic fractures, all due to blunt trauma. Twenty patients with unstable sacroiliac fracture-distractions underwent 22 percutaneous fixation procedures under general anesthesia in the radiology department by the third hospital day. Procedure times averaged 82 minutes. Localization with CT guidance was performed by the radiologist using 3-D images followed by percutaneous screw placement by the orthopaedic surgeon.

RESULTS

There was minimal procedural blood loss and no post-procedural wound complications. There was one operative delay due to respiratory difficulties and one postoperative death unrelated to the pelvic fracture. All patients were mobilized on the first post-procedural day.

CONCLUSION

CT guided fixation of unstable pelvic fractures minimizes blood loss during a short procedure with few subsequent complications and allows early mobilization of the patients.

Open reduction internal fixation of a pelvic malunion through an anterior approach

Whereas the initial treatment of pelvic fractures and their long-term outcomes have been well researched, little has been written concerning the surgical management of late pelvic malunions and nonunions causing residual pain and deformity. The available literature describes osteotomies usually done in multiple stages. The authors report the case of a progressive lateral compression pelvic disability treated in a unique one-stage procedure. This one-stage anterior approach allowed excellent correction of the deformity. In cases in which the deformity is purely one of internal or external rotation or medial or lateral displacement with no vertical migration, the authors think it is possible to adequately mobilize the pelvis to an anatomic reduction in a single-stage anterior approach. In cases in which vertical migration of the hemipelvis causes symptoms, it is probably necessary to approach the patient posteriorly to safely mobilize and adequately reduce the hemipelvis. With these factors in mind, the authors think a one-stage anterior approach can be an effective treatment for appropriately selected pelvic malunions.

Evolution of a multidisciplinary clinical pathway for the management of unstable patients with pelvic fractures

OBJECTIVE

To determine whether the evolution of the authors' clinical pathway for the treatment of hemodynamically compromised patients with pelvic fractures was associated with improved patient outcome.

SUMMARY BACKGROUND DATA

Hemodynamically compromised patients with pelvic fractures present a complex challenge. The multidisciplinary trauma team must control hemorrhage, restore hemodynamics, and rapidly identify and treat associated life-threatening injuries. The authors developed a clinical pathway consisting of five primary elements: immediate trauma attending surgeon's presence in the emergency department, early simultaneous transfusion of blood and coagulation factors, prompt diagnosis and management of associated life-threatening injuries, stabilization of the pelvic girdle, and timely insinuation of pelvic angiography and embolization. The addition of two orthopedic pelvic fracture specialists led to a revision of the pathway, emphasizing immediate emergency department presence of the orthopedic trauma attending to provide joint decision making with the trauma surgeon, closing the pelvic volume in the emergency department, and using alternatives to traditional external fixation devices.

METHODS

Using trauma registry and blood bank records, the authors identified pelvic fracture patients receiving blood transfusions in the emergency department. They analyzed patients treated before versus after the May 1998 revision of the clinical pathway.

RESULTS

A higher proportion of patients in the late period had blood pressure less than 90 mmHg (52% vs. 35%). In the late period, diagnostic peritoneal lavage was phased out in favor of torso ultrasound as a primary triage tool, and pelvic binding and C-clamp application largely replaced traditional external fixation devices. The overall death rate decreased from 31% in the early period to 15% in the later period, as did the rate of deaths from exsanguination (9% to 1%), multiple organ failure (12% to 1%), and death within 24 hours (16% to 5%).

CONCLUSIONS

The evolution of a multidisciplinary clinical pathway, coordinating the resources of a level 1 trauma center and directed by joint decision making between trauma surgeons and orthopedic traumatologists, has resulted in improved patient survival. The primary benefits appear to be in reducing early deaths from exsanguination and late deaths from multiple organ failure.