Mortality and functional outcomes of fragility fractures of the pelvis by fracture type with conservative treatment: a retrospective, multicenter TRON study

Imaging pitfalls in fragility fractures of the pelvis: a case series

BACKGROUND

Fragility fractures of the pelvis are low-energy pelvic ring fractures commonly occurring in older adults. Early diagnosis of fragility fractures of the pelvis is important because of the possibility of fracture progression and deterioration. Herein, we report the imaging characteristics of fragility fractures of the pelvis in three patients that resulted in delayed diagnoses and discuss ways to improve the diagnostic accuracy.

CASE PRESENTATION

We reviewed the images of three Japanese patients with delayed fragility fractures of the pelvis diagnoses (one male, two females, aged 74-89 years), whose diagnoses were confirmed by orthopedic trauma surgeons after the initial treatments were completed. Their images all showed fractures with minimal displacements, such as those with continuous deformities of the bone cortex, bulging of the bone cortex, and those visible only on multiplanar reconstruction images.

CONCLUSION

We identified several key imaging features related to the delayed diagnosis of fragility fractures of the pelvis. Emergency physicians should be familiar with the characteristics and imaging features of fragility fractures of the pelvis to prevent delays in their diagnoses.

Augmented ilio-sacral screws for the treatment of fragility pelvic fractures: review of literature, presentation of a novel low-cost technique, and clinical results of a case series

PURPOSE

Fragility pelvic fractures are an increasingly entity due to increase in life expectancy. A large proportion of these fractures require surgical treatment with stabilization of the posterior ring with ilio-sacral screws. Due to the poor bone quality of these patients, cement augmentation of the ilio-sacral screws can be performed and thus avoid treatment failures. The purpose of this review is to make a revision of the literature and present a novel cementation technique with clinical examples of patients treated with this surgical technique.

METHOD

Review of current literature on fragility pelvic fractures and modern treatment alternatives. We also describe a novel, easy to perform and low-cost technique for cement augmentation of ilio-sacral screws that we find useful when not having specific commercial instruments for this purpose. Additionally, we present a case series of five patients operated between 2017 and 2024 with augmented ilio-sacral screws due to fragility pelvic fracture.

CONCLUSION

The surgical technique presented is easy to perform, has a low training curve and requires standard instruments easy to find in a trauma center. Further clinical studies are required to demonstrate superiority of cement augmentation over the standard technique without augmentation.

Clinical frailty and short-term outcomes after low-energy pelvic fracture in the geriatric population: Nationwide inpatient sample 2016-2018 analysis

BACKGROUND

Pelvic fractures can be life-threatening for elderly individuals with diminished bone strength. Frailty is associated with fracture outcomes, but its impact on pelvic fracture recovery remains unexplored. The aim of this study was to investigate the association between frailty and short-term outcomes in older adults hospitalized for low-energy pelvic fractures.

METHODS

Data from the Nationwide Inpatient Sample (NIS) covering the years 2005 to 2018 were reviewed. Inclusion criteria were age ≥ 60 years admitted for a low-energy pelvic fracture. Patients were categorized into frail and non-frail groups using the 11-factor modified Frailty Index (mFI-11). Association between frailty and in-hospital outcomes were determined by univariate and multivariable regression analyses.

RESULTS

A total of 24,688 patients with pelvic fractures were included. The mean patient age was 80.6 ± 0.1 years, and 35 % were classified as frail. After adjustments, frailty was significantly associated with unfavorable discharge (adjusted odds ratio [aOR] = 1.07, 95 % confidence interval [CI]: 1.00-1.15, p = 0.038), prolonged hospitalization (aOR = 1.51, 95 % CI: 1.41-1.62, p < 0.001), complications (aOR = 1.42, 95 % CI:1.34-1.50, p < 0.001), and acute kidney injury (aOR = 1.68, 95 % CI: 1.56-1.82, p < 0.001). Stratified analyses based on age and fracture type showed frailty was consistently associated with adverse outcomes.

CONCLUSIONS

Persons ≥60 years old with mFI-11 assessed frailty and a low-energy pelvic fracture are at higher risk of adverse in-hospital outcomes than non-frail patients. Additional research is needed to disclose the prognostic impact of clinical frailty on long-term functional outcomes and quality of life after discharge.

Percutaneous hollow nail internal fixation treatment for fractures of the pubic symphysis and its adjacent areas

Purpose

To explore the percutaneous minimally invasive treatment of pubic symphysis and its adjacent fractures.

Method

Since May 2021, 13 cases of fractures involving the pubic symphysis and its adjacent parts were treated with x-ray fluoroscopic localization and percutaneous cannulated screw fixation across the symphysis pubis, the guide pin pierced the symphysis pubis and the fracture end and stopped at the inner edge of the acetabulum. Visual analogue scale (VAS) was used to evaluate the effect of the operation, and the patients were followed up.

Result

The screw insertion operation time was 25-40 min, with an average of 31.45 min; The number of perspectives is 20-40, with an average of 28.75. The average intraoperative blood loss was 10 ml, and there were no puncture complications such as nerve or vascular damage. The initial stability of the fractured end of the patient after surgery was good. The VAS score decreased from preoperative 8-10 points to postoperative 1-2 points (average of 1.5 points). The follow-up time was 3-25 months, with an average of 8.5 months. At the last follow-up, the excellent and good rate of pelvic function according to Majeed pelvic function scoring system was 100%. One patient had screws removed 1.5 years after surgery, while the remaining twelve patients did not have screws removed. All patients did not experience any discomfort symptoms caused by pubic symphysis fixation.

Conclusion

Percutaneous hollow nail internal fixation is an effective method for treating fractures of the pubic symphysis and its adjacent parts.

Evaluation of a treatment protocol based on conservative therapy for fragility fractures of the pelvis

PURPOSE

In an aging society, fragility fractures of the pelvis (FFP) have increased significantly. However, there is no clear consensus on the timing and criteria for transitioning from conservative treatment to surgery for these fractures. Thus, we aimed to investigate the effects of our treatment protocol for FFP based on conservative treatment.

METHODS

We conducted a retrospective study including 74 patients with FFP at our institution between 2015 and 2021. All patients were treated conservatively for the first two weeks. During this period, only wheelchair transfer was allowed. If the patient could not walk after this period, surgery was performed. Fracture type (Rommens classification), walking ability, presence of complications after admission, presence of fracture union, and surgical treatment was investigated. Patients were divided into two groups: a stable group (type I/II) and an unstable group (type III/IV).

RESULTS

Fracture union was achieved in all patients. Thirteen patients developed complications after being admitted to our hospital; seven showed decreased walking ability, and six required surgeries. The stable and unstable groups comprised 47 and 27 patients, respectively. There were no statistically significant differences between the groups regarding the percentage of patients who developed complications or experienced decrease in walking ability. The percentage of patients who required surgery was significantly higher in the unstable group (p < 0.05).

CONCLUSION

Our FFP management protocol was effective regardless of fracture type. It is important to provide a period for careful assessment of instability, and to try to prevent fracture progression.

Predictors of mortality one year after pelvic fractures in an older population: a retrospective cohort study

The goal was to investigate if patient characteristics can be used to predict 1-year post-fracture mortality after pelvic fracture. Multivariate logistic regression identified male gender, comorbidities and presence of in-hospital complications as predictors of 1-year mortality.

PURPOSE

Osteoporotic pelvic fractures have significant mortality and morbidity in the older population. The aim of this study was to investigate the factors predicting one-year mortality of patients sustaining a low-impact pelvic fracture (pelvic ring and acetabulum).

METHODS

A total of 282 patients aged ≥ 65 years presenting with a low-energy pelvic ring (n =254) or acetabular (n =28) fracture to the emergency department at the University Hospitals Leuven were included. Demographic and clinical data were retrospectively collected and predictors for mortality one year after pelvic ring fractures were evaluated.

RESULTS

The one-year mortality after osteoporotic pelvic ring fractures and acetabular fractures was respectively 20.4% (95% CI 15.7-26.0) and 14% (95% CI 4.0-32.7). Multivariate logistic regression adjusted for confounders identified male gender (OR 3.18; 95% CI (1.06-9.49), p =0.038), a higher number of comorbidities (OR 1.5; 95% CI (1.16-1.95), p =0.002) and in-hospital complications (OR 5.00; 95% CI (1.39-17.97), p =0.014) as independent predictors of one-year mortality after pelvic ring fractures.

CONCLUSION

The one-year mortality after low-energy pelvic is high and can be predicted by different patient characteristics. These findings can guide pelvis fracture treatment decisions in the older population.

What is the Radiographic Factor Associated with Meniscus Injury in Tibial Plateau Factures? Multicenter Retrospective (TRON) Study

Purpose

Tibial plateau fracture (TPF) is a complex intra-articular injury involving comminution and depression of the joint, which can be accompanied by meniscal tears. The aims of this study were (1) to demonstrate the rate at which surgical treatment for lateral meniscal injury and (2) to clarify the explanatory radiographic factors associated with meniscal injury in patients with TPF.

Methods

We extracted the patients who received surgical treatment for TPF from our multicenter database (named TRON) included from 2011 to 2020. We analyzed 79 patients who were received surgical treatment for TPF with Schatzker type II and III and evaluation for meniscal injury on arthroscopy. We investigated the rate at which surgical treatment of the lateral meniscus was required in patients with TPF and the explanatory radiographic factors associated with meniscal injury. Radiographs and CT scans were evaluated to measure the following parameters: tibial plateau slope, distance from lateral edge of the articular surface to fracture line (DLE), articular step, and width of articular bone fragment (WDT). Meniscus tears were classified according to whether surgery was necessary. The results were analyzed by multivariate Logistic analyses.

Results

We showed that 27.7% (22/79) of cases of TPF with Schatzker type II and III had lateral meniscal injury that required repair. WDT ≥ 10 mm (odds ratio 10.9; p = 0.005) and DLE ≥ 5 mm (odds ratio 5.7; p = 0.05) were independent explanatory factors for meniscal injury with TPF.

Conclusion

Bone fragment size and the location of fracture line on radiographs in patients with TPF are associated with meniscus injuries requiring surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00888-5.

A retrospective analysis of minimally invasive internal fixation versus nonoperative conservative management of pelvic ring fragility fractures and the elderly

OBJECTIVE

We aimed to investigate the adoption of treatment patterns for hip fractures combined with minimally invasive surgical treatment of fragility fractures of the pelvis in older individuals and reviewed and analysed the treatment efficacy and feasibility.

METHODS AND DATA

From September 2017 to February 2021, 135 older individuals with fragility fractures of the pelvis were admitted to our hospital. We retrospectively analysed patients who received surgical or conservative treatments. The general preoperative data, including sex, age, disease duration, cause of injury, AO/OTA type, BMI, bone mineral density, time from injury to admission, time from injury to surgery, ASA classification, number of underlying diseases, mean bed rest, clinical fracture healing, VAS score and Majeed functional score, were recorded.

RESULTS

The mean follow-up time for all 135 patients was 10.5 ± 3.6 months. Among 135 patients, 95 survived, and 11 and 29 patients passed after the surgical (mortality rate = 17.74%) and conservative (mortality rate = 39.73%) treatments, respectively. The average follow-up time for the 95 surviving patients was 14.5 ± 1.8 months. The Majeed and VAS scores for the operation group were significantly better than those of the conservative group. The bed rest and fracture healing times were also shorter in the surgical treatment group than in the conservative group.

CONCLUSION

The use of a minimally invasive surgical treatment combined with the geriatric hip fracture treatment model to treat fragility fractures of the pelvis improved the quality of life in older patients.

Comparative outcome of different treatment options for fragility fractures of the sacrum

BACKGROUND

Fragility fractures of the sacrum (FFS) have been detected more and more frequently in recent times, and the incidence will continue to increase due to increasing life expectancy. The aim of this study was to compare the clinical outcome of conservative, interventional and surgical treatment of FFS.

METHODS

Retrospectively, 292 patients (276 women, 16 men) with confirmed FFS were followed up over a period of 2 years. The age of the women was Ø 81.2 (58 - 99) and that of the men Ø 78.1 (76 - 85) years. The pain was quantified using a VAS. Fractures were classified in accordance with the Rommens and Hofmann and with the Denis classification using conventional X-rays, CT and MRI. A QCT of the lumbar spine was performed to quantify bone mineral density. Concomitant diseases of every patient were recorded. An interdisciplinary case conference determined the individual treatment concept considering the age, type of fracture, pain level and comorbidities with classification into conservative, interventional (any type of sacroplasty) or surgical treatment. Over the course pain and independence were measured, complications and patient satisfaction were documented. A vitamin D determination was done, and existing comorbidities were included.

RESULTS

Patients with a pain level of ≤5 benefited from the conservative therapy measures, with pain levels > 5 significantly delaying the development of mobility. After sacroplasty, the pain reduced significantly, which caused a rapid improvement in mobility without any significant difference being found between vertebro- (VSP), balloon (BSP), radiofrequency (RFS) and cement sacroplasty (CSP). In terms of pain reduction and mobilization, the surgical treated patients benefited from osteosynthesis, although more complex fracture types with lumbopelvic stabilization took longer. Overall, there were no deaths during the hospital stay. Mortality after 12 months was 21.7% for the conservative, 8.4% for the interventional and 13.6% for the surgical therapy group; the differences are significant. For patients in the conservative therapy group who were difficult to mobilize due to pain, the mortality increased to 24.3%. Over 24 months, patients achieved the best independence after sacroplasty. At 12 and 24 months, subjective satisfaction with the therapies was best after sacroplasty, followed by osteosynthesis and conservative measures. All patients had a pronounced vitamin D deficiency and manifest osteoporosis. Cardiovascular pathologies were the main concomitant diseases.

CONCLUSIONS

Patients with FFS with a low level of pain benefit from conservative therapy measures, whereby complications and mortality increase significantly in the case of persistent immobilizing pain. Patients with an unacceptable level of pain resulting from non-dislocated fractures benefit significantly from sacroplasty. Patients with unstable and displaced fractures (Rommens and Hofmann type III and IV) should be operated on promptly. Different techniques are available for sacroplasty and osteosynthesis, which lead to an improvement of independence and a reduction in mortality.

Fragility Fractures of the Pelvis: Current Practices and Future Directions

PURPOSE OF REVIEW

To summarise the current evidence and clinical practices for patients with fragility fractures of the pelvis (FFP).

RECENT FINDINGS

FFPs are an increasingly prevalent and recognised problem in the elderly population. Recent evidence indicates they have a significant impact on function, morbidity and mortality. While traditional management of FFPs was predominantly non-surgical, surgical options have been increasingly used, with a range of surgical methods available. To date, limited consensus exists on the optimal strategy for suitable patient selection, and clinical trials in this population have proved problematic. The management of FFPs requires a multi-faceted approach to enhance patient care, including adequate pain control, minimisation of complications and optimisation of medical management. Early return to mobilisation should be a key treatment goal to maintain functional independence. The selection of patients who will maximally benefit from surgical treatment, and the most appropriate surgical strategy to employ, remains contentious.

The grade of instability in fragility fractures of the pelvis correlates with impaired early mobilization

PURPOSE

This study aimed to investigate whether gait patterns of patients with fragility fractures of the pelvis (FFP) comply with the grade of fracture instability, defined by radiological patterns.

PATIENTS AND METHODS

This prospective, single-center, observational study included 39 patients with an FFP. Gait analysis was performed with a wearable insole force sensor (Loadsol® by Novel, Munich, Germany) 4-7 days after admission. Patients were divided in two groups: Group A included FFP type 1 fractures, which affect the anterior pelvic ring only, Group B contained FFP type 2-4 fractures with an involvement of the posterior pelvic ring. Primary outcome parameter was the FTI ratio (force-time integral (N*s)).

RESULTS

The mean age was 85.08 years (SD ± 6.45), 94.9% (37/39) of the patients were female. The most common fracture type was an FFP 2b (64.1%, 25/39). Group A showed a significantly higher FTI ratio (45.12%, SD ± 4.19%) than Group B (38.45%, SD ± 5.97%, p = 0.002). Further, a significant correlation of the FTI ratio and the average (r = 0.570, p < 0.001) and maximum (r = 0.394, p = 0.013) peak force was observed.

CONCLUSION

The gait pattern of patients with an FFP type 2-4 was more imbalanced than of patients with an FFP type 1 fracture. These findings match with the radiological classification of FFP, which indicates higher instability, when the posterior pelvis is affected. Gait analysis might offer earlier functional diagnostics and may accelerate the treatment decision with shorter periods of immobility in future. Especially in cross-border cases, early gait analysis could be beneficial to clarify the indication for or against surgery.