Einfluss der Sakrumfraktur auf das funktionelle Langzeitergebnis von Beckenringverletzungen

The surgical treatment of unstable osteoporotic pelvic ring fractures with bilateral vertebropelvic stabilization using a less invasive technique

By immobilizing the joint partners between the lumbar spine and the pelvis, the vertical and horizontal forces on the sacrum are both transferred through the ilium caudally. Therefore persistent stress on the fracture is avoided. To ensure sufficient soft tissue coverage the pedicle screws are inserted via small incisions in the lumbar spine area and the iliac screws via slightly oblique incisions on both sides laterally of the posterior iliac spine. At the end the instrumentation is completed by connecting the lumbar longitudinal carriers with the cross connection between the two iliac screws via the pre-existing incisions. Due to this less invasive technique, disorders of wound healing can be avoided. Due to the lower Morbidity rate and its associated reduction in blood loss, there is corresponding decrease in the number of postoperative symptoms, which has a positive effect on early mobilization. None of the described patients showed neurological deficits preoperatively or postoperatively. LEVEL OF EVIDENCE: IV; Technical note, retrospective.

Effect of the subcutaneous route for iliac screw insertion in lumbopelvic fixation for vertical unstable sacral fractures on the infection rate: A retrospective case series

OBJECTIVE

To report the perioperative results and surgical outcomes of patients with vertical unstable sacral fractures who underwent lumbopelvic fixation through a modified subcutaneous route for iliac screw fixation.

SUMMARY OF BACKGROUND DATA

Treating vertical unstable sacral fractures is still challenging for orthopedic surgeons. Among various methods for treating these fractures, lumbopelvic fixation provides a high reduction quality and promising stability for early weight-bearing ambulation. However, wound healing disturbance and surgical site infection (SSI) are the drawbacks of this extensive technique, especially after inserting iliac screws.

METHODS

Here, we provide an alternative subcutaneous route for iliac screw insertion during lumbopelvic fixation surgery to lessen soft tissue retraction and injury, and thus decrease soft tissue complications.

RESULTS

Using this modified technique, 28 patients with vertical unstable sacral fractures were treated between 2012 and 2014. One patient had an SSI (infection rate: 3.5%). All fractures were united with a mean sacral kyphosis correction angle of 10.5°. The mean Majeed score of the 17 patients during the 12-month follow-up was 84.5.

CONCLUSIONS

The subcutaneous route for iliac screw insertion is a simple, safe, and effective technique when performing lumbopelvic fixation for vertical unstable sacral fractures.

What are predictors for patients' quality of life after pelvic ring fractures?

BACKGROUND

Data from literature on predictors for patients' quality of life after pelvic ring fractures are conflicting and based on small study populations.

QUESTIONS/PURPOSES

We therefore evaluated predictors for health-related quality of life in patients with pelvic ring injuries at a minimum of 1 year postfracture.

METHODS

We surveyed 172 patients of the German Pelvic Trauma Registry admitted to four medical centers between February 3, 2004, and May 11, 2011. The median age of the followup cohort was 47 years (range, 8-88 years); 69 of 172 (40%) patients were female. Patients were characterized by a median Injury Severity Score of 17. There were 31 Tile Type A fractures (18%), 77 Type B fractures (45%), and 64 Type C fractures (37%). The incidence of complex fractures and multiple traumas was 34 of 172 (20%) and 116 of 172 (67%), respectively. One hundred twenty-five (73%) patients were treated operatively. We obtained the EQ-5D™ score to assess patients' health-related quality of life. For the analysis of predictors for quality of life, a multivariate linear regression model was built. The median followup was 3 years (range, 1-6 years).

RESULTS

The median EQ-5D™ score was 0.78 (interquartile limits, 0.63 and 1.00). Age, complex trauma, and surgery independently predicted the EQ-5D™ score.

CONCLUSIONS

We conclude patients with higher age, complex trauma, and surgery had a higher likelihood for a reduced quality of life after pelvic ring injuries.

The long-term clinical outcome after pelvic ring injuries

We report the functional and socioeconomic long-term outcome of patients with pelvic ring injuries.

We identified 109 patients treated at a Level I trauma centre between 1973 and 1990 with multiple blunt orthopaedic injuries including an injury to the pelvic ring, with an Injury Severity Score (ISS) of ≥ 16. These patients were invited for clinical review at a minimum of ten years after the initial injury, at which point functional results, general health scores and socioeconomic factors were assessed.

In all 33 isolated anterior (group A), 33 isolated posterior (group P) and 43 combined anterior/posterior pelvic ring injuries (group A/P) were included. The mean age of the patients at injury was 28.8 years (5 to 55) and the mean ISS was 22.7 (16 to 44).

At review the mean Short-Form 12 physical component score for the A/P group was 38.71 (22.12 to 56.56) and the mean Hannover Score for Polytrauma Outcome subjective score was 67.27 (12.48 to 147.42), being significantly worse compared with the other two groups (p = 0.004 and p = 0.024, respectively). A total of 42 patients (39%) had a limp and 12 (11%) required crutches. Car or public transport usage was restricted in 16 patients (15%). Overall patients in groups P and A/P had a worse outcome. The long-term outcome of patients with posterior or combined anterior/posterior pelvic ring injuries is poorer than of those with an isolated anterior injury.

Cite this article: Bone Joint J 2013;95-B:548–53.

Less invasive lumbopelvic stabilization of posterior pelvic ring instability: technique and preliminary results

BACKGROUND

Lumbopelvic distraction stabilization with (triangular osteosynthesis) or without additional iliosacral screw allows anatomic reduction of the posterior pelvic ring after severely displaced sacral fractures, correction or resection osteotomies of malunions, respectively, septic sacroiliitis and permits early weight bearing. However, this technique is complicated by wound necrosis or infection in up to 20% to 30%. We describe our experience with a less invasive technique.

METHODS

The presented technique was performed in a consecutive series (December 2006 to October 2009) of 10 patients (mean age: 47 years, 23-85 years; 5 men). Posterior pelvic ring instability was due to severely displaced vertical shear injuries of type C1/3.3 (6/10), delayed union 2 months after bilateral C 3.3 (1/10) fractures, and malunion 6 months after unilateral vertical shear injuries C 1.3 (1/10), occurred after resection of the iliosacral joint for treatment of spinal tuberculosis (1/10) or was related to a early loss of reduction of a type C 1.3 pelvic ring injury (1/10). Patients were prospectively evaluated for the occurrence of wound-healing disorders with a median follow-up of 9 months (range, 5-33).

RESULTS

The median duration of the hospital stay was 35 days (range, 16-57). One 85-year-old patient died 1 year after lumbopelvic stabilization for reasons unrelated to the surgical treatment. In the postoperative course, no wound-healing disorders or infections were observed, and in all cases, the soft tissues and the bone healed. Five of 10 removal of the lumbopelvic fixation was performed at a median of 8 months (range, 8-20) after stabilization to prevent sacroiliac arthrodesis or to mobilize the lumbar spine after the unilateral lumbopelvic stabilization. The indication for hardware removal was not related to wound disorders.

CONCLUSION

The presented technique respects the lumbar anatomy and provides the access required for lumbopelvic stabilization, while having the potential to decrease or even prevent postoperative wound disorders if combined with a polyaxial low-profile system. The low number of cases presented may, however, limit the relevance of the conclusions in cases of severe Morell-Lavallé lesions with skin disorders.

Navigation of vertebro-pelvic fixations based on CT-fluoro matching

Different navigation procedures (based on 2D-, 3D-fluoroscopy or CT modalities) with their respective limitations are established in orthopedic surgery. The hypothesis is that intraoperative matching of different modalities (fluoro and CT) increases the precision of navigated screw placement and reduces the fluoroscopy time. Vertical unstable pelvic ring fractures of 12 patients were treated with vertebro-pelvic fixations (6 in the standard technique and 6 using the fluoro-CT navigation). An optimal osseous corridor could be determined by the navigation procedure increasing the overall precision of screw placement (no misplacement in the second group as compared to one misplaced pedicle screw in the standard group). The achieved screw lengths were [(mean ± SE) 78 ± 5 vs. 53 ± 4 mm, p < 0.001). Less invasive open approaches and a reduction of fluoroscopy time (time per screw in seconds: 121 vs. 62 s) were observed. CT-fluoro-matched navigation improves the intraoperative visualization of osseous structures and increases the precision of screw placement with less radiation exposure.