[Fragility fractures of the pelvis]

Comparing different minimally invasive screw osteosyntheses methods for the stabilization of the sacral fractures

BACKGROUND CONTEXT

Percutaneous screw osteosynthesis is the gold standard for managing sacral fragility fractures in geriatric patients with immobilizing pain. However, comparative evidence regarding the optimal type, length, or insertion position of sacroiliac screws remains limited.

PURPOSE

This study aimed to compare outcomes between long transsacral screws bridging both sacroiliac joints and short sacroiliac screws.

STUDY DESIGN/SETTING

Retrospective cohort single-center study.

PATIENT SAMPLE

Geriatric patients treated with percutaneous sacroiliac screws for sacral fragility fractures.

OUTCOME MEASURES

Primary outcome: screw loosening at 3-, 6-, and 12-month follow-ups.

SECONDARY OUTCOMES

surgical duration, postoperative pain, mobility improvement, and hospital stay length.

METHODS

Data from 122 patients (median age 81, 84 % female) treated between 2018 and 2021 were analyzed. Patients were categorized into three groups [1]: two long transsacral screws [2], a combination of one long and two short screws, and[3] four short sacroiliac screws. Fracture characteristics, FFP classification, and risk factors for screw loosening were evaluated.

RESULTS

Fractures were bilateral in 73 %, with FFP classifications of type 2 (48 %), type 3 (12 %), and type 4 (40 %). Anterior pelvic fractures were present in 63 %, comminuted fractures in 34 %, and H-type fractures in 29 %. Loosening rates were 17 % in the long-screw group, 6 % in the combination group, and 4 % in the short-screw group. Surgical duration was shortest for long screws (mean 52.6 min) compared to the combination (61.8 min) and short-screw (83.4 min) groups. Pain scores decreased below 5 in 88 % of patients at 3 months and 92 % at 12 months. Screw length was a significant risk factor for loosening (p = 0.04).

CONCLUSIONS

Long transsacral screws offer minimally invasive fixation with reduced surgical duration but higher loosening rates. Osteosynthesis with four short sacroiliac screws demonstrates superior long-term stability, making it a promising option for sacral fragility fractures.

Internal Versus External Fixation of the Anterior Ring in Unstable Pelvic Fractures Was Associated With Discharge to Home

OBJECTIVE

To determine whether anterior internal or definitive external fixation combined with posterior internal fixation of unstable pelvic fractures was associated with frequency of discharge to home.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Two Level 1 trauma centers and one academic tertiary referral center.

PATIENT SELECTION CRITERIA

Patients aged 16 years or older with unstable OTA/AO 61B/C pelvis fractures treated with operative fixation of the anterior and posterior pelvic ring by three fellowship-trained orthopaedic trauma surgeons from October 2020 to November 2022.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was the adjusted odds of discharge to home with internal fixation compared with definitive external fixation of the anterior pelvic ring on multivariable analysis considering patient, injury, and treatment characteristics. Secondary outcomes included bivariable associations between anterior fixation type and intensive care unit (ICU) days, ventilator days, hospital length of stay, and hospital charges.

RESULTS

Seventy-nine patients (65%) who were treated with internal fixation presented with higher mean Glasgow Coma Scale scores (13.5 ± 3.6 vs. 10.5 ± 5.4, P < 0.01) than 43 patients treated with definitive external fixation but were otherwise similar regarding age [mean 48.1 ± 19.9 vs. 41.2 ± 15.8, range (16-96) versus (19-77), P = 0.07], sex (36.7% vs. 44.2% female, P = 0.42193), mean body mass index (28.4 ± 6.2 vs. 28.7 ± 7.4 kg/m 2 , P = 0.93), any medical comorbidities (50.6% vs. 44.2%, P = 0.62), substance use (13.9% vs. 27.9%, P = 0.09884), insurance type ( P = 0.97), mean Injury Severity Score (24.8 ± 12.0 vs. 29.5 ± 14.0, range 5-57 vs. 10-57, P = 0.14), pelvis fracture pattern ( P = 0.12187), and preinjury living environment ( P = 0.67695). On multivariable analysis, patients treated with internal fixation were more frequently discharged to home (53.2% vs. 27.9%, odds ratio 3.39, 95% confidence interval 1.29-9.84, P = 0.0198). Patients treated with anterior internal fixation also experienced fewer mean ICU days (6.0 ± 8.8 vs. 9.8 ± 16.3, P = 0.0213), ventilator days (3.5 ± 8.2 vs. 6.9 ± 15.9, P < 0.0081), and hospital days (18.7 ± 16.2 vs. 31.2 ± 26.7, P < 0.01) and incurred less hospital charges ($278,563.29±$261,602.35 vs. $580,625.98±$503,067.98, P < 0.01).

CONCLUSIONS

Patients who received anterior and posterior internal fixation of their unstable pelvis fractures were more likely to discharge to home than patients treated with anterior definitive external fixation and posterior internal fixation. Anterior internal fixation was also associated with fewer ICU, ventilator, and hospital days, as well as less hospital charges.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Isolated posterior stabilization of the pelvic ring in type III/IV fragility fractures of the pelvis are beneficial compared to 360° antero-posterior surgical approaches. A dual-center cohort analysis

BACKGROUND

Fragility fractures of the pelvis (FFP) in elderly patients are an increasing concern due to their association with osteoporosis and the aging population. These fractures significantly affect patients' mobility and quality of life. This study evaluates different surgical techniques in patients suffering from FFP to provide standardized recommendations for treatment strategies. In addition, we compared therapeutic concepts and their outcome between two major trauma centers in Germany.

METHODS

We conducted a retrospective analysis of 882 patients aged over 65 years who suffered from FFP between 2003 and 2020 at a level I and level III trauma center in a german metropolis. Fractures were classified according to Rommens and Hofmann. Data collection included patient demographics, fracture type, treatment strategy, and length of hospital stay.

RESULTS

FFP I fractures were predominantly treated conservatively at both centers. Significant variability was noted in the treatment of type II and III fractures, with level III trauma center having a higher surgical intervention rate for FFP II in 27.6 % compared to the level I trauma center in 9.9 % of the cases. The most common procedure at both hospitals was the stabilization of the posterior pelvic ring. Patients who underwent less invasive posterior-only stabilization had shorter length of hospital stay than those who received combined anterior and posterior stabilization.

CONCLUSIONS

The study reveals substantial differences in the treatment approaches for FFP between two major trauma centers. Less invasive surgical methods, particularly posterior-only stabilization, are associated with shorter hospital stays and potentially better outcomes for elderly patients with unstable FFP.

CLINICAL RELEVANCE

This study underscores the importance of minimally invasive surgical techniques in managing FFP in elderly patients, highlighting their potential to reduce the length of hospital stay and improve recovery.

Predictors of prolonged hospital stay of pelvic ring and acetabular fractures - a retrospective analysis in a 10-year period of a level 1 trauma center

BACKGROUND

Pelvic ring and acetabular fractures are among the most complicated and severe injury patterns in orthopaedic trauma surgery. Inpatient treatment is not only costly but also very time-consuming. The aim of this study is to identify predictors leading to a prolonged length of hospital stay.

METHODS

This study is a retrospective review of data of 211 patients admitted to a Level-1 trauma centre. In this cohort a surgical treatment of pelvic ring and acetabular fractures between 2010 and 2020 was performed. Preclinical data and clinical parameters were analysed.

RESULTS

Injury severity was the most important factor for a prolonged stay. High-energy trauma resulted in significantly longer hospital stays. Multiple injury had a significant effect. Low haemoglobin levels measured on admission and an increased shock index, as indicators of the severe trauma, could be identified as good predictors of a longer intensive care period and a long total length of stay. Except for the number of surgical procedures to treat the pelvic fracture, surgical approach and technique showed no predictive value. Age and gender do not play a role. Increased patient age does not result in a longer hospital stay or longer intensive care times.

CONCLUSION

Pelvic fractures demonstrate a prolonged hospital stay. It depends on the severity of the injury. There are good predictors of a long length of stay at admission. These include the presence of multiple injury, the complexity of the fractures, haemoglobin levels, and the shock index.

Lateral Compression Fragility Fractures of the Pelvis: Diagnosis, Classifications, and Modern Management

PURPOSE OF REVIEW

To describe the diagnosis, classification, and modern management of lateral compression fragility fractures of the pelvis.

RECENT FINDINGS

Practice patterns are shifting toward early operative treatment of fragility fractures of the pelvis among patients who are unable to mobilize or whose injuries demonstrate occult instability on stress imaging. Early internal fixation appears to decrease pain, facilitate mobilization, accelerate hospital discharge, and minimize morbidity in this population. Lateral compression pelvic ring injuries are the most common type of fragility fracture of the pelvis. Similar to fragility fractures of the hip, lateral compression fragility fractures of the pelvis are typically sustained in a ground level fall. These injuries are associated with long acute hospital and post-acute facility admissions, loss of physical function, loss of independence, mortality, anxiety, sleep disturbance, and caregiver burnout. Unlike hip fractures, for which urgent operative treatment and early mobilization reduce mortality, lateral compression fragility fractures of the pelvis are commonly treated without surgery. Recommendations for nonoperative management of these injuries in older adults may be inappropriately generalized from studies of younger patient populations with high-energy mechanisms of pelvis fracture. However, strong evidence to support early internal fixation of these injuries practice is lacking. High quality investigations of early surgical intervention for lateral compression fragility fractures of the pelvis are needed to guide care for these patients.

Short-term mobility in low-energy pelvic ring fractures after conservative treatment

BACKGROUND

The growing population of elderly people is leading to a rising number of pelvic ring fractures. These often involve combinations of pubic branch and sacrum fractures, as seen in lateral compression type 1 (LC1) and 2 (LC2) fractures or more precisely classified as fragility fractures of the pelvis (FFP). The combined impact on the anterior and posterior ring brings the risk of prolonged pain, resulting in decreased mobility and increased complications. Given the higher multimorbidity of this population, surgical treatment poses a greater risk of intra- and post-operative complications. Hence, the management and treatment of this particular type of fracture remain challenging.

METHODS

A retrospective data analysis of 41 patients (F/M; 27/14) treated conservatively for low-energy LC1 or LC2 fractures was performed between 2017 and 2020. The fractures were classified using Rommens' FFP classification. The primary outcome was mobility at 2 and 6 weeks, assessed through chart analysis and phone interviews. To determine factors influencing patient outcomes fracture consolidation was assessed via X-ray analysis. As a secondary outcome logistic regression and decision tree analyzes were conducted.

RESULTS

The mean age at the time of fracture was 79.8 ± 12.5 (SD) years. Thirty-two patients regained mobility (F/M; 25/7) after 2 weeks. Another 7 patients were mobile after 6 weeks (F/M; 2/5). Two male patients did not regain mobility. Male sex emerged as the sole independent predictor of non-mobility at 2 weeks (p = 0.0037). Age, BMI, pubic branch fracture dislocation >5 mm, analgesic use of opiates, corticosteroid therapy, alcohol and smoking showed no association with mobility recovery. Fracture consolidation was observed in 73.2 % of patients (F/M; 21/9), while one female had no consolidation. Ten patients (F/M; 5/5) were lost to follow-up.

CONCLUSIONS

Our study shows that LC1 (FFP IIb, IIc) and LC2 (FFP IIIc, IVb) fractures can be effectively treated conservatively, with successful remobilization within 6 weeks. The only independent negative predictor of early mobilization was male sex. Pubic branch displacement >5 mm did not affect the outcome. Therefore, conservative management proves to be a viable option for low-energy LC1 or LC2 fractures.

LEVEL OF EVIDENCE

IV (retrospective study).

Biomechanical evaluation of an experimental internal ring fixator (RingFix) for stabilization of pelvic ring injuries on an osteoporotic bone model

During the last decades, effective pain reduction and early mobilization were identified as the central priorities in therapy of insufficiency fractures of the pelvis. For operative treatment minimally-invasive stabilization techniques are favored. While there is consensus on the significance of sufficient dorsal stabilization the role of additional fixation of the anterior fracture component stays under discussion. Within the present study we developed an internal ring fixator system (RingFix) with the question whether an in-itself-closed construct can improve stability of the entire ring structure. RingFix was evaluated on an osteoporotic bone model with a standardized FFP IIIc fracture within an established biomechanical setup regarding its primary stabilization potential. Further, it was compared to transiliac-transsacral screw fixation with and without stabilization of the anterior fracture component. The transiliac-transsacral fixation with separate screw fixation of the anterior fracture showed significantly higher stability than the RingFix and the transiliac-transsacral screw fixation without anterior stabilization. Our results show that stabilization of the anterior fracture component relevantly improves the stability of the entire ring construct. As a bridging stabilizer, RingFix shows biomechanical advantages over an isolated dorsal fracture fixation, but inferior results than direct stabilization of the single fracture components.

Motion preservation for open book injuries of the pubic symphysis -a biomechanical cadaver study

INTRODUCTION

Open book injuries are challenging injuries that oftentimes require surgical treatment. Currently, treatment is performed with symphyseal plating requiring extensive surgery and entirely limiting physiological movement of the symphyseal joint, frequently resulting in implant failure. Therefore, we investigated the biomechanical properties of a minimally invasive tape suture construct (modified SpeedBridge™) as an alternative stabilization technique for the treatment of open book injuries in human cadaver pelvic rings.

MATERIALS AND METHODS

The symphysis of 9 human cadaver pelvises was dissected and dilated to 3 cm creating an open book injury. Next, the two osteosynthesis methods (plating, modified SpeedBridge™) were applied. All specimens then underwent cyclic horizontal and vertical loading, simulating biomechanical forces while sitting, standing and walking. For statistical analysis, 3D dislocation (mm) was calculated.

RESULTS

Total displacement (mm) of the pubic symphysis displayed the following means and standard deviations: native group 1.34 ± 0.62 mm, open book group 3.01 ± 1.26 mm, tape group 1.94 ± 0.59 mm and plate group 1.37 ± 0.41 mm. Comparison between native and open book (p = 0.029), open book and plate (p = 0.004), open book and tape (p = 0.031), as well as tape and plate group (p = 0.002) showed significant differences. No significant differences were found when comparing the native and tape (p = 0.059), as well as the native and plate (p = 0.999) group.

CONCLUSION

While both osteosynthesis techniques sufficiently stabilized the injury, symphyseal plating displayed the highest rigidity. The modified SpeedBridge™ as a tape suture construct provided statistically sufficient biomechanical stability while maintaining symphyseal micro mobility, consequently allowing ligamental healing of the injured joint without iatrogenic arthrodesis.

[Diagnostics and treatment of insufficiency fractures of the pelvis]

Insufficiency fractures of the pelvis have increased in recent years, primarily due to the demographic change and the incidence will continue to rise. In addition to conventional X‑rays, the diagnostics always require slice imaging. Unlike high-energy trauma magnetic resonance imaging (MRI) plays an important role in insufficiency fractures. Once the fracture has been diagnosed, in addition to the extent of instability in the anterior and posterior pelvic rings, the pain symptoms are crucial for the decision on surgical treatment. The basic principle is to stabilize as little as possible but as much as necessary. There are currently a variety of procedures that can be applied as a minimally invasive procedure, especially for the often slightly or displaced insufficiency fractures. The decisive factor for treatment is that it enables early mobilization of the patients. All of these measures must be accompanied by thorough diagnostics of osteoporosis and the appropriate treatment.

Do we need to fix the anterior fracture component in insufficiency fractures of the pelvis? A biomechanical comparison on an FFP type IIIc fracture in an osteoporotic pelvic bone model

There is a growing understanding of the specific characteristics of insufficiency fractures of the pelvis and of general requirements for the treatment of affected patients with focus on early mobilization and effective pain reduction as the main goals of therapy. While there is consensus on the significance of achieving stability of the dorsal pelvic ring structures there is still an open discussion about the potential benefits of additional stabilization of an anterior fracture component. Within a biomechanical test setup, two established methods of dorsal fracture fixation were tested under axial loading (25-1200 N; 1000 test cycles) on an explicit osteoporotic bone model (n = 32) with a standardized FFP type IIIc fracture with and without additional fixation of the anterior fracture component. Dorsal fixation was performed with and long and a short 7.3 mm cannulated screw in S1 in one group (n = 16), and a trans sacral bar with an additional short 7.3 mm cannulated screw in S1 in the other group (n = 16). Half of the samples received a 7.3 mm cannulated retrograde transpubic screw for anterior fixation. The fixation with the trans sacral bar and the additional anterior screw fixation showed the highest rate of stability (p = 0.0014), followed by the double SI-screw fixation with stabilization of the anterior fracture (p = 0.0002). During testing, we observed the occurrence of new sacral fractures contralateral to the initial fracture in 22/32 samples. The results let us assume that stabilization of an additional anterior fracture component relevantly improves the stability of the entire ring construct and might prevent failure of the dorsal stabilization or further fracture progression.

[Sacral H-shaped fractures between traumatic, insufficiency and fatigue fractures : Similarities, differences and controversies]

In the basic entirety of stress fractures, insufficiency fractures are defined as fractures caused by prolonged normal or physiological loading of a bone with insufficient elastic resistance. This clearly distinguishes it from fatigue fractures, in which excessive loads are continuously applied to a bone with normal elastic resistance. According to Pentecost (1964) both entities of stress fracture result from "the inherent inability of the bone to withstand stress applied without violence in a rhythmical, repeated, subthreshold manner". This distinguishes them from acute traumatic fractures. In the clinical routine these differences are not always so clearly presented. The example of the H‑shaped sacral fracture is used to illustrate the relevance of a clear terminology. In this context, current controversies in the treatment of sacral insufficiency fractures are discussed.

Insufficiency Fractures vs. Low-Energy Pelvic Ring Fractures - Epidemiological, Diagnostic and Therapeutic Characteristics of Fragility Fractures of the Pelvic Ring

BACKGROUND

Fragility fractures of the pelvis (FFP) encompass two fracture entities: fracture after low-energy trauma and insufficiency fracture without trauma. It is unclear whether the two subgroups differ in terms of diagnosis and therapy. The aim of this retrospective study was to evaluate insufficiency fractures with regard to defined parameters and to compare specific parameters with the fractures after low-energy trauma.

PATIENTS AND METHODS

In the period from 2008 to 2017, 203 patients with FFP were recorded at our clinic (Level 1 Trauma Centre DGU, SAV approval). Of these, 25 had an insufficiency fracture and 178 had a pelvic ring fracture after low-energy trauma. Epidemiological, diagnostic and therapeutic parameters were examined.

RESULTS

There was a relative increase in the insufficiency fracture within the FFP (2008 - 2009: 5.0% vs. 2015 - 2017: 17.8%). In these patients, osteoporosis tended to be more pronounced than in patients after low-energy trauma (t-value: - 3.66 vs. - 3.13). The diagnosis of insufficiency fractures showed increased use of MRI and DECT (60.9% vs. 26.0%) and a high proportion of type IV fractures after FFP (40.0% vs. 7.9%). In terms of therapy, surgical treatment of the insufficiency fracture was sought more often (68,2% vs. 52,1%), with a tendency towards increased use of combined osteosynthesis procedures (14.3% vs. 7.6%).

CONCLUSION

We were able to show that as the number of cases increases, the insufficiency fracture becomes more important within FFP. If these patients tend to have more pronounced osteoporosis, particular attention should be paid to the diagnosis and adequate therapy of the osteoporosis, especially in the case of an insufficiency fracture. In addition to the increased diagnostic testing using MRI and DECT to detect oedema and the increased surgical therapy for this type of fracture, it is also noteworthy that the insufficiency fracture can cause higher-grade fractures after FFP.

Tape suture constructs for instabilities of the pubic symphysis: is the idea of motion preservation a suitable treatment option? A cadaver study

INTRODUCTION

Current gold standard for the treatment of symphyseal disruptions includes anterior plating, almost entirely prohibiting symphyseal mobility and resulting in an iatrogenic arthrodesis followed by high rates of implant failure. Minimally invasive tape suture constructs have been found to maintain the micro mobility of ligamentous injuries, yet still providing sufficient biomechanical stability. Recently, this technique has been primarily investigated for symphyseal disruptions on synthetic pelvic models. Therefore, the aim of this study was to examine the feasibility of this novel flexible osteosynthesis on cadaveric pelvic models based on the following hypothesis: tape suture constructs ensure sufficient biomechanical stability without inhibiting micro mobility of the pubic symphysis for the treatment of symphyseal disruptions and maintain stability during long-term loading.

MATERIALS AND METHODS

9 cadaveric anterior pelvic rings were used in this study and a symphyseal disruption was created in every specimen. The specimens were then exposed to short- and long-term vertical and horizontal cyclic loading after treatment with a tape suture construct in criss-cross technique. The mean maximum displacement (mm) during cyclic loading and the corresponding stiffness (N/mm) were measured and compared.

RESULTS

Regarding both displacement (mm) and corresponding stiffness (N/mm), the tape sutures displayed a significant difference between short- and long-term loading for cranial and caudal vertical loading (p < 0.01) but differences remained non-significant for horizontal loading (p > 0.05). No tape suture suffered from implant failure during long-term loading.

CONCLUSIONS

The tape suture construct displayed sufficient biomechanical stability without exceeding the physiological mobility of 2 mm of the pubic symphysis; however, also maintained the desired micro mobility of the affected joint necessary to prevent an iatrogenic arthrodesis. Further, all tape sutures maintained stability throughout long-term loading.

Focusing on individual morphological fracture characteristics of pelvic ring fractures in elderly patients can support clinical decision making

Introduction

Pelvic ring fractures in the elderly are often caused by minor trauma. Treatment of these patients is currently based on fracture classification, clinical course, and ability to mobilize. Our aim was to identify morphological fracture characteristics with potential prognostic relevance and evaluate their association with clinical decision making and outcome, as well as their interobserver reliability.

Methods

Five fracture characteristics were investigated as potential variables: 1. Extent of the dorsal pelvic ring fracture (absent, unilateral, bilateral); 2. Extent of the ventral pelvic ring fracture (absent, unilateral, bilateral); 3. Presence of a horizontal sacral fracture; 4. Ventral dislocation; 5. Ventral comminution.

These characteristics were assessed retrospectively in a series of 548 patients. The association of their presence with the decision to perform surgery, failure of conservative treatment and the length of hospital stay (LOS) was determined. Further, the inter-observer reliability for the specific characteristics was calculated and the relation with survival assessed.

Results

Four of the five evaluated characteristics showed an association with clinical decision making and patient management. In particular the extent of the dorsal fractures (absent vs. unilateral vs. bilateral) (OR = 7.0; p < 00.1) and the presence of ventral comminution/dislocation (OR = 2.4; p = 0.004) were independent factors for the decision to perform surgery. Both the extent of the dorsal fracture (OR = 1.8; p < 0.001) and the presence of ventral dislocation (OR = 1.7; p = 0.003) were independently associated with a prolonged overall LOS.

The inter-observer agreement for the fracture characteristics ranged from moderate to substantial.

A relevant association with increased mortality was shown for horizontal sacral and comminuted ventral fractures with hazard ratios (HR) of 1.7 (95% CI: 1.1, 2.5; p = 0.008) and HR = 1.5 (95% CI: 1.0, 2.2; p = 0.048).

Conclusion

In the elderly, the extent of the dorsal fractures and the presence of ventral comminution/dislocation were associated to the decision to undergo surgery, failure of conservative treatment and length of stay. Survival was related to horizontal sacral fractures and ventrally comminuted fractures. These characteristics thus represent a simplified but highly informative approach for the evaluation of pelvic ring fractures in the elderly. This approach can support clinical decision making, promote patient-centred treatment algorithms and thus improve the outcome of individualized care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03222-0.

Midterm follow-up of elderly patients with fragility fractures of the pelvis: A prospective cohort-study comparing operative and non-operative treatment according to a therapeutic algorithm

INTRODUCTION

The treatment of fragility fractures of the pelvis (FFP) is a challenge. The variations of non-operative- and of operative treatment are manifold and a structured treatment algorithm is lacking. The purpose of this study was to evaluate the outcome of elderly patients with a FFP who were treated with a therapeutic algorithm based on the FFP-classification.

PATIENTS AND METHODS

In a prospective cohort study 154 patients (mean age: 81.8 ±.61 (65-96); female: (86.8%; 131/154). BMI: 23.7 ±.34 (15-43)) with a FFP after inadequate mono trauma were treated according to a strict therapeutic algorithm between 04/2016 and 12/2018. According to a classification based on CT-scans either a standardized operative treatment or conservative therapy was induced and the outcome regarding objective measurements of mobility, pain, need for analgesics and mortality during hospital stay and after one year was analyzed.

RESULTS

82/154 participants (53.2%) were assigned to the conservative treatment group and 72 participants (46.8%) to the operative treatment group. The overall one-year survival rate was 78.1% (118/151). The survival of the operative treatment group was 90.7% (49/54) and significantly higher than the survival of the conservative treatment group (74.7%; 56/75; p=.023). The one-year follow up showed a high dispersion of the pain level in the operatively treated patients and a significantly higher mean in comparison to conservatively treated patients. Both treatment groups showed increasing numbers of patients with unlimited mobilization but also immobile patients. Overall in 31.0% (18/58) of the operative participants and in 14.9% (14/93) of the non-operatively treated participants complications occurred (p=.04).

CONCLUSION

The strict compliance to the presented treatment algorithm of FFP with an operative strategy starting from FFP IIc leads to a significantly lower mortality within one year in comparison to the conservatively treated patients. The worst outcome and the highest mortality was seen in patients who refused the recommendation of operative stabilization. The results of this study justify to proceed with the strict classification dependent treatment algorithm and also support the early switch-over to operative treatment of patients with failed conservative therapy in FFP I to FFP IIb.

Novel minimally invasive tape suture osteosynthesis for instabilities of the pubic symphysis: a biomechanical study

INTRODUCTION

Open book fractures are challenging injuries oftentimes requiring surgical treatment. The current treatment of choice is symphyseal plating, which requires extensive surgery and entirely limits physiological movement of the symphyseal joint, frequently resulting in implant failure. Therefore, we investigated the biomechanical properties of a semi-rigid implant (modified SpeedBridge^™) as a minimally invasive tape suture construct for the treatment of open book fractures and evaluated the superiority of two techniques of implementation: criss-cross vs. triangle technique.

MATERIALS AND METHODS

Nine synthetic symphyseal joints were dissected creating an open book fracture. The different osteosynthesis methods (plating, modified SpeedBridge^™ in criss-cross/triangle technique) were then applied. All constructs underwent horizontal and vertical loading, simulating biomechanical forces while sitting, standing and walking. For statistical analysis, dislocation (mm) and stiffness (N/mm) were calculated.

RESULTS

Symphyseal plating for the treatment of open book fractures proved to be a rigid osteosynthesis significantly limiting the physiological mobility of the symphyseal joint (dislocation: 0.08 ± 0.01 mm) compared to the tape sutures (dislocation: triangle technique 0.27 ± 0.07 mm, criss-cross technique 0.23 ± 0.05 mm) regarding horizontal tension (p < 0.01). Both modified SpeedBridge^™ techniques showed sufficient biomechanical stability without one being superior to the other (p > 0.05 in all directions). Considering vertical loading, no statistical difference was found between all osteosynthesis methods (caudal: p = 0.41; cranial: p = 0.61).

CONCLUSIONS

Symphyseal plating proved to be the osteosynthesis method with the highest rigidity. The modified SpeedBridge^™ as a semi-rigid suture construct provided statistically sufficient biomechanical stability while maintaining a minimum of symphyseal movement, consequently allowing ligamental healing of the injured joint without iatrogenic arthrodesis. Furthermore, both the criss-cross and the triangle technique displayed significant biomechanical stability without one method being superior.

Fragility Fractures of the Pelvis and Sacrum: Current Trends in Literature

Fragility fractures of the pelvis (FFP) and fragility fractures of the sacrum (FFS), which are emerging in the geriatric population, exhibit characteristics that differ from those of pelvic ring disruptions occurring in the younger population. Treatment of FFP/FFS by a multidisciplinary team can be helpful in reducing morbidity and mortality with the goal of reducing pain, regaining early mobility, and restoring independence for activities of daily living. Conservative treatment, including bed rest, pain therapy, and mobilization as tolerated, is indicated for treatment of FFP type I and type II as loss of stability is limited with these fractures. Operative treatment is indicated for FFP type II when conservative treatment has failed and for FFP type III and type IV, which are displaced fractures associated with intense pain and increased instability. Minimally invasive stabilization techniques, such as percutaneous fixation, are favored over open reduction internal fixation. There is little evidence regarding outcomes of patients with FFP/FFS and more literature is needed for determination of optimal management. The aim of this article is to provide a concise review of the current literature and a discussion of the latest recommendations for orthopedic treatment and management of FFP/FFS.

Beyond Hip Fractures: Other Fragility Fractures' Associated Mortality, Functional and Economic Importance: A 2-year-Follow-up

Background

Hip fractures are well researched in orthogeriatric literature. Equivalent investigations for fragility-associated periprosthetic and periosteosynthetic femoral, ankle joint, pelvic ring, and rib fractures are still rare.

The purpose of this study was to evaluate mortality, functional outcome, and socioeconomic parameters associated to the upper-mentioned fragility fractures prospectively in a 2-year follow-up.

Methods

Over the course of a year, all periprosthetic and periosteosynthetic femoral fractures (PPFF), ankle joint fractures (AJ), pelvic ring fractures (PR), and rib fractures (RF), that were treated on a co-managed orthogeriatric ward, were assessed. Parker Mobility Score (PMS), Barthel Index (BI), place of residence, and care level were recorded. After 2 years, patients and/or relatives were contacted by mailed questionnaires or phone calls in order to calculate mortality and reevaluate the mentioned parameters.

Results

Follow-up rate was 77.7%, assessing 87 patients overall. The relative mortality risk was significantly increased for PR (2.9 (95% CI: 1.5–5.4)) and PPFF (3.5 (95% CI: 1.2–5.8)) but not for RF (1.5 (95% CI: 0.4–2.6)) and AJ (2.0 (95% CI: 0.0–4.0)). Every fracture group except AJ showed significantly higher BI on average at follow-up. PMS was, respectively, reduced on average for PR and RF insignificantly, but significantly for PPFF and AJ in comparison to pre-hospital values. 10.0–27.3% (each group) of patients had to leave their homes permanently; care levels were raised in 30.0–61.5% of cases.

Discussion

This investigation provides a perspective for further larger examinations. PR and PPFF correlate with significant increased mortality risk. Patients suffering from PPFF, PR, and RF were able to significantly recover in their activities of daily living. AJ and PPFF conclude in significant reduction of PMS after 2 years.

Conclusion

Any fragility fracture has its impact on mortality, function, and socioeconomic aspects and shall not be underestimated. Despite some fractures not being the most common, they are still present in daily practice.

[Radiological diagnosis of pelvic ring fractures]

EPIDEMIOLOGY

Traumatic fractures of the pelvic ring are relatively rare, but are associated with increased risk of mortality. Depending on injury mechanism and main vector of energy impact, a distinction is made between anteroposterior compression, lateral compression, and vertical shear (Young and Burgess classification), while the stability-related classification according to Tile distinguishes between type A (stable), type B (rotationally unstable) and type C (completely unstable). A comprehensive modern classification is given by the AO/OTA.

RADIOLOGICAL FRACTURE DIAGNOSIS

Plain pelvis x‑rays lack sufficient sensitivity but are still used to detect highly unstable pelvic fractures. CT has superior sensitivity and specificity. In addition to fracture classification, CT allows reliable assessment of associated vascular and bladder/urethral injuries and large soft tissue hemorrhage. MRI is unparalleled in showing bone marrow edema, cauda and plexus complications, and peripelvic soft tissue damage. MRI may also prove to be a valuable diagnostic tool for pelvic ring injuries in children, adolescents and young women, provided they are hemodynamically stable. Angiography, ultrasonography and bone scintigraphy are additional important diagnostic and therapeutic options.

PRACTICAL RECOMMENDATIONS

Knowledge of basic pelvic trauma mechanisms is important to understand the potential severity of traumatic pelvic fractures and to classify them correctly in terms of stability. Being familiar with typical concomitant injuries in pelvic ring fractures allows reliable diagnosis and their communication with the clinician. CT remains the "diagnostic workhorse". In fragile pelvic fractures, the often prolonged course with fracture progression must be taken into account, which is why MRI is of particular importance herein.

Fragility Fractures of the Pelvic Ring – Does the Evidence of Oedema Lead us to More Surgeries?

Introduction The choice of therapy for fragility fractures of the pelvis (FFP) is largely determined by the diagnosed fracture morphology. It is now unclear whether the change in diagnostic options – sensitive detection of fracture oedema in the sacrum using MRI and dual-energy computed tomography (DECT) – has an impact on the therapeutic consequences. The aim of this retrospective study was therefore to evaluate the change in the diagnostics used and the resulting therapy regimen in our patient population.

Materials and Methods We performed a monocentric-retrospective analysis of 196 patients with a fragility fracture of the pelvis in our clinic (national TraumaZentrum® DGU and SAV approval) in the period from 2008 to 2017. We examined changes in epidemiology, diagnostics/classification and therapy of the pelvic ring fractures treated by us.

Results The diagnostic procedures used are subject to a clear change towards oedema detection using MRI and DECT. The graduation has changed towards more severe forms of fracture after FFP. There is now also an increasing proportion of patients treated by surgery (2008 – 2009: 5.3% vs. 2015 – 2017: 60.3%).

Conclusion We were able to show that the introduction of sensitive diagnostic procedures coincided with a higher classification of the fractures. It is also noteworthy that the increase in operations is not only due to a higher degree of classification; also in relative terms, more patients are operated on within type FFP II.