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

Long-Term Follow-Up after Iliosacral Screw Fixation of Unstable Pelvic Ring Fractures

(1) Background: High-energy injuries of the pelvic ring are rare. The wide application of iliosacral screw fixation of the posterior pelvic ring is relatively new. The aim of the present study was to evaluate the long-term quality of life. (2) Methods: All patients treated with an iliosacral screw for a posterior pelvic ring stabilization after high-energy trauma at a level 1 trauma center between 2005 and 2015 were included. Pelvic ring injuries were classified according to the Tile classification adapted by AO/ASIF. The clinical evaluation included the patient-oriented questionnaires surveys of the Majeed Score, Iowa Pelvic Score (IPS), Work Ability Index (WAI), SF-36, EQ5D-5L. (3) Results: A total of 84 patients were included with a median follow-up of 130.1 months (IQR 95.0-162.0 months). The median ISS was 22.5 (IQR 16.0-29.0), mean Majeed Score 83.32 (SD ± 19.26), IPS 77.88 (SD ± 13.96), WAI 32.71 (SD ± 11.31), SF-36 PF 71.25 (SD ± 29.61) and EQ5D-5L 0.83 (SD ± 0.21). There was a notably difference between uni- and bilateral pelvic fractures (p = 0.033) as well as a correlation with the ISS (p = 0.043) with inferior functional outcome measured by IPS. (4) Conclusions: Long-term follow-up of iliosacral screw fixation of unstable pelvic ring fractures showed a good quality of life and functional outcome with equal EQ5D-5L results and inferior SF-36 physical functioning compared to the German population.

Treatment of Anterior Dislocation of the Sacroiliac Joint via the Lateral-rectus Approach: Surgical Techniques and Preliminary Outcomes

OBJECTIVE

Anterior dislocation of the sacroiliac joint (ADSIJ) is caused by strong violence, and because of its low morbidity, there are no standardized diagnostic and therapeutical guidelines at this moment. This study aims to explore the surgical techniques and preliminary outcomes of the lateral-rectus approach (LRA) for treating ADSIJ.

METHODS

A retrospective study was conducted of 15 patients with ADSIJ from January 2016 to January 2021. The patients' age ranged from 1.8 years old to 57 years old (37 ± 18 years old). All patients underwent open reduction and internal fixation (ORIF) through the LRA. Eight patients were combined with lumbosacral plexus injury and underwent neurolysis during operation. Patients' fracture type, mechanism of injury, associated injuries, operation time and intraoperative bleeding volume were accessed by reviewing medical history. Quality of fracture reduction was evaluated with the Matta score. At 1-year follow-up, the functional rehabilitation was evaluated by the Majeed rehabilitation criteria. For those with lumbosacral plexus injury, the neuromotor function was evaluated using muscle strength grading proposed by the British Medical Research Council (BMRC) and recovery was recorded.

RESULTS

All 15 patients underwent the operation successfully. The surgical time ranged from 70 to 220 min (126 ± 42 min), and the intraoperative blood loss ranged from 180 to 2000 mL (816 ± 560 mL). Eighty percent of the cohort (12/15) were rated as excellent and good in the Matta score for fracture reduction quality after operation without surgical incision-related complications. At 1-year follow-up, the overall excellent and good rate was 73.3% (11/15) according to the Majeed criteria, the neuromotor function recovered completely in six cases and partially in two cases according to the BMRC muscle strength grading, and the recovery of sensory function was evaluated as excellent in six cases, good in one case and poor in one case, with an overall excellent and good rate of 87.5%.

CONCLUSION

The LRA can well expose the surrounding structures of the sacroiliac joint from the front, which helps surgeons reduce and fix the anterior dislocation of the sacroiliac joint under direct vision and effectively decompress the entrapment of the lumbosacral plexus to achieve better clinical efficacy.

Epidemiology and socioeconomic consequences of work-related pelvic and acetabular fractures recorded in the German Social Accident Insurance

INTRODUCTION

Pelvic and acetabular fractures can result from work-related accidents and frequently require lengthy medical treatments. Consequently, high medical costs as well as delayed or absent return to work can be the consequence. Therefore, we aimed to study the socioeconomic consequences of work-related pelvic and acetabular fractures.

MATERIALS AND METHODS

This retrospective study investigated work-related pelvic and acetabular fractures recorded in the German Social Accident Insurance in 2011 and 2017, in terms of age, sex, type of accident, duration of incapacity to work, reductions in earning capacity, costs for outpatient and inpatient treatment and costs for pension and severance pay.

RESULTS

Among a total of 606 injuries in 2011 and 619 injuries in 2017, male patients and patients between 40 and 65 years were predominantly affected. Acetabular fractures caused higher rates of long absence from work of 6-12 months (2011: 24.7% vs. 9.5-16.9%; 2017: 26.1% vs. 6.1-11.0%) and >12 months (2011: 15.8% vs. 9.8-10.2%; 2017: 13.3% vs. 1.9-8.2%) as well as more cases with a reduction in earning capacity of at least 20% (2011: 61 vs. ≤27 cases; 2017: 39 vs. ≤12 cases) compared to pelvic ring fractures. The total costs for pelvic ring and acetabular fractures in the German social accident insurances amounted € 18,726,630 and € 9637,189 in the periods 2011-2020 and 2017-2020, respectively. The average costs per case for treatment and rehabilitation until 2020 was € 19,079 for injuries from 2011 and € 13,629 for injuries from 2017. Acetabular fractures were found to be the most cost-intensive injuries compared to anterior, posterior or complex pelvic ring fractures.

CONCLUSIONS

Work-related pelvic and especially acetabular fractures have a considerable socioeconomic impact in the German Social Accident Insurance. Measures to prevent work-related accidents and to improve treatment of pelvic injuries can help to reduce their socioeconomic burden.

Surgical treatment of sacral nonunions

Sacral fractures are complex injuries that follow a bimodal distribution, typically involving acute high energy trauma in young adults and low energy trauma in older adults (> 65 years old). Nonunion is a rare but debilitating potential complication of undiagnosed or improperly managed sacral fractures. Various surgical techniques, including open reduction and internal fixation, sacroplasty, and percutaneous screw fixation, have been used to manage these fracture nonunions. In addition to reviewing the initial management of sacral fractures and the risk factors for fracture nonunion, this article describes techniques, specific cases and outcomes of these treatment strategies.

Value of Direct Decompression of Lumbosacral Roots in Sacral Fractures with Neurologic Deficit: Is It Mandatory?

Background

The value of direct decompression of neural structures to treat lumbosacral plexus injury associated with sacral fractures is still debatable. Direct decompression allows decompression of nerve roots by sacral laminectomy and removal of bone fragments in the spinal canal. In contrast, indirect decompression may offer similar neurological outcomes if good fracture reduction and correction of sacral kyphosis are achieved. In this comparative retrospective study, we analyzed differences between direct and indirect neurological decompression in terms of neurological recovery, complications, and functional outcome.

Methods

This study included 33 cases with spinopelvic dissociation with variable degrees of lumbosacral plexus injury. All cases were managed by spinopelvic fixation. Eighteen patients (group 1) had direct decompression of lumbosacral nerve roots while 15 patients (group 2) had indirect decompression.

Results

Initial sacral kyphosis, quality of fracture reduction, and postoperative residual kyphosis were the main factors that significantly affected functional and neurological outcome in both groups. The final neurological improvement was similar in both groups. No significant difference was observed between both groups in the residual Gibbons' score recorded in the last visit (p = 0.206). The final Majeed score also showed no significant difference between the two groups (p = 0.869).

Conclusions

Indirect decompression of sacral fractures showed similar final functional outcome and neurological recovery compared to direct decompression. Restoration of lumbosacropelvic stability and anatomic reduction seem to be the cornerstone for better functional outcome and neurological recovery rather than direct decompression of neural elements.

Use of calcaneal plates in the treatment of posterior pelvic ring injuries and displaced iliac blade fractures- A case series

Introduction

The operative fixation of pelvic ring injuries and associated acetabulum fractures presents a challenging scenario to most of the orthopaedic trauma surgeons. Current development of anatomically contoured reconstruction (ACR) plates gained popularity in fixing complex pelvic ring fractures. This study was done to assess the functional and radiological outcomes using of lateral wall stainless steel (LWSS) calcaneal plates in posterior pelvic ring injuries and displaced iliac blade fractures.

Materials and methods

Retrospectively selected eight cases of pelvic ring injuries planned for fixing posterior pelvic instability and iliac blade fractures using LWSS plates. Mean follow-up was 18 months (Range 12-26 months).

Results

Average time for radiological bony union achieved in 18 weeks (Range 13-22). Seven patients returned to their normal work. Average Majeed score was 60 (Range 50-68). Mean duration of surgery was 160 min (Range 120-200).

Conclusion

This technique can be routinely used as supplementary fixation for posterior pelvic ring instability and iliac blade fractures. LWSS calcaneal plates showed no screw breakage or implant failure. Further this technique was cost effective in developing countries with limited resources.

Biomechanical study of anterior and posterior pelvic rings using pedicle screw fixation for Tile C1 pelvic fractures: Finite element analysis

Objective

The purpose of this study was to analyse the biomechanical characteristics of pedicle screws with different placement methods and diameters in the treatment of Tile C1 pelvic fractures by finite element simulation technology and to compare them with the plate fixation model to verify the effectiveness of pedicle screw fixation.

Methods

A three-dimensional digital model of a normal pelvis was obtained using computed tomography images. A finite element model of a normal pelvis containing major ligaments was built and validated (Model 1). Based on the verified normal pelvis finite element model, a Tile C1 pelvic fracture model was established (Model 2), and then a plate fixation model (Model 3) and a pedicle screw fixation model with different screw placement methods and diameters were established (Models 4–15). For all pelvic fracture fixation models, a vertical load of 500 N was applied on the upper surface of the sacrum to test the displacement and stress distribution of the pelvis in the standing state with both legs.

Results

The finite element simulation results showed the maximum displacement of Model 1 and Models 3–15 to be less than 1 mm. The overall maximum displacement of Models 4–15 was slightly larger than that of Model 3 (the maximum difference was 177.91×10⁻³ mm), but the maximum displacement of iliac bone and internal fixation in Models 4–15 was smaller than that of Model 3. The overall maximum stress (maximum stress of the ilium) and maximum stress of internal fixation in Models 4–15 were less than those in Model 3. The maximum displacement difference and maximum stress difference at the fracture of the pubic ramus between each fixed model were less than 0.01 mm and 1 MPa, respectively. The greater the diameter and number of pedicle screws were, the smaller the maximum displacement and stress of the pelvic fracture models were.The maximum displacement and stress of the pelvic fracture models of the screws placed on the injured side of the pubic region were smaller than the screws on the healthy side.

Conclusion

Both the anterior and posterior pelvic rings are fixed with a pedicle screw rod system for treatment of Tile C1 pelvic fractures, which can obtain sufficient biomechanical stability and can be used as a suitable alternative to other implants.The greater the diameter and number of pedicle screws were, the greater the pelvic stability was, and the greater was the stability of the screws placed on the injured side of the pubic region than the screws on the healthy side.

Long-term patient reported sexual and urological dysfunction in males after operatively treated pelvic ring injuries Do generic outcome measures identify genitourinary health problems?

BACKGROUND

A consecutive series of 177 male patients, with high energy pelvic ring injuries, were treated operatively in our institution. The purpose of this study was to evaluate long-term sexual and urological dysfunction in these patients using validated disease specific patient reported outcome measures (PROMs), and identify if sexual and urological dysfunction is detectable from generic outcome scores used in the assessment of pelvic ring injury at a minimum of 10 years follow-up (range 10-22).

METHODS

Surviving patients were contacted to complete validated PROMs to examine genitourinary and global functional outcome. Fifty-two male participants, had a mean age of 44-years-old (range,16-69) and ISS of 17 at time of injury. Mean duration follow-up of 15 years. The primary outcome measures were the Sexual Health Inventory for Men (SHIM) and the Modular Questionnaire for Male Lower Urinary Tract Symptoms (MLUTS). Secondary outcomes were the EQ-5D and Short Form 36. Responses were tested for correlation between generic and disease-specific PROMs and analyzed for association with genitourinary injury and age as risk factors of poor outcome.

RESULTS

Genitourinary injuries occurred in 7 patients (13%), and ten patients (19%) had documented neurological dysfunction following injury. Satisfactory general functional outcome was reported with EQ-5D-3L VAS score of 71. However, 80% report some level of sexual dysfunction with 37% reporting it as severe. MLUTS mean symptom score was 9 (range, 0 - 26) and bothersomeness score was 21 (range, 0-90). There was poor correlation between urological and sexual dysfunction scores and between the disease specific and generic scores.

CONCLUSION

In operatively treated pelvic ring injuries, validated disease specific PROMs, (SHIM and MLUTs) identified a significant impact to both sexual and urological patient health, with 37% reporting severe sexual dysfunction. Longstanding sexual and/or urological dysfunction can be a source of significant psychological impact that this study has shown is not identifiable using generic PROMs; EQ-5D-3L and SF-36. To gain a holistic understanding of the functional outcome of patients following a pelvic injury, urological and sexual dysfunction must not be overlooked.

Accuracy of Radiographic Displacement Measurement in a Pelvic Ring Injury Model

BACKGROUND

Pelvic ring injury outcome studies rely on radiographic assessment. To date, no study investigates the accuracy of radiographic measurement. The aim of this study was to assess the accuracy and interobserver reliability of pelvic ring displacement measurement in an injury model. We hypothesize that current radiographic measurement methods do not accurately quantify the three-dimensional pelvic ring displacement.

METHODS

Ten orthopaedic traumatologists evaluated 12 pelvic ring injury model displacements using AP, inlet, and outlet radiographs and axial CT images. Observers completed a survey of demographic and treatment approach strategies. Radiographic displacement measurements in axial, coronal, and sagittal planes were analyzed for accuracy using. Absolute displacement measurements were categorized with Matta and Tornetta grading system for Fleiss Kappa inter-reliability correlation evaluation.

RESULTS

The mean age of orthopaedic traumatologists was 47.5 years (range 36 to 59) with a mean 15.3 years (range 4 to 27) of pelvic fracture surgery experience. Radiographic measurement of isolated uniplanar of pelvic displacement in axial, sagittal, or coronal plane alone was more accurate than multiplanar pelvic displacements with more than one plane of displacement, 6.6 ± 5.7 mm error compared with 9.6 ± 6.3 mm error, respectively (P = 0.0035). Measurement accuracy was greater with isolated coronal plane (4 ± 3.5 mm error) compared with isolated axial plane (9.9 ± 7.1 mm error) or isolated sagittal plane displacement (6.7 ± 4 mm error). Interrater reliability for the radiographic displacement measurement by observers showed an overall poor agreement with 0.24.

CONCLUSION

Radiographic displacement measurement in these modeled pelvic ring injuries has notable inaccuracy among various measurement methods. Coronal and sagittal plane radiographic displacement measurements are more accurate compared with axial plane measurement. The reporting of radiographic displacement measurement outcomes in clinical research studies should be critically evaluated, and standardization of pelvic ring injury displacement may not be achievable with radiography.

LEVEL OF EVIDENCE

Level V.

Postoperative Reduction Quality May Be the Most Important Factor That Causes Worse Functional Outcomes in Open and Closed Pelvic Fractures

Background

Data on the functional outcomes of patients with open pelvic fractures after osteosynthesis are limited, and whether open fracture is a risk factor for worse outcomes, as compared with closed fracture, remains unclear. This study aimed to compare the functional outcomes of patients with open and closed pelvic fractures and evaluate potential factors that might affect outcomes.

Methods

Overall, 19 consecutive patients with open pelvic fractures and 78 patients with closed pelvic fractures between January 2014 and June 2018 were retrospectively reviewed. All fractures were surgically treated, with a minimal follow-up period of three years. Patients’ demographic profile, associated injuries, management protocol, quality of reduction, and outcomes were recorded and analyzed.

Results

Patients with open pelvic fractures had higher new injury severity score, higher incidence of diverting colostomy, and longer length of stay. Both radiological and functional evaluations revealed no significant differences between the two groups at 1-year and 3-year evaluations. Multiple logistic regression analysis identified poor radiological outcomes (using Lefaivre criteria) and longer length of stay as risk factors for worse short-term functional outcomes. At 3-year evaluation, fair-to-poor radiological outcomes (using Matta/Tornetta and Lefaivre criteria) and the presence of diverting colostomy were potential risk factors.

Conclusions

Compared with closed pelvic fracture, open pelvic fracture was not an indicator of worse functional outcomes. Functional outcomes may be comparable between patients with open and closed pelvic fractures at different time points within three years postoperatively. Achieving anatomical reduction in a fracture is crucial, because it might affect patient satisfaction.

Can locking plate fixation of symphyseal disruptions allow early weight bearing?

INTRODUCTION

Anterior pubic symphyseal plate fixation is the recommended treatment for disruption of pubic symphysis in an unstable pelvic ring injury. The rigid construct offered by locking symphyseal plate has the theoretical advantage of allowing patients to weight bear early. However, there are concerns of catastrophic failure about the locked plate construct. The purpose of the study was to establish if locking plate fixation for pubic symphysis disruption was effective to allow patients to mobilise weight bearing immediately after surgery.

PATIENT AND METHODS

Retrospective analysis of a prospectively collected database from a single centre was performed. The study period was from 2008 to 2017. Radiographic evidence of fixation failure, revision surgery, removal of metalwork and follow up duration was noted.

RESULTS

We identified 46 patients (F:M 8:38) with a mean age of 46 years (range 14 to 74 years). Based on the mechanism of injury patients were classified into Antero-posterior compression (28), Vertical shear [10], lateral compression [4] and combined mechanism [4]. Either a 4-hole or 6-hole locking plate was used in all patients, depending on fracture extension. Posterior fixation was required in 28 (61%) patients. All patients were allowed to fully or partial weight bear. The mean radiological follow-up period was 31 weeks with 13 (28%) patients having evidence of radiological failure. Revision was performed in 1 (2%) patient, in whom the screws had pulled out of the bone. The most common mode of failure was either the screw backing out from the plate or broken screw. Among the 4 (8%) patients who had their metalwork removed, 1 (2%) had delayed onset of infection, 2 (4%) had symptoms related to backed out screw and 1 (2%) opted electively to have metalwork removed.

CONCLUSIONS

With our series of patients, we have found that using locking plate for pubic symphyseal diastasis is safe and effective in allowing patients to weight bear early. A low complication rate and need for re-operation is demonstrated.

Can preoperative radiographs predict hardware complication or fracture displacement after operative treatment of pelvic ring injuries?

INTRODUCTION

Operative fixation of pelvic ring injuries is associated with a high risk of hardware failure and loss of reduction. The purpose of this study was to determine whether preoperative radiographs can predict failure after operative treatment of pelvic ring injuries and if the method of fixation effects their risk.

PATIENTS AND METHODS

We conducted a retrospective cohort study of 143 patients with pelvic ring injuries treated with operative fixation at a level 1 trauma center. Preoperative radiographs were examined for the presence of the following characteristics: bilateral rami fractures, segmental or comminuted rami fractures, contralateral anterior and posterior injuries, complete sacral fracture, and displaced inferior ramus fractures. The method of fixation was classified based on the presence of anterior, posterior, or combined anterior and posterior fixation as well as whether or not posterior fixation was performed at a single or multiple sacral levels. Post-operative radiographs were examined for hardware failure or loss of reduction.

RESULTS

Twenty-one patients (14.7%) demonstrated either hardware complication or fracture displacement within 6 months of surgery. Male sex was associated with a decreased risk of hardware complication (OR 0.11 [0.014, 0.86]; p=0.03). Posterior pelvic ring fixation at multiple sacral levels was associated with a decreased risk of fracture displacement (OR 0.21 [0.056, 0.83]; p=0.02). We were unable to demonstrate a significant association between preoperative radiographic characteristics and risk of hardware failure or fracture displacement.

CONCLUSION

Our study demonstrates that both gender and the method of posterior fixation are associated with hardware failure or displacement.

Radiostereometric Analysis Allows Assessment of the Stability and Inducible Displacement of Pelvic Ring Disruptions during Healing: A Case Series

There is currently no accurate data on fracture displacement during the rehabilitation of pelvic ring injuries. This study investigated the use of radiostereometric analysis (RSA) in assessing the stability of C1 pelvic ring injuries stabilised with a posterior plate and an anterior external fixator. Six patients, instructed to weight-bear as tolerated after surgery, were reviewed at 2, 4, 6, 12, 26, 52 and 104 weeks. The external fixators were removed at 6 weeks. Outcomes, including the Iowa Pelvic Score (IPS), and complications were recorded. Fracture stability was assessed using measurements on plain radiographs and RSA. All patients progressed to full weight-bearing without support within 6 weeks. At 104 weeks, the IPS was excellent in four patients, good in one patient and fair in one patient. Plain radiographs showed that all fractures were well reduced, and no loss of reduction occurred over time. By contrast, RSA measurements identified displacement in all cases. The maximum three-dimensional (3D) displacement at any time point in each patient ranged from 2 to 10 mm. Two patients with the largest displacement over time had the lowest IPS. RSA also demonstrated displacements above the currently defined normal threshold through the ‘un-injured’ sacroiliac joint in the same two patients, suggesting a subtle C2 injury, missed at initial assessment. This study demonstrates the limitations of plain radiographs in assessing pelvic fracture stability and displacement during healing, and the potential of RSA to monitor more accurately the effects of stabilisation and weight-bearing on fracture stability.

Vertical shear pelvic ring injuries: do transsacral screws prevent fixation failure?

OBJECTIVES

To determine the frequency of fixation failure after transsacral-transiliac (TS) screw fixation of vertical shear (VS) pelvic ring injuries (OTA/AO 61C1) and to describe the mechanism of failure of TS screws.

DESIGN

Retrospective cohort study.

SETTING

Level 1 academic trauma center.

PATIENTS/PARTICIPANTS

Twenty skeletally mature patients with unilateral, displaced, unequivocal VS injuries were identified between May 1, 2009 and April 31, 2016. Mean age was 31 years and mean follow-up was 14 months. Twelve had sacroiliac dislocations (61C1.2) and eight had vertical sacral fractures (61C1.3).

INTERVENTION

Operative treatment with at least one TS screw.

MAIN OUTCOME MEASUREMENTS

Radiographic failure, defined as a change of >1 cm of combined displacement of the posterior pelvis compared with the intraoperative position on inlet and outlet radiographs.

RESULTS

Radiographic failure occurred in 4 of 8 (50%) vertical sacral fractures. Posterior fixation was comprised of a single TS screw in 3 of these 4 failures. The dominant mechanism of screw failure was bending. All of these failures occurred early in the postoperative period. No fixation failures occurred among the sacroiliac dislocations. There were no deep infections or nonunions.

CONCLUSIONS

This is the first study to describe the mechanism of failure of TS screws in a clinical setting after VS pelvic injuries. We caution surgeons from relying on single TS screw fixation for vertically unstable sacral fractures. Close radiographic monitoring in the first few weeks after surgery is advised.

LEVEL OF EVIDENCE

Level IV.

Part 1: Outcome of Posterior Pelvic Ring Injuries and Associated Prognostic Factors - A Five-Year Retrospective Study of One Hundred and Sixty Five Operated Cases with Closed Reduction and Percutaneous Fixation

PURPOSES

The aim of this study was to evaluate: 1. the outcome of pelvic ring fractures treated by closed reduction and percutaneous fixation, 2. the prognostic factors associated with a poor quality reduction, 3. the prognostic factors associated with ilio-sacral screws misplacement and 4. the prognostic factors associated with nonunion.

METHODS

Data from medical charts for all patients admitted with unstable posterior pelvic ring injuries from 2009 to 2013 were extracted. A total of 165 patients with a mean age of 40 years were included. One hundred and five patients were reviewed at a mean of 32 months of follow-up. The prognostic factors analyzed were clinical and radiological factors. Tile B and Tile C pelvic ring fractures were compared and analyzed separately. Then specific statistical analysis was performed using a logistic regression model to eliminate confusion factors.

RESULTS

An excellent or good clinical result was achieved for 94 patients (90%). An excellent or good reduction was achieved for 141 patients (85%). Nonunion rate, smoking patients, bad reductions, age of patients and ISS score were significantly higher in Tile C group. To eliminate confusion factors we used a multivariate analysis logistic regression model. Only unstable vertical bilateral posterior injuries (Tile C2 and C3) were independent prognostic factors for unsatisfactory reduction (p = 0.001; OR = 4.72; CI 95% [2.08-16.72]). Screw misplacement was recorded for 30 patients (16%) and sacral dysmorphia was an associated prognostic factor (p = 0.0001; OR = 15.6; CI95% [3.41-98.11]). Nonunion was recorded for ten patients (6%) and smoking was an associated prognostic factor (p = 0.01, OR = 5.12; CI95% [1.1-24.1]).

CONCLUSIONS

Posterior pelvic ring fractures treated by closed reduction and percutaneous fixation are associated with excellent/good clinical results if excellent/good reduction and bone healing are achieved without screw misplacement. Bilateral unstable vertical posterior pelvic ring injuries, and sacral dysmorphia are risk factors for bad quality reduction and screw misplacement respectively.

Definitive External Fixation for Anterior Stabilization of Combat-related Pelvic Ring Injuries, With or Without Sacroiliac Fixation

BACKGROUND

Combat-related pelvic ring injuries frequently lead to placement of a temporizing external fixation device for early resuscitation and transport. These injuries are commonly complicated by concomitant polytrauma and extensive soft-tissue injuries, which may preclude early internal fixation and lead to prolonged use of external fixation. To date, few studies have reported on the outcomes of definitive external fixation for combat-related pelvic ring injuries.

QUESTIONS/PURPOSES

(1) In patients treated with definitive external fixation after combat-related pelvic ring injuries, how often is the quality of reduction within radiographically acceptable parameters at the end of treatment? (2) What proportion of patients demonstrate local heterotopic ossification after these injuries? (3) What patient- and treatment-related factors are associated with increased complications and pain?

METHODS

We retrospectively studied all patients with pelvic ring injuries treated at a tertiary military referral center from January 2003 to December 2012. In total, 114 patients were identified, 55 of whom maintained an external fixation frame throughout their treatment. During that time, the general indications for definitive external fixation were an open, contaminated pelvic ring injury with a high risk of infection or open urologic injury; confluent abdominal, perineal, and thigh wounds; or comminution of the pubic ramus that would necessitate plate fixation extending up the anterior column in patients with open abdomen or exposure-compromising abdominal wounds. Posterior fixation, either sacroiliac or lumbopelvic, was applied in patients with sacroiliac instability. Of the 55 patients with pelvic ring injuries treated with definitive external fixation (27 open and 28 closed), four underwent hemipelvectomy and construct removal for massive ascending infections and four were lost to follow-up, leaving 47 patients (85%) who were available at a minimum follow-up of 12 months (median 29 months, interquartile range 17-43 months). All 47 patients underwent serial imaging to assess their injury and reduction during treatment. External fixators were typically removed after 12 weeks, except in patients in whom pin-site irritation or infection prompted earlier removal, and all were confirmed to be grossly stable during an examination under anesthesia. Clinical union was defined as the absence of radiographically present fracture lines and stable examination findings under anesthesia when the external fixator was removed. Data on demographics, injury pattern, associated injuries, revision procedures, complications, and final functional outcomes including ambulation status, sexual function, and pain were collected. Pelvic radiographs were reviewed for the initial injury pattern, type of pelvic fixation construct, residual displacement after removal of the frame, and evidence of formation of heterotopic ossification in the pelvis or bilateral hips. Pelvic displacement and diastasis were determined by digital caliper measurement on plain images; malunion was defined as anterior diastasis of the pelvis or vertical incongruity of the hemipelvis greater than 10 mm.

RESULTS

Radiographic malunion after construct removal occurred in eight of 24 patients with open injuries and in five of 23 patients with closed injuries. Heterotopic ossification developed in the pelvis or hips of all 24 patients with open injuries and in two of the 23 patients with closed injuries. In patients with open pelvic ring injuries, concomitant acetabular fractures were associated with pelvic pain at the final follow-up examination (risk ratio 1.9; 95% confidence interval, 1.0-3.5; p = 0.017). No treatment factor resulted in superior functional outcomes. In the closed-injury group, concomitant lower-extremity amputation was associated with improved radiographic final reduction (RR 0.4; 95% CI, 0.2-0.7; p = 0.02). There was no association between radiographic malunion and increased pain (RR 1.9; 95% CI, 0.5-7.0; p = 0.54 for the open group; RR 0.8; 95% CI, 0.7-1.0; p = 0.86 for the closed group).

CONCLUSION

In this series of patients with severe combat-related pelvic ring injuries who were treated anteriorly with definitive external fixation because of a severe soft-tissue injury, high infection risk, or unacceptable physiologic cost of internal fixation, malunion and chronic pelvic pain were less common than previously observed. Prior studies primarily differ in their lack of sacroiliac or lumbopelvic stabilization for posteriorly unstable fracture patterns, likely accounting for much of these differences. There may have been important between-study differences such as extremely severe injuries, concomitant injuries, and study population. Our study also differs because we specifically analyzed a large cohort of patients who sustained open pelvic ring injuries. Future studies should prospectively investigate the ideal construct type and pin material, optimize the length of treatment and assessment of healing, and improve radiographic measures to predict long-term functional outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Radiological measurement of pelvic fractures using a pelvic deformity measurement software program

BACKGROUND

It is difficult for the surgeon to measure pelvic displacement in the closed reduction operation for unstable pelvic fracture. We therefore developed a pelvic deformity measurement software program based on standardized radiographs. The objectives of the present study were to evaluate the inter-observer reliability of the program for measuring specific fracture types on preoperative pelvic films and to assess the validity of the measurement software program by comparing it with a gold standard.

METHODS

Twenty-five patients diagnosed with AO/OTA type B or C pelvic fractures with the unilateral pelvis fractured and dislocated were included in this study. Four separate observers repeatedly determined the translational and rotational patterns and outcomes using the software program and hand measurement, and calculated the displacement using computed tomography (CT) coupled with a three-dimensional (3D) CT model. The validity of the measurement software was calculated by assessing the consistency between the software measurements and the gold standard. Additionally, inter-observer reliability was assessed for the software. The software was also applied in preliminary clinical practice for closed reduction procedures.

RESULTS

The overall inter-observer reliabilities of the software program, CT coupled with 3D reconstruction, and hand measurements were high, with kappa values of 0.956, 0.958, and 0.853, respectively. The software showed validity similar to that of CT coupled with 3D reconstruction (0.939 vs. 0.969), and better than that of hand measurement (0.939 vs. 0.858). A preliminary clinical application demonstrated that the software is effective for guiding closed reduction of pelvic fractures.

CONCLUSIONS

Our newly established pelvic deformity measurement program is a reliable and accurate tool for analyzing pelvic displacement patterns and can be used for guidance of closed reduction and planning of the reduction pathway.

LEVEL OF EVIDENCE

III.

Regional Injury Classification and Treatment of Open Pelvic Fractures

OBJECTIVES

To propose the regional injury classification of open pelvic fracture and summarize the characteristics of its treatment.

METHODS

Clinical data for 67 open pelvic fractures treated from January 2001 to December 2017 were retrospectively analyzed. There were 48 male and 19 female patients. The patients were aged from 12 to 68 years old, and their pelvic fractures were categorized according to Tile classification (type A: 23 cases; type B: 19 cases; type C: 25 cases). Main injury distribution: pubic perineum, 29 cases; ilioinguinal, 20 cases; and sacroiliac, 7 cases. There were 5 cases of ilioinguinal-perineum and 6 cases of sacroiliac-perineum injury. Based on the region of the injury, the mortality and combined injury of each group were observed. The relationship between regional injury groups and death was examined.

RESULTS

Following active treatment, 28 patients died. The mortality rate was 41.8% (28/67), with 39 patients surviving. The average follow-up time was 6 months (3 months to 1 year after discharge). Majeed pelvic fracture score: the score was excellent in 12 cases, good in 14 cases, fair in 9 cases, and poor in 4 cases; there was an excellent and good rate of 66.7%. Open pelvic fracture regional injury classification includes: the perineal type (type I); the ilioinguinal type (type II); the sacroiliac type (type III); and the composite type (type IV). All types were independent of each other, and the mortality of open pelvic fractures was positively correlated with this classification, with a correlation coefficient of 0.620 (P = 0.001 < 0.05; the difference was statistically significant). In this study, cystourethral injury, anorectal injury, and infection were the main combined injuries of type I. The type II and III injuries were mainly iliac vascular injuries. The main combined injuries of type IV were infection, injury of ilium vessels and its branches. There was a statistical difference among the combined injuries of each subtype (P = 0.001 < 0.05).

CONCLUSIONS

The criteria for regional classification were clear, the mortality of the four subtypes increased gradually, and the incidence of combined injury of each subtype varied. Each subtype had different therapeutic characteristics.

Decision-making, therapy, and outcome in lateral compression fractures of the pelvis - analysis of a single center treatment

Background

Pelvic lateral compression fractures are the most stable of the unstable fractures. Therefore, decision making regarding operative or non-operative therapy is still a matter of debate.

Methods

Factors, influencing decision making for therapy, were explored based on prospectively collected register data of a single Level-1 trauma center. The analysis included epidemiological records such as age and gender, and injury characterizing parameters such as degree of displacement and the Injury Severity Score (ISS). In-hospital mortality and complications served as short-term outcome variables. After matching for relevant confounders, long-term results were compared between operatively and non-operatively treated patients, evaluating the Merle d’Aubigne and the EQ. 5D-3 L scores.

Results

Over an 11-year period (2004–14), 134 patients suffered from lateral compression fractures out of 567 pelvic fractures (33%). After excluding patients with clear indications for operation (complex pelvic fractures and pubic symphysis ruptures) and pediatric fractures, 114 patients could be included in the analysis. Sixty-one patients were treated conservatively (54%), 53 with an operation (46%). The operated patients were younger (43.7 vs 58.3 years), had higher ISS (19.9 vs 15.5 points) and fracture displacements (2.3 vs 4.9 mm) (p < 0.001 for all). The length of hospital stay was shorter in the conservatively treated group (12.7 vs 17.3 days, p < 0.02). Although the types of complications were different, the incidence was not. The mortality was less in the operated group (1.9% vs. 6.6%), however, a logistic regression analysis showed that only the ISS was an independent risk factor, but not the type of therapy. Merle d’Aubigne and EQ. 5D-3 L scores were not different in the matched cohorts.

Conclusion

Decision-making for operative therapy was favored in severely injured young patients with high displacement. However, short- and long-term outcomes showed no difference between operatively and non-operatively treated patients.

Trial registration

DRKS, no. 00000488. Registered 14th July 2010 - Retrospectively registered

Comparative Study of Percutaneous Sacroiliac Screw with or without TiRobot Assistance for Treating Pelvic Posterior Ring Fractures

Objectives

To analyze the curative effect of TiRobot surgical robotic navigation and location system‐assisted percutaneous sacroiliac screw fixation and percutaneous sacroiliac screw by traditional fluoroscopy, and to summarize the safety and benefits of TiRobot.

Methods

A total of 91 patients with pelvic posterior ring fractures from December 2015 to February 2018 were included in this study. According to the surgical methods selected by the patients, the patients were divided into a TiRobot surgical robotic navigation and location system group (TiRobot group) and a percutaneous sacroiliac screw fixation group (traditional group). Statistical indicators included the number of sacroiliac screws, the time of planning the sacroiliac screw path, fluoroscopy frequency, fluoroscopy time, operation time, length of incision, blood loss, anesthesia time, the healing process of skin incisions, and fracture healing time. Fracture reduction was evaluated according to the maximum displacement degree at the inlet and outlet view X‐ray or CT. Matta standard was used to evaluate fracture reduction. At the last follow‐up, the Majeed function system was used to evaluate the function.

Results

All patients were followed up for 8 to 32 months. A total of 66 sacroiliac screws were implanted in the TiRobot group. A total of 43 sacroiliac screws were implanted in the traditional group. There were statistically significant differences in terms of fluoroscopy frequency, fluoroscopy time, operation time, incision length, anesthesia time, and blood loss between the two groups; the TiRobot group was superior to the traditional group. The healing time of the TiRobot group and the traditional group was 4.61 ± 0.68 months (range, 3.5–6.3 months) and 4.56 ± 0.78 months (range, 3.4–6.2 months), respectively, and there was no statistical difference. Postoperatively, by Matta standard, the overall excellent and good rate of fracture reduction was 89.28% and 88.57%, respectively. At the last follow‐up, by Majeed function score, the overall excellent and good rate was 91.07% and 91.43%. There was no statistical difference between the two groups.

Conclusion

Sacroiliac screw implantation assisted by TiRobot to treat the posterior pelvic ring fractures has the characteristics of less trauma, shorter operation time, and less blood loss. TiRobot has the characteristics of high safety and accuracy and has great clinical application value.

Factors associated with gait outcomes in patients with traumatic lumbosacral plexus injuries

PURPOSE

Lumbosacral plexus injuries usually occur in patients with severe, multiple traumas requiring intensive care, affecting gait function. The purpose of the present study was to identify the initial factors associated with gait outcome in lumbosacral plexus injuries caused by traumas.

METHODS

We retrospectively identified 664 patients with pelvic fractures caused by trauma between 2006 and 2017. The lumbosacral plexus injuries were electrodiagnostically confirmed in 30 patients (4.5%). Demographic, injury-related, fracture-related and electrodiagnostic factors were compared between patients with long-term unassisted gait outcomes to those with assisted gait outcomes, with an average of 27 months elapsing after the trauma.

RESULTS

Eleven patients (36.7%) remained in the assisted gait group during the follow-up period. Complex pelvic trauma, rather than the severity of trauma to the entire body, was associated with a poor gait outcome. Among the various causes of injury, pedestrians struck by vehicles were associated with assisted gait outcomes. The number of anatomic locations involved in pelvic fractures, pelvic ring instability by Tile classification, and the proportion of unstable sacral fractures were higher in patients with assisted gait outcomes compared with those having unassisted gait outcomes. Weaknesses in the initial hip extensor, knee flexor, ankle dorsiflexor and ankle plantar flexor were observed significantly more often in patients with assisted gait outcomes. The Dumitru and Wilbourn's scale of the anterior and posterior sacral plexus was significantly higher in the assisted gait group.

CONCLUSIONS

Gait outcome after lumbosacral plexus injury is associated with the range and stability of the pelvic fracture and the severity of the anterior and posterior sacral plexus injury. Poor gait outcome was associated with the severity of the trauma to the pelvis rather than that to the entire body.

Patient Weight-bearing after Pelvic Fracture Surgery-A Systematic Review of the Literature: What is the Modern Evidence Base?

Background

Little attention in the literature appears to have been paid to the issue of postoperative weight-bearing protocols for different injury patterns after pelvic fracture surgery. The primary aim of this study is to review the currently available literature to define the level of available evidence used to inform surgical decisions on weight-bearing after pelvic fracture surgery. Secondary aims are to assess the published methods of fracture classification, surgical management, and assessment or reporting of patient outcomes.

Methods

A systematic review of the English language literature from 1990 to 2016 was undertaken. Eligible papers were all papers reporting minimum 6-month outcomes following surgery for pelvic fractures in adults. Exclusion criteria included pathological fractures or those resulting from penetrating injury, solely osteoporotic fractures, or series with less than 6 months of follow-up data.

Results

There is very little published scientific data to inform the treating surgeon on postoperative weight-bearing protocols after pelvic fracture surgery, with no randomized trials and only 1 paper out of 122 stating this as a primary aim. More than half of the papers published did not state what postoperative protocol was employed. There is no standardization of outcome measures, with less than 20% of papers using the most common validated outcome scoring system; in contrast, there is good agreement on the use of either the Tile (75%) or Burgess and Young (20%) classification.

Limitations

Due to the lack of published studies looking at the topic of postoperative weight-bearing after pelvic fractures, no specific recommendations are possible. As large numbers of papers were included, they were not individually assessed for bias.

Conclusion

A review of postoperative weight-bearing regimes reveals a nonexistent scientific evidence base from which to make recommendations, although a consensus strategy has been identified. Future research needs to be directed at this topic, as has already been the case in numerous other fracture areas, since the advantages of early mobility are potentially significant. The reported methodology for assessing and reporting patient outcomes after pelvic fracture surgery reveals no consistent standards, and the majority of papers use no specific outcome scoring system.

How to cite this article

Rickman M, Link B-C, Solomon LB. Patient Weight-bearing after Pelvic Fracture Surgery-A Systematic Review of the Literature: What is the Modern Evidence Base? Strategies Trauma Limb Reconstr 2019;14(1):45-52.

Functional outcomes in pelvic fractures and the factors affecting them- A short term, prospective observational study at a tertiary care hospital

BACKGROUND

Pelvic fractures are markers of high energy trauma and are associated with significant morbidity and mortality. With evolution of modern diagnostic tools and intervention their management has come a long way.

RESEARCH QUESTION

Whether or not modern healthcare could provide the victims of such high energy trauma with a good functional outcome and optimal quality of life, such that they are able to perform their activities of daily living independently?

OBJECTIVES

To evaluate the functional outcomes in pelvic fractures and to find out factors that could indicate the prognosis.

METHODOLOGY

Ours is a prospective observational study with 75 patients at a tertiary care hospital between September 2015 to December 2016. The minimum duration of follow up was six months. Patients' demographic profile, mode and pattern of injury, associated injuries, management and subsequent complications, if any were recorded prospectively. Functional outcomes were assessed using the Majeed score. All preoperative parameters were correlated statistically with the Majeed score to find out their association.

RESULTS

Majeed scores were excellent in 27 patients, good in 29 patients, fair in 12 patients and poor in 7 patients. Overall functional outcome were good due to availability of sophisticated diagnostic tools, dedicated trauma management team and experienced pelvi-acetabular surgeon. Poorer outcomes were seen in male gender, associated urogenital injuries, associated acetabulum and sacrum fractures, associated nerve injuries and bedsore. No association were seen with age, fracture pattern, treatment modality and timing of surgery.

CONCLUSION

With modern day diagnostic and therapeutic modalities the functional outcome a patient could achieve is promising. With associated risk factors guiding the outcome, the health care provider can individualise the management and decrease the overall morbidity and mortality of such high energy injuries.

Traumatic Spino-pelvic Dissociation with Bilateral Triangular Fixation

OBJECTIVE

To evaluate the clinical outcomes of traumatic spino-pelvic dissociation (TSD) treated with modified bilateral triangular fixation.

METHODS

Eighteen consecutive patients of TSD were included in the study from March 2011 to March 2015, and the medical records of patients were reviewed retrospectively. There were 14 men and 4 women with an average age of 33.1 ± 1.4 years (range, 18-55 years). A total of 16 cases were caused by falling, and 2 cases were caused by traffic accident. All sacral fractures had associated injuries. According to the morphology of sacral fracture, U-shaped fractures were present in 10 cases, H-shaped fractures in 6 cases, and Y-shaped fractures in 2 cases. According to Roy-Camille classification, there were 12 cases of type II and 6 cases of type III. All patients received surgical treatment with modified bilateral triangular fixation, and the sacral plexus decompression was performed simultaneously on 6 cases whose scores were more than 2 according to Gibbons classification and were found having traumatic canal stenosis or sacral nerve compression detected by preoperative imaging examination. Mears' radiological evaluation criterion was applied to evaluate the reduction quality of fractures; Gibbons score was applied as the index of neurological deficiency healing, and the clinical outcome of fracture was evaluated with Majeed function assessment at last follow-up.

RESULTS

All patients were followed up continuously within an average of 32.4 ± 3.6 months (range, 22-48 months). All sacral fractures were healed in an average time of 11.3 ± 2.8 months (range, 8-28 months). According to the Majeed function evaluation, 12 cases were classified as excellent, 4 cases as good, and 2 cases as fair. Meanwhile, the anatomical reduction was obtained in 11 cases, satisfactory reduction in 6 cases, and unsatisfactory reduction in 1 case according to Mears' radiological evaluation criterion. The average Gibbons score changed from 2.5 ± 0.2 preoperatively to 1.4 ± 0.5 24 months postoperatively, which had a significant difference (t = 2.15, P < 0.05).

CONCLUSION

Modified triangular fixation combined with internal fixations shows satisfactory clinical outcomes in the treatment of TSD, which is recommended as an effective and advanced surgical choice.

Fixation Strategy Using Sequential Intraoperative Examination Under Anesthesia for Unstable Lateral Compression Pelvic Ring Injuries Reliably Predicts Union with Minimal Displacement

BACKGROUND

Examination under anesthesia (EUA) has been used to identify pelvic instability. Surgeons may utilize percutaneous methods for posterior and anterior pelvic ring stabilization. We developed an intraoperative strategy whereby posterior fixation is performed, with reassessment using sequential EUA to determine the need for anterior fixation. Our aim in the current study was to evaluate whether this strategy reliably results in union with minimal displacement.

METHODS

This was a multicenter retrospective study involving adult patients with closed lateral compression (LC) pelvic ring injuries treated during the period of 2013 to 2016. Included were patients who underwent percutaneous pelvic fixation based on sequential EUA. Data points included patient demographics, injury and fixation details, and displacement as observed on follow-up radiographs.

RESULTS

Complete documentation was available for 74 patients (mean age, 41 years). The mean duration of follow was 11 months. Fifty-three of the patients had LC-1 injuries, 19 had LC-2 injuries, and 2 had LC-3 injuries. Twenty-five (47.2%) of the 53 patients with LC-1 and 11 (57.9%) of the 19 patients with LC-2 injuries did not undergo anterior fixation on the basis of the algorithm. The 36 LC-1 or LC-2 patients who underwent combined anterior and posterior fixation had no measurable displacement at union. Of the 36 LC-1 or LC-2 patients with no anterior fixation, 27 with unilateral rami fractures had no measurable displacement at union. The remaining 9 LC-1 or LC-2 cases with no anterior fixation had bilateral superior and inferior rami fractures; each of these patients demonstrated displacement (mean, 7.5 mm; range, 5 to 12 mm) within 6 weeks of fixation that remained until union. All patients had protected weight-bearing for 12 weeks.

CONCLUSIONS

A fixation strategy based on sequential intraoperative EUA reliably results in union with minimal displacement for unstable LC pelvic ring injuries. Injuries requiring combined anterior and posterior fixation healed with no displacement. Those without anterior fixation and a unilateral ramus fracture healed with no displacement. In the presence of bilateral rami fractures, even with a negative finding on sequential EUA, the pelvis healed with 7.5 mm average displacement. Surgeons may consider anterior fixation to prevent this displacement.

LEVEL OF EVIDENCE

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

Vertical shear pelvic injury: evaluation, management, and fixation strategies

Vertical shear pelvic ring fractures are rare and account for less than 1% of all fractures. Unlike severely displaced antero-posterior compression and lateral compression pelvic fractures, patients' mortality is lower. Nevertheless, patients must be managed acutely using well-defined ATLS protocols and institution-specific protocols for haemodynamically unstable pelvic ring fractures. The definitive treatment of vertical shear pelvic fractures is however more controversial with a paucity of literature to recommend the ideal reduction and fixation strategy. While the majority of injuries can be reduced and fixed in a closed manner, orthopaedic traumatologists should be familiar with the contraindications to those techniques as well as options such as tension band plating and lumbo pelvic fixation. Our paper reviews the acute management, associated injuries and definitive reduction and fixation strategies of vertical shear pelvic fractures. In addition, we propose a treatment algorithm for the selection of the most appropriate fixation technique.

Early Experience with Reduction of Unstable Pelvic Fracture Using a Computer-Aided Reduction Frame

Purpose

The optimal closed reduction technique for unstable pelvic fractures remains controversial. The purpose of this study is to verify the effectiveness and report early experiences with the reduction of unstable pelvic fractures using a computer-aided pelvic reduction frame.

Methods

From January 2015 to August 2016, a total of 10 patients with unilateral unstable pelvic fractures were included in this study. The surgical reduction procedure was based on the protocol of the computer-aided pelvic reduction frame that we proposed in a previous work. The quality of the reductions achieved using this system was evaluated with residual translational and rotational differences between the actual and virtual reduction positions of pelvis. The duration of the operation was recorded for quality control.

Results

The mean times required to set up the frame, to complete the virtual surgery simulation, and to reduce the unstable pelvic fractures were 10.3, 20.9, and 7.5 min, respectively. The maximum residual translational and rotational displacements were less than 6.5 mm and 3.71 degrees, respectively.

Conclusions

This computer-aided reduction frame can be a useful tool for the speedy and accurate reduction of unstable pelvic fractures. Further clinical studies should be conducted with larger patient samples to verify its safety and efficacy.

Non-anatomic fixation for longstanding traumatic pubic diastasis using a bone graft: A report of two cases

The incidence of internal fixation failure of symphysis diastasis varies from 6% to 75%. Hardware breakage or migration and symphysis disruption recurrence are often asymptomatic and only in a few cases reoperation is required. This report describes the managements of two cases after failed internal fixation and neglected traumatic symphysis diastasis when it was technically impossible to achieve anatomical reduction of the anterior pelvic ring. Internal fixation and a bone graft for the symphysis without anatomical reposition were performed. Both of the patients achieved good results and had no complaints of pain during daily activities. Restoration of the anatomy should not be the aim in treating recurrence of the symphysis diastasis after failed fixation. The aim of the surgery was static fixation of the anterior pelvic ring with bone grafting.

Intraoperative Topical Antibiotics for Infection Prophylaxis in Pelvic and Acetabular Surgery

OBJECTIVES

To determine if topical vancomycin and tobramycin powder reduces the incidence of surgical site infection after pelvic ring and acetabulum fracture surgery.

DESIGN

Retrospective cohort study.

SETTING

University of Alabama at Birmingham, Academic Level I Trauma Center.

PATIENTS/PARTICIPANTS

Two hundred nineteen patients (140 meeting inclusion criteria) with pelvic and acetabular fractures who underwent open reduction and internal fixation from March 2012 to November 2013.

INTERVENTION

One gram vancomycin and 1.2 g tobramycin powder applied deep in the surgical wound of the treatment group.

MAIN OUTCOME MEASUREMENTS

Postoperative infection rate.

RESULTS

One hundred forty patients were included. Control group (n = 69) and treatment group (n = 71) were similar for sex, age, ethnicity, and body mass index. There was no difference between groups with regards to renal function postoperative day 2 (P = 0.24). The risk of infection was 14.5% and 4.2% (P = 0.04) for the control and treatment groups, respectively. No significant effect of antibiotic treatment was observed overall after adjusting for EBL (odds ratio 0.20, 95% confidence interval, 0.02-1.06). Of note, a nonsignificant 71% increase was observed among those with ≥1 L EBL (odds ratio 1.71, 95% confidence interval, 0.02-147.02).

CONCLUSIONS

Topical antibiotics possibly reduce the incidence of surgical site infection after open pelvic and acetabulum fixation without increasing risk of renal impairment. The protective effect of topical antibiotics may be limited to patients with minimal intraoperative blood loss.

LEVEL OF EVIDENCE

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

Three-dimensional reduction and finite element analysis improves the treatment of pelvic malunion reconstructive surgery: A case report

RATIONALE

Pelvic malunion is a rare complication and is technically challenging to correct owing to the complex three-dimensional (3D) geometry of the pelvic girdle. Hence, precise preoperative planning is required to ensure appropriate correction. Reconstructive surgery is generally a 2- or 3-stage procedure, with transiliac osteotomy serving as an alternative to address limb length discrepancy.

PATIENT CONCERNS

A 38-year-old female patient with a Mears type IV pelvic malunion with previous failed reconstructive surgery was admitted to our department due to progressive immobilization, increasing pain especially at the posterior pelvic arch and a leg length discrepancy. The leg discrepancy was approximately 4 cm and rotation of the right hip joint was associated with pain.

DIAGNOSIS

Radiography and computer tomography (CT) revealed a hypertrophic malunion at the site of the previous posterior osteotomy (Mears type IV) involving the anterior and middle column, according to the 3-column concept, as well as malunion of the left anterior arch (Mears type IV).

INTERVENTIONS

The surgery was planned virtually via 3D reconstruction, using the patient's CT, and subsequently performed via transiliac osteotomy and symphysiotomy. Finite element method (FEM) was used to plan the osteotomy and osteosynthesis as to include an estimation of the risk of implant failure.

OUTCOMES

There was not incidence of neurological injury or infection, and the remaining leg length discrepancy was ≤ 2 cm. The patient recovered independent, pain free, mobility. Virtual 3D planning provided a more precise measurement of correction parameters than radiographic-based measurements. FEM analysis identified the highest risk for implant failure at the symphyseal plate osteosynthesis and the parasymphyseal screws. No implant failure was observed.

LESSONS

Transiliac osteotomy, with additional osteotomy or symphysiotomy, was a suitable surgical procedure for the correction of pelvic malunion and provided adequate correction of leg length discrepancy. Virtual 3D planning enabled precise determination of correction parameters, with FEM analysis providing an appropriate method to predict areas of implant failure.

Negative Stress Examination Under Anesthesia Reliably Predicts Pelvic Ring Union Without Displacement

OBJECTIVES

To identify the negative predictive value of examination under anesthesia (EUA) for determining pelvic ring stability and union without further displacement.

DESIGN

Retrospective cohort study.

SETTING

Two academic Level 1 trauma centers.

PATIENTS/PARTICIPANTS

Thirty-four adult patients with closed pelvic ring injuries treated over a 5-year period.

INTERVENTIONS

Pelvic stress EUA.

MAIN OUTCOME MEASURES

Pelvic ring union and pelvic ring displacement at final follow-up.

RESULTS

Thirty-four patients with closed pelvic ring injuries who underwent pelvic EUA during the study period and had a negative examination (indicating a stable pelvis) were identified. Mean age was 38 years (range 16-76), and 19 patients (55.9%) were male. Twenty-two patients (64.7%) had Young-Burgess lateral compression (LC)-1 injuries with complete sacral fractures, 4 patients (11.8%) had LC-2 injuries, and 8 patients (23.5%) had anteroposterior compression (APC)-1 injuries. Eight patients (23.5%) had associated injuries requiring restricted weight-bearing on one or both lower extremities and were excluded from the analysis. Immediate weight-bearing as tolerated was permitted bilaterally in the remaining 26 patients. Mean pelvic ring displacement at the time of injury was 3.8 mm (range 1-15 mm) for LC injuries and 9.1 mm (range 2-20 mm) for APC injuries. Patients were followed for a mean of 8 months (range 3-34 months). At final follow-up, mean displacement was 3.7 mm (range 0-17 mm) for LC injuries and 7.1 mm (range 2-19 mm) for APC injuries. Mean change in displacement from injury to union was -0.1 mm for LC injuries and -2.0 mm for APC injuries, indicating decreased pelvic ring displacement at union. All patients were able to tolerate full weight-bearing bilaterally with no pain, and there were no instances of delayed operative fixation after negative EUA.

CONCLUSIONS

Negative pelvic EUA after closed pelvic ring injury accurately predicts pelvic stability and union without displacement after nonoperative treatment with full weight-bearing bilaterally. Unless otherwise dictated by associated injuries, immediate weight-bearing as tolerated seems safe in patients with pelvic ring injuries who have had a negative EUA.

LEVEL OF EVIDENCE

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

Functional outcome of patients with unstable pelvic ring fracture

The purpose of this study was to evaluate factors that correlated with unsatisfactory short- and long-term outcome in patients who sustained unstable pelvic ring fracture. The study subjects of this study were those of type B and C pelvic ring fractures (82 patients; mean age 54 years). Age, gender, associated injuries, fracture type, Injury Severity Score rating and treatment methods were assessed, and Majeed score for functional outcome and radiographic studies at 1 year after injury (short-term) and at final follow-up (long-term), with mean follow-up of 98 months were analyzed. Significant univariate factors ( p < 0.05) were entered in a multivariate logistic regression model to determine the independent predictors of unsatisfactory functional outcome. Univariate analysis showed that fractures of the lower extremity, nerve damage, conservative treatment, and radiological outcome correlated with unsatisfactory short-term functional outcome, while female gender, brain injury, nerve damage, conservative treatment, fracture location at the posterior portion of pelvic ring, radiological outcome, and pure sacroiliac dislocation only for type C fracture correlated with unsatisfactory long-term outcome. Multiple logistic regression analysis identified fractures of the lower extremity (odds ratio (OR): 5.364), conservative treatment (OR: 13.690), and nerve damage (OR: 21.392) as determinants of unsatisfactory short-term functional outcome and nerve damage (OR: 66.926) and poor radiological results (OR: 33.944) as determinant of long-term functional outcome. In patients with unstable pelvic ring injury, fractures of the lower extremity, conservative therapy, and nerve damage influenced short-term functional outcome, while that nerve damage and the pelvic ring displacement over 20 mm negatively affected long-term outcome.

Open Pelvic Fractures: Review of 30 Cases

BACKGROUND

Open pelvic fractures are rare but usually associated with a high incidence of complications and increased mortality rates. The aim of this study was to retrospectively evaluate all consecutive open pelvic fractures in patients treated at a single Level-1 Trauma Center during a 10-year interval.

PATIENTS AND METHODS

In a 10-year interval, 30 patients with a diagnosis of open pelvic fracture were admitted at a Level-1 Trauma Center. A retrospective analysis was conducted on data obtained from the medical records, which included patient's age, sex, mechanism of injury, classification of the pelvic lesion, Injury Severity Score (ISS), emergency interventions, surgical interventions, length of hospital and Intensive Care Unit stay, and complications, including perioperative complications and death. The Jones classification was used to characterize the energy of the pelvic trauma and the Faringer classification to define the location of the open wound. Among the survivors, the results were assessed in the last outpatient visit using the EuroQol EQ-5D and the Blake questionnaires. It was established the relationship between the mortality and morbidity and these classification systems by using the Mann-Whitney non-parametric test, with a level of significance of 5%.

RESULTS

Twelve (40%) patients died either from the pelvic lesion or related injuries. All of them had an ISS superior to 35. The Jones classification showed a direct relationship to the mortality rate in those patients (p = 0.012). In the 18 (60%) other patients evaluated, the mean follow-up was 16.3 months, ranging from 24 to 112 months. Eleven (61%) patients had a satisfactory outcome. The Jones classification showed a statistically significant relationship both to the objective and subjective outcomes (p < 5%). The Faringer classification showed a statistically significant relationship to the subjective, but not to the objective outcome. In addition, among the 18 patients evaluated at the last outpatient visit, the Faringer classification showed statistical significance on the need of colostomy (p = 0.001) in the acute phase of treatment.

CONCLUSION

We suggest the routine use of the Jones classification for the emergency room assessment and management of all open fractures of the pelvic ring. We believe the Faringer classification seems to be useful for the abdominal surgeons for the indication of gut transit derivation but not for the acute management of the bony component of an open pelvic fracture.

Does Surgical Stabilization of Lateral Compression-type Pelvic Ring Fractures Decrease Patients' Pain, Reduce Narcotic Use, and Improve Mobilization?

BACKGROUND

Debate remains over the role of surgical treatment in minimally displaced lateral compression (Young-Burgess, LC, OTA 61-B1/B2) pelvic ring injuries. Lateral compression type 1 (LC1) injuries are defined by an impaction fracture at the sacrum; type 2 (LC2) are defined by a fracture that extends through the posterior iliac wing at the level of the sacroiliac joint. Some believe that operative stabilization of these fractures limits pain and eases mobilization, but to our knowledge there are few controlled studies on the topic.

QUESTIONS/PURPOSES

(1) Does operative stabilization of LC1 and LC2 pelvic fractures decrease patients' narcotic use and lower their visual analog scale pain scores? (2) Does stabilization allow patients to mobilize earlier with physical therapy?

METHODS

This retrospective study of LC1 and LC2 fractures evaluated patients treated definitively at one institution from 2007 to 2013. All patients treated surgically, all nonoperative LC2, and all nonoperative LC1 fractures with complete sacral injury were included. In general, LC1 or LC2 fractures with greater than 10 mm of displacement and/or sagittal/axial plane deformity on static radiographs were treated surgically. One hundred fifty-eight patients in the LC1 group (107 [of 697 screened] nonoperative, 51 surgical) and 123 patients in the LC2 group (78 nonoperative, 45 surgical) met inclusion criteria. The surgical and nonoperative groups were matched for fracture type. To account for differences between patients treated surgically and nonoperatively, we used propensity modeling techniques incorporating treatment predictors. Propensity scores demonstrated good overlap and were used as part of multiple variable regression models to account for selection bias between the surgically treated and nonoperative groups. Patient-reported pain scores and narcotic administration were tallied in 24-hour increments during the first 24 hours of hospitalization, at 48 hours after intervention, and in the 24 hours before discharge. Time from intervention to mobilization out of bed was recorded; intervention was defined as the date of definitive surgical intervention or the day the surgeon determined the patient would be treated without surgery.

RESULTS

There was no difference in the narcotics distributed to any of the groups with the exception that the patients with surgically treated LC2 fractures used, on average (mean [95% confidence interval]) 40.2 (-72.9 to -7.6) mg morphine less at the 48-hour mark (p = 0.016). In general, there were no differences between the groups' pain scores. The surgically treated patients with LC1 fractures mobilized 1.7 (-3.3 to -0.01) days earlier (p = 0.034) than their nonoperative counterparts. There was no difference in the LC2 cohort in terms of time to mobilization between those treated with and without surgery.

CONCLUSIONS

There were few differences in pain scores and morphine use between the surgical and nonoperative groups, and the differences observed likely were not clinically important. We found no evidence that surgical stabilization of certain LC1 and LC2 pelvic fractures improves patients' pain, decreases their narcotic use, and improves time to mobilization. A randomized trial of patients with similar fractures and similar degrees initial displacement would help remove some of the confounders present in this study.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Computer-aided pelvic reduction frame for anatomical closed reduction of unstable pelvic fractures

Traditional closed reductions of unstable pelvic fractures are mainly performed by surgeons using manual manipulation and subjective verification based on intra-operative roentgenography. It is difficult to perform an accurate closed reduction because of a lack of adequate knowledge of the displacement patterns and an inability to apply the reduction in correct direction. Using the concept of the remote center of motion mechanism and computer-aided design software, we developed a pelvic reduction frame for use in anatomical closed reductions of unstable pelvic fractures. With three-dimensional reconstruction technique and the matrix algorithm, the spatial orientation of the displaced hemipelvis can be calculated and deconstructed into several rotational and translational movements that can be completed with the frame. To verify the accuracy of this system, the rotations were repeated 10 times in arbitrary degrees and directions. After the matrix is calculated, the displaced hemipelvis can be reduced to the anatomical position using our frame. The maximum residual translational and rotational displacements were less than 5 mm and 4 degrees, which indicated the accuracy of this system. The maximum average residual translation and rotation were 1.87 mm in Z-axis (ranging: 4.63-0.1 mm) and 1.1 degrees around Y-axis (ranging: 3.81-0.13 degrees), respectively. Only the Z-axial translation showed a statistically significant difference (p < 0.05). In conclusion, the proposed pelvic reduction frame could be a useful tool for the anatomical reduction of unstable pelvic fractures.

A computer aided measurement method for unstable pelvic fractures based on standardized radiographs

BACKGROUND

To set up a method for measuring radiographic displacement of unstable pelvic ring fractures based on standardized X-ray images and then test its reliability and validity using a software-based measurement technique.

METHODS

Twenty-five patients that were diagnosed as AO/OTA type B or C pelvic fractures with unilateral pelvis fractured and dislocated were eligible for inclusion by a review of medical records in our clinical centre. Based on the input pelvic preoperative CT data, the standardized X-ray images, including inlet, outlet, and anterior-posterior (AP) radiographs, were simulated using Armira software (Visage Imaging GmbH, Berlin, Germany). After representative anatomic landmarks were marked on the standardized X-ray images, the 2-dimensional (2D) coordinates of these points could be revealed in Digimizer software (Model: Mitutoyo Corp., Tokyo, Japan). Subsequently, we developed a formula that indicated the translational and rotational displacement patterns of the injured hemipelvis. Five separate observers calculated the displacement outcomes using the established formula and determined the rotational patterns using a 3D-CT model based on their overall impression. We performed 3D reconstruction of all the fractured pelvises using Mimics (Materialise, Haasrode, Belgium) and determined the translational and rotational displacement using 3-matic suite. The interobserver reliability of the new method was assessed by comparing the continuous measure and categorical outcomes using intraclass correlation coefficient (ICC) and kappa statistic, respectively.

RESULT

The interobserver reliability of the new method for translational and rotational measurement was high, with both ICCs above 0.9. Rotational outcome assessed by the new method was the same as that concluded by 3-matic software. The agreement for rotational outcome among orthopaedic surgeons based on overall impression was poor (kappa statistic, 0.250 to 0.426). Compared with the 3D reconstruction outcome, the interobserver reliability of the formula method for translational and rotational measures was perfect with both ICCs more than 0.9.

CONCLUSIONS

The new method for measuring displacement using a formula was reliable, and could minimise the measurement errors and maximise the precision of pelvic fracture description. Furthermore, this study was useful for standardising the operative plan and establishing a theoretical basis for robot-assisted pelvic fracture surgery based on 2-D radiographs.

Nonunions and malunions of the pelvis

INTRODUCTION

Neglected pelvic fractures manifesting as pelvic nonunion or malunion are usually due to inadequate initial fixation or negligence of the injury because of increased attention towards other associated life-threatening conditions. The management of such injuries is complex. A systematic review was conducted to spot the clinical manifestations, evaluation, management and outcome of pelvic nonunion and malunion.

MATERIALS AND METHODS

Two databases ("Pubmed" and "Google scholar") were searched to look for relevant literature on pelvic non-union and malunion.  The search was limited to 'English language' and 'Human being'.

RESULTS

A total of 500 articles found, of which 10 articles were only reviewed which met the inclusion criteria. These articles discussed the clinical management and treatment of pelvic malunion and non-union following trauma without associated acetabular injury.

CONCLUSION

The usual presentations of pelvic non-union and malunion are pain, deformity, gait abnormality or instability. A detailed preoperative evaluation is essential as a majority of them have associated hip and spine injury which may be the cause of symptoms. Radiographs and 3D CT scans have helped surgeons in deciding the best way of management. The surgeries are usually complex and may need multiple-staged procedures. Soft tissue release, multiple osteotomies to achieve anatomical or near-anatomical reduction, augmentation of healing process using bone graft and stabilizing the nonunion/ osteotomy site using plates/screws/rods is the basic principle of surgery. Per-operative use of somato-sensory evoked potential evaluation helps the surgeon in preventing iatrogenic nerve injury. Despite these precautions and surgeries, most of the patients do not regain their preinjury functional activity.

Treatment of pelvic fractures through a less invasive ilioinguinal approach combined with a minimally invasive posterior approach

BACKGROUND

Unstable pelvic fractures usually result from high-energy trauma. There are several treatment modalities available. The purpose of this study was to evaluate the clinical application of a new less invasive ilioinguinal approach combined with a minimally invasive posterior approach technique in patients with unstable pelvic fractures. We also address the feasibility, validity, and limitations of the technique.

METHODS

Thirty-seven patients with unstable pelvic fractures were treated with our minimally invasive technique. The anterior pelvic ring fractures were treated with a less invasive ilioinguinal approach, and the sacral fractures were treated with a minimally invasive posterior approach. The clinical outcome was measured using the Majeed scoring system, and the quality of fracture reduction was evaluated. The patients were followed up for 13 to 60 months (mean, 24 months).

RESULTS

Anatomical or near to anatomical reduction was achieved in 26 (70.3 %) of the anterior pelvic ring fractures and a satisfactory result was obtained in another 11(29.7 %). For the posterior sacral fractures, excellent reduction was obtained in 33 (89.2 %) of the fractures, with a residual deformity in the other 4 patients. One superficial wound infection and two deep vein thromboses occurred, all of which resolved with conservative treatment. The clinical outcome at one year was "excellent" in 29 patients and "good" in 8 patients (Majeed score).

CONCLUSIONS

The satisfactory results showed that a reduction and fixation of unstable pelvic fractures is possible through a combination of a limited ilioinguinal approach and posterior pelvic ring fixation. We believe our method is a new and effective alternative in the management of pelvic fractures.

Outcome of Surgical Treatment of AO Type C Pelvic Ring Injury

Purpose

To evaluate the radiologic and clinical outcomes of AO type C pelvic ring injury and identify the prognostic factors.

Materials and Methods

We studied 53 patients who were treated for AO type C pelvic ring injury from January 2002 to February 2010. Mean age and mean follow-up duration were 42.4 years and 14 months, respectively. We had 8 cases of AO type C1-1, 19 cases of C1-2, 11 cases of C1-3, 6 cases of C2 and 9 cases of C3 injury. We analyzed type of fracture, displacement, method of fixation and associated injuries. Radiologic outcome was evaluated with Matta and Saucedo criteria and clinical outcome was evaluated using Majeed score.

Results

The average Majeed score was 86.2 distributing as 36 excellent cases, 15 good cases and 2 fair cases. Using radiologic Matta and Saucedo criteria, patients were divided as 31 excellent cases, 17 good cases and 5 fair cases. There was no significant difference between the outcomes of anterior, posterior and antero-posterior fixation. Neurologic injury was the reason for an unsatisfactory functional outcome. We identified two cases with complication, one with postoperative infection and the other with nonunion following anterior-posterior fixation.

Conclusion

Satisfactory radiologic and clinical outcomes were obtained with open reduction and internal fixation in the management of AO type C pelvic ring injuries. Neurologic injuries affected the clinical outcome.

Factors associated with outcome of spinopelvic dissociation treated with lumbopelvic fixation

Spinopelvic dissociation is a rare high-energy injury, which is frequently associated with lumbosacral plexus and cauda equina deficits. During an 18-year period, 36 consecutive patients with a H-type sacral fracture and spinopelvic dissociation were treated using lumbopelvic fixation with a minimum follow-up of 18 months. We evaluated factors prognostic of outcome after standardised surgical fixation and neural decompression. Neurological recovery was assessed by Gibbons’ criteria. Pelvis Outcome Scale (POS clinical score) was used to evaluate the clinical outcome. Despite excellent or good radiological results in the vertical components of the sacral fractures having been achieved in all patients, 15 patients (42%) had a poor clinical outcome. The degree of initial translational displacement in the transverse sacral fracture was significantly associated with neurological recovery (as defined by a change in Gibbons score) (p = 0.038) and final POS clinical score (p < 0.001). Both neurological recovery and clinical outcome were worse in patients with completely displaced fractures than in patients with a partially displaced sacral fracture. The degree of residual translational displacement and kyphosis in the transverse sacral fracture were also associated with clinical outcome (POS clinical score) (p = 0.011 and p = 0,018, respectively). However, Roy-Camille classification (type 2 vs. type 3), age, gender, ISS, timing of surgery, and sacral laminectomy did not have a statistically significant association with the outcome. Based on the results, Roy-Camille sacral fracture classification (type 2 vs. type 3) was not prognostic of neurological impairment. Thus further categorisation of the transverse sacral fractures as partially displaced or completely displaced could be used to predict the rate of neurological recovery following lumbopelvic fixation. Accurate reduction of all sacral fracture components seems to be associated with better clinical outcome.

Radiological findings correlate with neurological deficits but not with pain after operatively treated sacral fractures

BACKGROUND AND PURPOSE

Neurological deficits and pain are common after displaced sacral fractures. However, little is known about the association between the long-term clinical outcomes and radiological findings. We examined the long-term radiological findings and their correlations with lumbosacral pain and neurological deficits in the lower extremities after surgery for sacral fractures.

METHODS

28 consecutive patients with operatively treated displaced sacral fractures were followed for mean 11 (8-13) years. Sensorimotor impairments of the lower extremities were classified according to the American Spinal Injury Association (ASIA). Pain was assessed using a visual analog scale (VAS). All patients underwent conventional radiographic examination and CT, and the images were scrutinized for nonunion, residual displacement, narrowing of the sacral foramina, and post-foraminal encroachment of the L5 and S1 nerves.

RESULTS

There was residual displacement of ≥ 10 mm in 16 of the 28 patients. 26 patients had narrowing of 1 or more neural root foramina in L5-S4. 8 patients reported having no pain, 11 had pain only in the lumbosacral area, and 9 had pain in combination with radiating leg pain. Statistically significant correlations were found between narrowing of the sacral foramina and neurological deficits in the corresponding dermatomes. Significant correlations were also found between post-foraminal encroachment of L5 nerves and both sensory and motor deficits. No correlations were found between pain and radiological findings.

INTERPRETATION

Pathological radiological findings are common 11 years after operatively treated displaced sacral fractures. Sacral foraminal and L5 post-foraminal bony encroachments were common findings and correlated with neurological deficits. However, lumbosacral pain did not correlate with radiological sequelae after fracture healing.