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Madsen JE, Flugsrud GB, Hammer N, Puchwein P. Emergency treatment of pelvic ring injuries: state of the art. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05447-7. [PMID: 38970673 DOI: 10.1007/s00402-024-05447-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Accepted: 06/29/2024] [Indexed: 07/08/2024]
Abstract
High energy pelvic injuries sustain significant mortality rates, due to acute exsanguination and severe associated injuries. Managing the hemodynamically unstable trauma patient with a bleeding pelvic fracture still forms a major challenge in acute trauma care. Various approaches have been applied through the last decades. At present the concept of Damage Control Resuscitation (DCR) is universally accepted and applied in major trauma centers internationally. DCR combines hemostatic blood transfusions to restore blood volume and physiologic stability, reduced crystalloid fluid administration, permissive hypotension, and immediate hemorrhage control by operative or angiographic means. Different detailed algorithms and orders of hemostatic procedures exist, without clear consensus or guidelines, depending on local traditions and institutional setups. Fracture reduction and immediate stabilization with a binder constitute the basis for angiography and embolization (AE) or pelvic packing (PP) in the hemodynamically unstable patient. AE is time consuming and may not be available 24/7, whereas PP offers a quick and technically easy procedure well suited for the patient in extremis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has also been described as a valuable adjunct in hemostatic non-responders, but merely constitute a bridge to surgical or angiographic hemostasis and its definitive role in DCR is not yet clearly established. A swift algorithmic approach to the hemodynamically unstable pelvic injury patient is required to achieve optimum results. The present paper summarizes the available literature on the acute management of the bleeding pelvic trauma patient, with emphasis on initial assessment and damage control resuscitation including surgical and angiographic hemostatic procedures. Furthermore, initial treatment of open fractures and associated injuries to the nervous and genitourinary system is outlined.
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Affiliation(s)
- Jan Erik Madsen
- Division of Orthopaedic Surgery, Oslo University Hospital, Kirkeveien 166, 0450, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Klaus Torgårds Vei 3, 0372, Oslo, Norway.
| | | | - Niels Hammer
- Division of Macroscopic and Clinical Anatomy Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
- Department of Orthopaedic and Trauma Surgery, University of Leipzig, Leipzig, Germany
- Division of Medical Technology, Fraunhofer Institute for Machine Tools and Forming Technology (Fraunhofer IWU), Dresden, Germany
| | - Paul Puchwein
- Department of Orthopaedic and Trauma Surgery, University of Leipzig, Leipzig, Germany
- Division of Medical Technology, Fraunhofer Institute for Machine Tools and Forming Technology (Fraunhofer IWU), Dresden, Germany
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
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Rovere G, De Mauro D, Smakaj A, Sassara G, De Vitis R, Farsetti P, Camarda L, Maccauro G, Liuzza F. Triangular osteosynthesis and lumbopelvic fixation as a valid surgical treatment in posterior pelvic ring lesions: a systematic review. Front Surg 2024; 11:1266393. [PMID: 38456170 PMCID: PMC10917920 DOI: 10.3389/fsurg.2024.1266393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 02/07/2024] [Indexed: 03/09/2024] Open
Abstract
Objective Unstable fractures of the sacrum often occur in patients with pelvic fractures and represent a real challenge for the orthopedic surgeon. Triangular osteosynthesis (TOS) and lumbopelvic fixation (LP) may represent a valid management option for the treatment of this condition. We present a systematic literature review about lumbopelvic fixation and triangular fixation as treatment option for unstable sacral fractures, to assess clinical and radiological outcomes after surgery and to evaluate appropriate indications and impact on the natural history of sacral fractures. Methods The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 50 articles out of 108 titles, were considered eligible for the full-text analysis. Finally, 16 studies that met inclusion criteria were included in this review. Results Overall, 212 patients (87 males, 58 females) with sacral fractures treated with TOS triangular fixation or LP lumbopelvic fixation were collected. The mean age was 37.6 years. Mean follow-up reported in all studies was 24.14 months. Conclusion The results presented by the different authors, highlight the effectiveness of TOS triangular fixation and LP lumbopelvic fixation for the treatment of unstable sacral fractures associated with other pelvic fractures, in terms of function, stability, cost-effectiveness, and quality of life postoperatively.
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Affiliation(s)
- Giuseppe Rovere
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Domenico De Mauro
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Amarildo Smakaj
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulia Sassara
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rocco De Vitis
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Pasquale Farsetti
- Department of Clinical Science and Translational Medicine, Section of Orthopaedics and Traumatology, University of Rome “Tor Vergata”, Rome, Italy
| | - Lawrence Camarda
- Department of Orthopaedic Surgery (DICHIRONS), University of Palermo, Palermo, Italy
| | - Giulio Maccauro
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Liuzza
- Department of Orthopaedics and Traumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
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Karamian BA, Schroeder GD, Lambrechts MJ, Canseco JA, Vialle EN, Rajasekaran S, Benneker LM, Dvorak MR, Kandziora F, Oner C, Schnake K, Kepler CK, Vaccaro AR. The Influence of Regional Differences on the Reliability of the AO Spine Sacral Injury Classification System. Global Spine J 2023; 13:2025-2032. [PMID: 35000410 PMCID: PMC10556908 DOI: 10.1177/21925682211068419] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Global cross-sectional survey. OBJECTIVE To explore the influence of geographic region on the AO Spine Sacral Classification System. METHODS A total of 158 AO Spine and AO Trauma members from 6 AO world regions (Africa, Asia, Europe, Latin and South America, Middle East, and North America) participated in a live webinar to assess the reliability, reproducibility, and accuracy of classifying sacral fractures using the AO Spine Sacral Classification System. This evaluation was performed with 26 cases presented in randomized order on 2 occasions 3 weeks apart. RESULTS A total of 8320 case assessments were performed. All regions demonstrated excellent intraobserver reproducibility for fracture morphology. Respondents from Europe (k = .80) and North America (k = .86) achieved excellent reproducibility for fracture subtype while respondents from all other regions displayed substantial reproducibility. All regions demonstrated at minimum substantial interobserver reliability for fracture morphology and subtype. Each region demonstrated >90% accuracy in classifying fracture morphology and >80% accuracy in fracture subtype compared to the gold standard. Type C morphology (p2 = .0000) and A3 (p1 = .0280), B2 (p1 = .0015), C0 (p1 = .0085), and C2 (p1 =.0016, p2 =.0000) subtypes showed significant regional disparity in classification accuracy (p1 = Assessment 1, p2 = Assessment 2). Respondents from Asia (except in A3) and the combined group of North, Latin, and South America had accuracy percentages below the combined mean, whereas respondents from Europe consistently scored above the mean. CONCLUSIONS In a global validation study of the AO Spine Sacral Classification System, substantial reliability of both fracture morphology and subtype classification was found across all geographic regions.
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Affiliation(s)
- Brian A. Karamian
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Jose A. Canseco
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - AO Spine Sacral Classification Group Members
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
- Spine Surgery Group, Department of Orthopaedics, Cajuru University Hospital, Catholic University of Parana, Curitaba, Brazil
- Department of Orthopedics and Spine Surgery, Ganga Hospital, Coimbatore, India
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
- Division of Spine, University of British Columbia
- Unfallklinik Frankfurt am Main, Frankfurt, Germany
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, Netherlands
- Center for Spinal Surgery, Schön Klinik Nürnberg Fürth, Fürth, Germany
| | - Emiliano N. Vialle
- Spine Surgery Group, Department of Orthopaedics, Cajuru University Hospital, Catholic University of Parana, Curitaba, Brazil
| | | | - Lorin M. Benneker
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, Netherlands
| | - Klaus Schnake
- Center for Spinal Surgery, Schön Klinik Nürnberg Fürth, Fürth, Germany
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Elliott IS, Kleweno C, Agel J, Coale M, Patterson JT, Firoozabadi R, Githens M, Johnsen NV. Erectile dysfunction after acetabular fracture. OTA Int 2023; 6:e276. [PMID: 37214108 PMCID: PMC10194699 DOI: 10.1097/oi9.0000000000000276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 03/25/2023] [Indexed: 05/24/2023]
Abstract
Objectives To determine the rate of erectile dysfunction in male patients who have sustained an acetabular fracture with no previously identified urogenital injury. Design Cross-sectional survey. Setting Level 1 Trauma Center. Patients/Participants All male patients treated for acetabular fracture without urogenital injury. Intervention The International Index of Erectile Function (IIEF), a validated patient-reported outcome measure for male sexual function, was administered to all patients. Main Outcome Measurements Patients were asked to complete the International Index of Erectile Function score for both preinjury and current sexual function, and the erectile function (EF) domain was used to quantify the degree of erectile dysfunction. Fractures were classified according the OTA/AO classification schema, fracture classification, injury severity score, race, and treatment details, including surgical approach were collected from the database. Results Ninety-two men with acetabular fractures without previously diagnosed urogenital injury responded to the survey at a minimum of 12 months and an average of 43 ± 21 months postinjury. The mean age was 53 ± 15 years. 39.8% of patients developed moderate-to-severe erectile dysfunction after injury. The mean EF domain score decreased 5.02 ± 1.73 points, which is greater than the minimum clinically important difference of 4. Increased injury severity score and associated fracture pattern were predictive of decreased EF score. Conclusion Patients with acetabular fractures have an increased rate of erectile dysfunction at intermediate-term follow-up. The orthopaedic trauma surgeon treating these injuries should be aware of this as a potential associated injury, ask their patients about their function, and make appropriate referrals. Level of Evidence III.
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Affiliation(s)
- Iain S. Elliott
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Seattle, WA
| | - Conor Kleweno
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Seattle, WA
| | - Julie Agel
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Seattle, WA
| | - Max Coale
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Seattle, WA
| | - Joseph T. Patterson
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Seattle, WA
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA; and
| | - Reza Firoozabadi
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Seattle, WA
| | - Michael Githens
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Seattle, WA
| | - Niels V. Johnsen
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, Seattle, WA
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
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Kweh BTS, Tee JW, Oner FC, Schnake KJ, Vialle EN, Kanziora F, Rajasekaran S, Dvorak M, Chapman JR, Benneker LM, Schroeder G, Vaccaro AR. Evolution of the AO Spine Sacral and Pelvic Classification System: a systematic review. J Neurosurg Spine 2022; 37:914-926. [PMID: 35907199 DOI: 10.3171/2022.5.spine211468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 05/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The purpose of this study was to describe the genesis of the AO Spine Sacral and Pelvic Classification System in the context of historical sacral and pelvic grading systems. METHODS A systematic search of MEDLINE, EMBASE, Google Scholar, and Cochrane databases was performed consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all existing sacral and pelvic fracture classification systems. RESULTS A total of 49 articles were included in this review, comprising 23 pelvic classification systems and 17 sacral grading schemes. The AO Spine Sacral and Pelvic Classification System represents both the evolutionary product of these historical systems and a reinvention of classic concepts in 5 ways. First, the classification introduces fracture types in a graduated order of biomechanical stability while also taking into consideration the neurological status of patients. Second, the traditional belief that Denis central zone III fractures have the highest rate of neurological deficit is not supported because this subgroup often includes a broad spectrum of injuries ranging from a benign sagittally oriented undisplaced fracture to an unstable "U-type" fracture. Third, the 1990 Isler lumbosacral system is adopted in its original format to divide injuries based on their likelihood of affecting posterior pelvic or spinopelvic stability. Fourth, new discrete fracture subtypes are introduced and the importance of bilateral injuries is acknowledged. Last, this is the first integrated sacral and pelvic classification to date. CONCLUSIONS The AO Spine Sacral and Pelvic Classification is a universally applicable system that redefines and reorders historical fracture morphologies into a rational hierarchy. This is the first classification to simultaneously address the biomechanical stability of the posterior pelvic complex and spinopelvic stability, while also taking into consideration neurological status. Further high-quality controlled trials are required prior to the inclusion of this novel classification within a validated scoring system to guide the management of sacral and pelvic injuries.
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Affiliation(s)
- Barry Ting Sheen Kweh
- 1National Trauma Research Institute, Melbourne.,2Department of Neurosurgery, The Alfred Hospital, Melbourne.,3Department of Neurosurgery, Royal Melbourne Hospital, Parkville
| | - Jin W Tee
- 1National Trauma Research Institute, Melbourne.,2Department of Neurosurgery, The Alfred Hospital, Melbourne.,4Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - F Cumhur Oner
- 5Department of Orthopaedics, University Medical Center Utrecht, The Netherlands
| | - Klaus J Schnake
- 6Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen.,7Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Germany
| | | | - Frank Kanziora
- 9Spinal Surgery and Neurotraumatology Centre, BG Trauma Clinic Frankfurt, Frankfurt am Main, Germany
| | | | - Marcel Dvorak
- 11Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jens R Chapman
- 12Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington
| | | | - Gregory Schroeder
- 14The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexander R Vaccaro
- 14The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Abstract
CT is often performed as part of a whole-body protocol in the setting of polytrauma and is the standard of care for diagnosing and characterizing sacral fractures. These fractures are not uncommon, occurring in conjunction with pelvic ring disruption in approximately 40%-50% of patients. Knowledge of basic functional anatomy and fracture biomechanics is important in understanding sacral fracture patterns, which only rarely result from direct impact. More often, sacral fractures result from an indirect mechanism with fracture lines that propagate along relative lines of weakness, leading to predictable fracture patterns. Each fracture pattern has implications with respect to neurologic injury, spinopelvic stability, management, and potential complications. The authors explore the Denis, Roy-Camille, Isler, Robles, Sabiston-Wing, and shape-based classification systems for sacral fractures. These form the basis of the subsequently discussed unified AOSpine sacral fracture classification, a consensus system developed by spine and orthopedic surgeons as a means of improving and standardizing communication. The AOSpine sacral fracture classification also includes clinical designations for neurologic status and patient-specific modifiers. When a patient is unexaminable owing to obtundation or sedation, CT is an invaluable indirect marker of nerve compression or traction injury. It also plays an important role in visualizing and characterizing the type and extent of any associated soft-tissue injuries that may warrant a delay in surgery or an alternative operative approach. ©RSNA, 2022.
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Affiliation(s)
- David Dreizin
- From the Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201
| | - Elana B Smith
- From the Department of Diagnostic Radiology and Nuclear Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 655 W Baltimore St, Baltimore, MD 21201
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Vereecke E, Herregods N, Morbée L, Laloo F, Chen M, Jans L. Imaging of Structural Abnormalities of the Sacrum: The Old Faithful and Newly Emerging Techniques. Semin Musculoskelet Radiol 2022; 26:469-477. [PMID: 36103888 DOI: 10.1055/s-0042-1754342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
The sacrum and sacroiliac joints pose a long-standing challenge for adequate imaging because of their complex anatomical form, oblique orientation, and posterior location in the pelvis, making them subject to superimposition. The sacrum and sacroiliac joints are composed of multiple diverse tissues, further complicating their imaging. Varying imaging techniques are suited to evaluate the sacrum, each with its specific clinical indications, benefits, and drawbacks. New techniques continue to be developed and validated, such as dual-energy computed tomography (CT) and new magnetic resonance imaging (MRI) sequences, for example susceptibility-weighted imaging. Ongoing development of artificial intelligence, such as algorithms allowing reconstruction of MRI-based synthetic CT images, promises even more clinical imaging options.
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Affiliation(s)
- Elke Vereecke
- Department of Radiology, Ghent University Hospital, Gent, Belgium
| | - Nele Herregods
- Department of Radiology, Ghent University Hospital, Gent, Belgium
| | - Lieve Morbée
- Department of Radiology, Ghent University Hospital, Gent, Belgium
| | - Frederiek Laloo
- Department of Radiology, Ghent University Hospital, Gent, Belgium
| | - Min Chen
- Department of Radiology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Lennart Jans
- Department of Radiology, Ghent University Hospital, Gent, Belgium
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Epidemiology and aetiology of male and female sexual dysfunctions related to pelvic ring injuries: a systematic review. INTERNATIONAL ORTHOPAEDICS 2021; 45:2687-2697. [PMID: 34378143 PMCID: PMC8514382 DOI: 10.1007/s00264-021-05153-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/17/2021] [Indexed: 11/05/2022]
Abstract
Introduction Pelvic ring injuries, frequently caused by high energy trauma, are associated with high rates of morbidity and mortality (5–33%), often due to significant blood loss and disruption of the lumbosacral plexus, genitourinary system, and gastrointestinal system. The aim of the present study is to perform a systematic literature review on male and female sexual dysfunctions related to traumatic lesions of the pelvic ring. Methods Scopus, Cochrane Library MEDLINE via PubMed, and Embase were searched using the keywords: “Pelvic fracture,” “Pelvic Ring Fracture,” “Pelvic Ring Trauma,” “Pelvic Ring injury,” “Sexual dysfunction,” “Erectile dysfunction,” “dyspareunia,” and their MeSH terms in any possible combination. The following questions were formulated according to the PICO (population (P), intervention (I), comparison (C), and outcome (O)) scheme: Do patients suffering from pelvic fracture (P) report worse clinical outcomes (C), in terms of sexual function (O), when urological injury occurs (I)? Is the sexual function (O) influenced by the type of fracture (I)? Results After screening 268 articles by title and abstract, 77 were considered eligible for the full-text analysis. Finally 17 studies that met inclusion criteria were included in the review. Overall, 1364 patients (902 males and 462 females, M/F ratio: 1.9) suffering from pelvic fractures were collected. Discussion Pelvic fractures represent challenging entities, often concomitant with systemic injuries and subsequent morbidity. Anatomical consideration, etiology, correlation between sexual dysfunction and genitourinary lesions, or pelvic fracture type were investigated. Conclusion There are evidences in the literature that the gravity and frequency of SD are related with the pelvic ring fracture type. In fact, patients with APC, VS (according Young-Burgess), or C (according Tile) fracture pattern reported higher incidence and gravity of SD. Only a week association could be found between GUI and incidence and gravity of SD, and relationship between surgical treatment and SD. Electrophysiological tests should be routinely used in patient suffering from SD after pelvic ring injuries.
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Walton AB, Leinwand GZ, Raheem O, Hellstrom WJG, Brandes SB, Benson CR. Female Sexual Dysfunction After Pelvic Fracture: A Comprehensive Review of the Literature. J Sex Med 2021; 18:467-473. [PMID: 33593705 DOI: 10.1016/j.jsxm.2020.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 12/16/2020] [Accepted: 12/25/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Female sexual dysfunction (FSD) after pelvic fracture (PFx) has garnered little attention in the urology literature. AIM To review and summarize the current evidence regarding female PFx-related sexual function. METHODS We performed a systematic review in accordance with PRISMA guidelines, including PubMed, EMBASE, and MEDLINE. We included only English-language manuscripts and abstracts with sufficient data for inclusion. We used the search terms "female sexual dysfunction AND pelvic fracture," "sexual dysfunction AND pelvic fracture," and "female pelvic fracture AND sexual dysfunction." A total of 177 articles were identified; 41 abstracts were reviewed; of which, 19 manuscripts were reviewed. Fifteen met inclusion criteria for analysis. OUTCOMES The main outcome measures of this study are rates and types of female sexual dysfunction after pelvic fracture. RESULTS FSD is prevalent after PFx, with reported rates between 25% and 62%. Three studies used the validated Female Sexual Function Index. The other 12 used non-validated questionnaires or adapted quality-of-life questionnaires with specific questions regarding FSD. The most common complaints include difficulty with intercourse, dyspareunia, orgasmic dysfunction, genitourinary pain, decreased interest in intercourse, decreased satisfaction with intercourse, and pelvic floor dysfunction. Only 1 study addressed resolution of dysfunction (30 of 98 patients [30.4%]). CLINICAL IMPLICATIONS FSD is prevalent and an under-recognized sequela of pelvic fracture. This requires future prospective study to better characterize sexual dysfunction and identify effective treatments in trauma survivors. STRENGTH AND LIMITATIONS To Increase awareness of FSD after pelvic trauma and the impact on the quality of life in trauma survivors. The current literature is limited by a lack of standardized assessment of FSD, limited follow-up, and minimal discussion of treatment options, in addition to the inherent bias of retrospective studies. CONCLUSIONS FSD after traumatic PFx is not uncommon, occurs mostly in young women, and can be morbid. FSD after PFx is underreported in the urology literature. Thus, all female PFx patients should be screened for FSD by validated questionnaires. The published literature offers little knowledge as to the epidemiology, evaluation, definition, and potential treatments of FSD after PFx. Prospective studies are needed to better understand female sexual function in trauma survivors and the potential methods for prevention and rehabilitation, all within the context of a multidisciplinary approach. Walton AB, Leinwand GZ, Raheem O, et al. Female Sexual Dysfunction After Pelvic Fracture: A Comprehensive Review of the Literature. J Sex Med 2021;18:467-473.
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Affiliation(s)
- Alice B Walton
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Gabriel Z Leinwand
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Omer Raheem
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Wayne J G Hellstrom
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Steven B Brandes
- Columbia University Medical Center, Department of Urology, New York, NY, USA
| | - Cooper R Benson
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA.
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Anterior supra-acetabular external fixation for tile C1 pelvic fractures: a digital anatomical study and a finite element analysis. Eur J Trauma Emerg Surg 2020; 47:1679-1686. [PMID: 33029659 DOI: 10.1007/s00068-020-01517-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/26/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Investigating the anatomical characteristics of supra-acetabular screw corridor as well as comparing the biomechanical stability between semi- and full-length screw external fixations for Tile C1 pelvic fractures. METHODS 50 male and 50 female uninjured pelvic CT data were converted into three-dimensional models and the supra-acetabular corridors were reconstructed by the Mimics software. The horizontal slice was redefined passing through the bilateral anterior inferior iliac spine and bilateral posterior superior iliac spine at the same time. On every horizontal slices, a 5 mm diameter virtual screw was placed along with the unilateral anterior narrowing to posterior narrowing of the supra-acetabular corridor, and the relevant parameters of the semi- and full-length screw fixations were measured from inferior to superior at an interval height of 2.5 mm until the width of the corridor was less than 5 mm. Thus, the insertion position was located, as well as the inclination angle ranges were measured. The same procedure was done on a bilateral supra-acetabular corridor for each patient. Last, a Tile C1 pelvic finite element model was simulated and fixed with either semi- or a full-length anterior supra-acetabular external fixator. A 500 N loading was tested on the model with three directions (cranial-caudal, anterior-posterior and lateral-medial) and the stiffness was determined by the max displacements. RESULTS The insertion points of supra-acetabular screw for 66% (66/100) of men and 78% (78/100) of women were located at the outer lower part of the anterior inferior iliac spine (AIIS) (p < 0.001). The medial inclination angles of the screw were 29.50 ± 4.05° for men and 28.00 ± 3.78° for women (p = 0.007). The cranial inclination angles of the screw were 29.40 ± 5.38° for men and 28.57 ± 6.01° for women (p = 0.306). The safe inclination angle ranges of the semi-length screw were 3°-6° bigger than the full-length screw. For semi-length corridor, the widths were 14.07 ± 2.39 mm for men and 11.29 ± 1.81 mm for women (p < 0.001) and the depths were 71.77 ± 5.96 mm for men and 69.26 ± 5.21 mm for women (p < 0.001). For full-length corridor, the widths were 10.61 ± 2.10 mm for men and 8.44 ± 2.03 mm for women (p < 0.001) and the depths were 133.37 ± 7.60 mm for men and 129.01 ± 8.12 mm for women (p < 0.001). In the finite element analysis, the max displacements of the pelvis under three loading modes (cranial-caudal, anterior-posterior and lateral-medial) for semi-length fixation were 0.772 mm, 0.409 mm and 0.331 mm and for full-length fixation were 0.727 mm, 0.385 mm and 0.262 mm. CONCLUSION The outer lower part of AIIS is recommended as an insertion point of the supra-acetabular screw with about 30° medial and cranial inclination angles, and the semi-length screw is safer for placing and has satisfactory biomechanical stability by compared with a full-length screw.
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Vaccaro AR, Schroeder GD, Divi SN, Kepler CK, Kleweno CP, Krieg JC, Wilson JR, Holstein JH, Kurd MF, Firoozabadi R, Vialle LR, Oner FC, Kandziora F, Chapman JR, Schnake KJ, Benneker LM, Dvorak MF, Rajasekaran S, Vialle EN, Joaquim AF, El-Sharkawi MM, Dhakal GR, Popescu EC, Kanna RM, Muijs S, Tee JW, Bellabarba C. Description and Reliability of the AOSpine Sacral Classification System. J Bone Joint Surg Am 2020; 102:1454-1463. [PMID: 32816418 PMCID: PMC7508295 DOI: 10.2106/jbjs.19.01153] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Several classification systems exist for sacral fractures; however, these systems are primarily descriptive, are not uniformly used, have not been validated, and have not been associated with a treatment algorithm or prognosis. The goal of the present study was to demonstrate the reliability of the AOSpine Sacral Classification System among a group of international spine and trauma surgeons. METHODS A total of 38 sacral fractures were reviewed independently by 18 surgeons selected from an expert panel of AOSpine and AOTrauma members. Each case was graded by each surgeon on 2 separate occasions, 4 weeks apart. Intrarater reproducibility and interrater agreement were analyzed with use of the kappa statistic (κ) for fracture severity (i.e., A, B, and C) and fracture subtype (e.g., A1, A2, and A3). RESULTS Seventeen reviewers were included in the final analysis, and a total of 1,292 assessments were performed (646 assessments performed twice). Overall intrarater reproducibility was excellent (κ = 0.83) for fracture severity and substantial (κ = 0.71) for all fracture subtypes. When comparing fracture severity, overall interrater agreement was substantial (κ = 0.75), with the highest agreement for type-A fractures (κ = 0.95) and the lowest for type-C fractures (κ = 0.70). Overall interrater agreement was moderate (κ = 0.58) when comparing fracture subtype, with the highest agreement seen for A2 subtypes (κ = 0.81) and the lowest for A1 subtypes (κ = 0.20). CONCLUSIONS To our knowledge, the present study is the first to describe the reliability of the AOSpine Sacral Classification System among a worldwide group of expert spine and trauma surgeons, with substantial to excellent intrarater reproducibility and moderate to substantial interrater agreement for the majority of fracture subtypes. These results suggest that this classification system can be reliably applied to sacral injuries, providing an important step toward standardization of treatment.
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Affiliation(s)
- Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gregory D. Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Srikanth N. Divi
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania,Email address for S.N. Divi:
| | - Christopher K. Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Conor P. Kleweno
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
| | - James C. Krieg
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jörg H. Holstein
- Department of Orthopaedic Surgery, Saarland University Medical Center, Homburg, Germany
| | - Mark F. Kurd
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Reza Firoozabadi
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Luiz R. Vialle
- Department of Orthopaedics, Catholic University of Parana, Curitiba, Brazil
| | | | - Frank Kandziora
- Center for Spine Surgery and Neurotraumatology, BG Unfallklinik Frankfurt am Main, Frankfurt, Germany
| | - Jens R. Chapman
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington
| | - Klaus J. Schnake
- Center for Spine and Scoliosis Surgery, Schön Klinik Nürnberg Fürth, Fürth, Germany
| | - Lorin M. Benneker
- Spine Unit, Department of Orthopaedic Surgery and Traumatology, Insel Hospital and Bern University Hospital, Bern, Switzerland
| | - Marcel F. Dvorak
- Department of Orthopaedics, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Emiliano N. Vialle
- Department of Orthopaedics, Catholic University of Parana, Curitiba, Brazil
| | - Andrei F. Joaquim
- Neurosurgery Division, Department of Neurology, State University of Campinas, Campinas-Sao Paulo, Brazil
| | | | | | | | - Rishi M. Kanna
- Department of Orthopaedics, Trauma, and Spine Surgery, Ganga Hospital, Coimbatore, India
| | - S.P.J. Muijs
- University Medical Center, Utrecht, the Netherlands
| | - Jin W. Tee
- Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Carlo Bellabarba
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
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Pelvic Fractures and Associated Genitourinary and Vascular Injuries: A Multisystem Review of Pelvic Trauma. AJR Am J Roentgenol 2019; 213:1297-1306. [DOI: 10.2214/ajr.18.21050] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
OBJECTIVES To evaluate unilateral sacral fractures and compare those treated operatively versus nonoperatively to determine indications for surgery. DESIGN Prospective, multicenter, observational study. SETTING Sixteen trauma centers. PATIENTS/PARTICIPANTS Skeletally mature patients with pelvic ring injury and unilateral zone 1 or 2 sacral fractures and without anteroposterior compression injuries. MAIN OUTCOME MEASUREMENTS Injury plain anteroposterior, inlet, and outlet radiographs and computed tomography scans of the pelvis were evaluated for fracture displacement. RESULTS Three hundred thirty-three patients with unilateral sacral fractures and a mean age of 41 years with a mean Injury Severity Score of 15 were included. Ninety-two percent sustained lateral compression injuries, and 63% of all fractures were in zone 1. Thirty-three percent of patients were treated operatively, including all without lateral compression patterns. Operative patients were more likely to have zone 2 fractures (54%) and to have posterior cortical displacement (29% vs. 6.2%), both with P < 0.001. Over 60% of all patients had no posterior displacement. Mean rotational displacements comparing the injured side versus the intact side were no different for patients treated operatively compared with those treated nonoperatively. CONCLUSIONS Most unilateral sacral fractures are minimally or nondisplaced. Many patients with radiographically similar fractures were treated operatively and nonoperatively by different surgeons. This suggests an opportunity to develop consistent indications for treatment. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Bagheri H, Govsa F. Anatomical considerations of safe drilling corridor upper sacral segment screw insertion. J Orthop 2019; 16:543-551. [PMID: 31660021 PMCID: PMC6806658 DOI: 10.1016/j.jor.2019.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 04/15/2019] [Indexed: 10/26/2022] Open
Abstract
The upper segment of sacrum is an important for screw insertions of unstable lumbosacral spine. Measurements of the S1-S2 as sacral wings, pedicles, sacral foraminas and sacral canal were taken from 87 sacrums. The mean depths of S1 pedicle and sacral wing were estimated as 25.8 ± 2.3 mm and 50.1 ± 1.7 mm, respectively. Angles screw trajectory of sacral pedicle anteromedial and sacral wing were measured as 29.6 ± 0.9° and 29.7 ± 2.1°, respectively. To avoid injury to the vascular structures anteriorly and nerve roots medially, depth and angle of screw trajectory is important for the entrance off pedicular screw placement to the S1.
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Affiliation(s)
| | - Figen Govsa
- Department of Anatomy Digital Imaging and 3D Modelling Laboratory, Faculty of Medicine, Ege University, Izmir, Turkey
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Johnsen NV, Lang J, Wessells H, Vavilala MS, Rivara FP, Hagedorn JC. Barriers to Care of Sexual Health Concerns in Men Following Traumatic Pelvic Fractures. J Sex Med 2019; 16:1557-1566. [PMID: 31447382 DOI: 10.1016/j.jsxm.2019.07.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Traumatic pelvic fractures are associated with sexual dysfunction in men. However, how men are counseled and access care for sexual health following injury remains unknown. AIM The purpose of this study was to identify factors associated with accessing and obtaining care for sexual health concerns following traumatic pelvic fracture in men. METHODS Men treated for traumatic pelvic fractures at a level 1 trauma center were invited to participate in an online cross-sectional survey. The survey addressed multiple demographic and sexual function domains, as well as the postinjury sexual health care experience. De novo sexual dysfunction following injury was ascertained and reasons for not seeking care examined. Inverse probability weighting was utilized to adjust for nonresponse. Multivariable logistic regression was performed to identify factors associated with discussion of sexual health with providers after injury. OUTCOMES The primary outcome was discussion of sexual health with health care providers after injury. Secondary outcomes included prevalence of self-reported sexual dysfunction, classification of sexual dysfunction experienced, and perceived barriers to accessing or obtaining care for sexual health concerns. RESULTS 277 men completed the survey. After adjustment, 46.3% (95% CI = 39.4%-53.0%) reported de novo sexual dysfunction after injury, with erectile dysfunction the most common symptom (27.9%). Only 20.4% (95% CI = 15.1%-26.0%) recalled having discussions or being asked about their sexual health following injury, and of these conversations 70.7% were patient-initiated. The most common perceived barriers to discussing sexual health with providers were the belief that sexual dysfunction would resolve with time (26.1%), and a lack of knowledge about their condition and treatment options (21.5%). On multivariate analysis, the presence of postinjury sexual dysfunction (adjusted odds ratio [aOR] = 3.42), private insurance (aOR = 2.17), and being married or in a partnership (aOR = 3.10) were independently associated with likelihood of having had sexual health discussions. CLINICAL IMPLICATIONS Despite the high prevalence of sexual dysfunction in men following pelvic trauma, sexual health concerns are inadequately addressed due to both patient and provider factors. STRENGTHS & LIMITATIONS The major strengths include large sample size, detailed reporting of subject experience, and new information in a previously understudied area of pelvic trauma survivorship. The primary limitations are low survey response rate, lack of representativeness of survey participants to whole pelvic fracture cohort, single-center experience, and cross-sectional study design. CONCLUSION Sexual health concerns after pelvic fracture are common but inadequately addressed by health care providers. Improved postinjury, survivorship-model care pathways need to be designed to better address sexual health after injury. Johnsen NV, Lang J, Wessells H, et al. Barriers to Care of Sexual Health Concerns in Men Following Traumatic Pelvic Fractures. J Sex Med 2019;16:1557-1566.
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Affiliation(s)
- Niels V Johnsen
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA.
| | - Jonathan Lang
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA
| | - Hunter Wessells
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Frederick P Rivara
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Judith C Hagedorn
- Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA; Department of Urology, University of Washington, Seattle, WA, USA
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Factors associated with gait outcomes in patients with traumatic lumbosacral plexus injuries. Eur J Trauma Emerg Surg 2019; 46:1437-1444. [PMID: 31011759 DOI: 10.1007/s00068-019-01137-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 04/17/2019] [Indexed: 10/27/2022]
Abstract
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.
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Rickman M, Link BC, 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; 14:45-52. [PMID: 32559267 PMCID: PMC7001596 DOI: 10.5005/jp-journals-10080-1414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
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.
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Affiliation(s)
- Mark Rickman
- Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
| | - Bjorn-Christian Link
- Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
| | - Lucian B Solomon
- Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
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O’Neill N, VanWagner M, Vitale C. Midline Longitudinal Sacral Fracture in an Anterior-Posterior Compression Pelvic Injury -A Surgical Decision-making and Outcome. J Orthop Case Rep 2019; 9:64-68. [PMID: 31534938 PMCID: PMC6727463 DOI: 10.13107/jocr.2250-0685.1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Anterior-posterior compression pelvic injuries occur from high-energy blunt trauma and can result in devastating outcomes. Often, widening of the pubic symphysis occurs with subsequent disruption of posterior pelvic ligamentous structures. Associated sacral fractures may increase the likelihood of neurologic injury and pelvic ring instability. The most common sacral fracture in this injury is an avulsion fracture of the sacral ala. Midline longitudinal sacral fractures into the spinal canal are an extremely rare variant of sacral injuries in conjunction with pelvic trauma. In contrast to traditional anterior-posterior pelvic ring injuries, those associated with this unique fracture type carry a decreased risk of neurologic injury. Only a small number of these cases exist in English literature. Given its rarity, further, investigation of the fracture mechanism and treatment protocol is warranted. CASE REPORT A 67-year-old Caucasian male presented with an anterior-posterior compression pelvic ring injury after he was struck by an oncoming vehicle on his motorcycle. Radiographs revealed pubic symphyseal widening of 4.7 cm. A pelvic binder was placed as a temporary measure to minimize intrapelvic hemorrhage. Advanced imaging revealed a complete, midline sagittal sacral fracture through the posterior sacral elements. During his hospital admission, the patient required multiple procedures for sustained upper extremity fractures and subsequently underwent surgical fixation of his anterior and posterior pelvic ring injuries 2 days after admission. Our patient to date has achieved sacral fracture union, minimal residual pubic diastasis, and has no evidence of neurologic injury. He has some persistent impotence and is ambulating without assistance. Despite his significant injuries, his outcome to date has been quite impressive. CONCLUSION It is critical to always examine the posterior pelvis and sacrum when examining anterior-posterior compression injuries. While most cases have reported fixation of only the anterior pelvis, we explain the need for additional posterior pelvic fixation to address the inherent instability of these unique sacral fractures and ultimately decrease patient morbidity. The surgical fixation technique of this patient's pelvic injuries is described, as well as his post-operative course and outcome to date.
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Affiliation(s)
- Nicholas O’Neill
- Department of Orthopedic Surgery, McLaren Macomb Regional Medical Center, Graduate Medical Education, Michigan State University, 1000 Harrington St. Mount Clemens, MI, Michigan, USA
| | - Michael VanWagner
- Department of Orthopedic Surgery, McLaren Macomb Regional Medical Center, Graduate Medical Education, Michigan State University, 1000 Harrington St. Mount Clemens, MI, Michigan, USA
| | - Christopher Vitale
- Department of Orthopedic Surgery, McLaren Macomb Regional Medical Center, Graduate Medical Education, Michigan State University, 1000 Harrington St. Mount Clemens, MI, Michigan, USA
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Rodrigues-Pinto R, Kurd MF, Schroeder GD, Kepler CK, Krieg JC, Holstein JH, Bellabarba C, Firoozabadi R, Oner FC, Kandziora F, Dvorak MF, Kleweno CP, Vialle LR, Rajasekaran S, Schnake KJ, Vaccaro AR. Sacral Fractures and Associated Injuries. Global Spine J 2017; 7:609-616. [PMID: 28989838 PMCID: PMC5624377 DOI: 10.1177/2192568217701097] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Literature review. OBJECTIVE The aim of this review is to describe the injuries associated with sacral fractures and to analyze their impact on patient outcome. METHODS A comprehensive narrative review of the literature was performed to identify the injuries associated with sacral fractures. RESULTS Sacral fractures are uncommon injuries that result from high-energy trauma, and that, due to their rarity, are frequently underdiagnosed and mistreated. Only 5% of sacral fractures occur in isolation. Injuries most often associated with sacral fractures include neurologic injuries (present in up to 50% of sacral fractures), pelvic ring disruptions, hip and lumbar spine fractures, active pelvic/ abdominal bleeding and the presence of an open fracture or significant soft tissue injury. Diagnosis of pelvic ring fractures and fractures extending to the lumbar spine are key factors for the appropriate management of sacral fractures. Importantly, associated systemic (cranial, thoracic, and abdominopelvic) or musculoskeletal injuries should be promptly assessed and addressed. These associated injuries often dictate the management and eventual outcome of sacral fractures and, therefore, any treatment algorithm should take them into consideration. CONCLUSIONS Sacral fractures are complex in nature and often associated with other often-missed injuries. This review summarizes the most relevant associated injuries in sacral fractures and discusses on their appropriate management.
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Affiliation(s)
- Ricardo Rodrigues-Pinto
- Centro Hospitalar do Porto, Hospital de Santo António, Porto, Portugal
,Ricardo Rodrigues-Pinto, Department of Orthopaedics, Centro Hospitalar do Porto, Hospital de Santo António, Largo Prof. Abel Salazar, Porto 4099-001, Portugal.
| | - Mark F. Kurd
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - James C. Krieg
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jörg H. Holstein
- Institute for Clinical & Experimental Surgery, University of Saarland, Homburg/Saar, Germany
| | - Carlo Bellabarba
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | - Reza Firoozabadi
- Harborview Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Frank Kandziora
- Berufsgenossenschaftliche Unfallklinik Frankfurt, Center for Spinal Surgery and Neurotraumatology, Frankfurt am Main, Germany
| | - Marcel F. Dvorak
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Conor P. Kleweno
- R. Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Luiz R. Vialle
- Cajuru University Hospital, Catholic University of Parana, Curitiba, Brazil
| | | | - Klause J. Schnake
- Schön Klinik Nürnberg Fürth, Center for Spinal Surgery, Fürth, Germany
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Vijayan S, Basani V, Naik M, Rao SK. Longitudinal Midline Sacral Split Fracture - A Rare Entity. BMJ Case Rep 2017; 2017:bcr-2017-220397. [PMID: 28756379 DOI: 10.1136/bcr-2017-220397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Fractures involving the central canal of the sacrum are rare injuries and can be transverse or longitudinal. Transverse fractures are by far common and associated with high incidence of neurological injuries. On the contrary, longitudinal midline split fracture is an extremely rare injury with minimal or no neurological injury. They are always associated with anterior pelvic ring fracture and are vertically stable needing only fixation of the anterior pelvic injury. Plating of the anterior pelvic ring in two planes would be beneficial than single plate to prevent gradual loss of reduction.
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Affiliation(s)
- Sandeep Vijayan
- Department of Orthopaedics, Kasturba Medical College, Manipal University, Manipal - Udupi, Karnataka, India
| | - Viksheth Basani
- Department of Orthopaedics, Kasturba Medical College, Manipal University, Manipal - Udupi, Karnataka, India
| | - Monappa Naik
- Department of Orthopaedics, Kasturba Medical College, Manipal University, Manipal - Udupi, Karnataka, India
| | - Sharath Kumar Rao
- Department of Orthopaedics, Kasturba Medical College, Manipal University, Manipal - Udupi, Karnataka, India
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Beckmann NM, Chinapuvvula NR. Sacral fractures: classification and management. Emerg Radiol 2017; 24:605-617. [DOI: 10.1007/s10140-017-1533-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 06/19/2017] [Indexed: 12/16/2022]
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A Method of Using a Pelvic C-Clamp for Intraoperative Reduction of a Zone 3 Sacral Fracture. Case Rep Orthop 2017; 2016:8586517. [PMID: 28101390 PMCID: PMC5214600 DOI: 10.1155/2016/8586517] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 12/06/2016] [Indexed: 12/16/2022] Open
Abstract
It is challenging to properly reduce pelvic ring injuries that involve a zone 3 sacral fracture. Several open and closed reduction methods have been described. Percutaneous reductions are challenging, and improper reductions can have poor long-term outcomes. The pelvic C-clamp is a tool designed to provide emergency stabilization to patients suffering from c-type pelvic ring injuries. We describe a case in which a patient's open book pelvic ring injury with a zone three sacral fracture is reduced intraoperatively with the use of a pelvic C-clamp and stabilized with transsacral screws.
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Nambiar M, Heaton SR, Stevenson AJ, Bucknill AT. Prominent metalware from pelvic surgery causing dyspareunia. BMJ Case Rep 2017; 2017:bcr2016217285. [PMID: 28062423 PMCID: PMC5256533 DOI: 10.1136/bcr-2016-217285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 11/04/2022] Open
Abstract
We present a case of female dyspareunia secondary to metalware placement during extensive pelvic surgery following a motor vehicle accident. The patient initially had an uneventful recovery from her operations. However, she noticed pain with vaginal intercourse, due to a screw tip which was palpable on vaginal examination. X-ray imaging confirmed long screws in the medial part of an anterior column plate, which were impacting on the anterior vaginal wall. Subsequent percutaneous removal of two screws resulted in resolution of her symptoms of painful vaginal intercourse. While the pain from mechanical irritation of the vagina was resolved, the patient continues to have difficulty with intercourse, which is related to hip pain as a result of her initial injury and complex pelvic surgery.
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Affiliation(s)
- Mithun Nambiar
- Department of Orthopaedic Surgery, The Royal MelbourneHospital, Parkville, Victoria, Australia
| | - Samuel Raymond Heaton
- Department of Orthopaedic Surgery, The Royal MelbourneHospital, Parkville, Victoria, Australia
| | - Andrew John Stevenson
- Department of Orthopaedic Surgery, The Royal MelbourneHospital, Parkville, Victoria, Australia
| | - Andrew Thomas Bucknill
- Department of Orthopaedic Surgery, The Royal MelbourneHospital, Parkville, Victoria, Australia
- Department of Surgery (RMH), The University of Melbourne, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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CT characteristics of traumatic sacral fractures in association with pelvic ring injuries: correlation using the Young-Burgess classification system. Emerg Radiol 2016; 24:255-262. [DOI: 10.1007/s10140-016-1476-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 12/15/2016] [Indexed: 10/20/2022]
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Schroeder GD, Kurd MF, Kepler CK, Krieg JC, Wilson JR, Kleweno CP, Firoozabadi R, Bellabarba C, Kandizoria F, Schnake KJ, Rajesekaran S, Dvorak MF, Chapman JR, Vialle LR, Oner FC, Vaccaro AR. The Development of a Universally Accepted Sacral Fracture Classification: A Survey of AOSpine and AOTrauma Members. Global Spine J 2016; 6:686-694. [PMID: 27781189 PMCID: PMC5077717 DOI: 10.1055/s-0036-1580611] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 01/25/2016] [Indexed: 11/29/2022] Open
Abstract
Study Design Survey study. Objective To determine the global perspective on controversial aspects of sacral fracture classifications. Methods While developing the AOSpine Sacral Injury Classification System, a survey was sent to all members of AOSpine and AOTrauma. The survey asked four yes-or-no questions to help determine the best way to handle controversial aspects of sacral fractures in future classifications. Chi-square tests were initially used to compare surgeons' answers to the four key questions of the survey, and then the data was modeled through multivariable logistic regression analysis. Results A total of 474 surgeons answered all questions in the survey. Overall 86.9% of respondents felt that the proposed hierarchical nature of injuries was appropriate, and 77.8% of respondents agreed that that the risk of neurologic injury is highest in a vertical fracture through the foramen. Almost 80% of respondents felt that the separation of injuries based on the integrity of L5-S1 facet was appropriate, and 83.8% of surgeons agreed that a nondisplaced sacral U fracture is a clinically relevant entity. Conclusion This study determines the global perspective on controversial areas in the injury patterns of sacral fractures and demonstrates that the development of a comprehensive and universally accepted sacral classification is possible.
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Affiliation(s)
- Gregory D. Schroeder
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Mark F. Kurd
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Christopher K. Kepler
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - James C. Krieg
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Jefferson R. Wilson
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Conor P. Kleweno
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, United States
| | - Reza Firoozabadi
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, United States
| | - Carlo Bellabarba
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, United States
| | - Frank Kandizoria
- Berufsgenossenschaftliche Unfallklinik Frankfurt, Center for Spinal Surgery and Neurotraumatology, Frankfurt/Main, Germany
| | - Klause J. Schnake
- Schön Klinik Nürnberg Fürth, Center for Spinal Surgery, Fürth, Germany
| | - S. Rajesekaran
- Department of Orthopaedic Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Marcel F. Dvorak
- Department of Orthopaedic Surgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jens R. Chapman
- Department of Orthopaedic Surgery, The Swedish Neuroscience Institute, Seattle, Washington, United States
| | - Luiz R. Vialle
- Department of Orthopaedic Surgery, Catholic University, Curitiba, Brazil
| | - F. C. Oner
- Department of Orthopaedic Surgery, University Medical Center, Utrecht, The Netherlands
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
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Radiographic displacement in pelvic ring disruption: reliability of 3 previously described measurement techniques. J Orthop Trauma 2014; 28:160-6. [PMID: 23760181 DOI: 10.1097/bot.0b013e31829efcc5] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The literature on pelvic ring disruptions is based largely on nonstandardized and nonvalidated radiographic outcomes. A thorough review of the literature revealed only 3 described methods for measuring radiographic displacement and 1 frequently used grading system for displacement. We aimed to test the reliability of these previously published radiographic measurement methods and grading system. METHODS Five separate observers measured radiographic displacement on the standardized pre- and postoperative anteroposterior, inlet, and outlet views of 25 patients with surgically treated Tile B and C pelvic fractures. The readers measured their initial impression based on the Tornetta and Matta grading system (excellent, good, fair, and poor). Next, they measured displacement using the inlet and outlet ratio as described by Sagi, the cross measurement technique as described by Keshishyan, and the absolute displacement method (ADM) as described by Lefaivre. The millimeter measurement obtained by the ADM was converted using the Tornetta and Matta grading system. Each continuous measure was compared for interobserver reliability using intraclass correlations (ICCs), and the categorical outcomes were compared using a kappa statistic. Finally, the relationship of the initial impression to the grade as determined by the ADM was compared using kappa agreement. RESULTS The agreement among observers based on initial impression was poor (kappa statistic, 0.306) but was fair among those reductions that were excellent (κ = 0.495). Using the Sagi method, the reliability ICC was moderate for the postoperative inlet [0.515, 95% confidence interval (CI), 0.338-0.702] and outlet ratio (0.594, 95% CI, 0.423-0.760) but almost perfect in preoperative radiographs (inlet: 0.814, 95% CI, 0.703-0.901; outlet: 0.863, 95% CI, 0.775-0.929). The ICCs for all interpretations of the Keshishyan technique were excellent but were highest when considered as a ratio (preoperative: 0.938, 95% CI, 0.894-0.969; postoperative: 0.912, 95% CI, 0.850-0.955). Using the ADM, the location and film used for measurement had poor agreement, and the ICC for the measurement in millimeters was moderate (preoperative: 0.522, 95% CI, 0.342-0.708; postoperative: 0.432, 95% CI, 0.255-0.634) and the kappa agreement poor when converted using the Tornetta and Matta scale (κ = 0.2190). The agreement between the impression and the converted grade from the ADM was poor (κ = 0.2520). CONCLUSIONS Radiographic measurement in pelvic x-rays to date has been nonvalidated, and we found the interobserver reliability on common methods, including overall impression and absolute displacement in millimeters, to be poor. The inlet/outlet ratio as described by Sagi was reliable only with wide displacement. The cross measurement technique allows least observer choice and had excellent reliability but does not give a measurement that we can easily interpret based on convention in pelvic fracture description.
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Abstract
OBJECTIVES To provide evidence on the midterm sexual-function- and health-related quality-of-life outcome of patients with a traumatic pelvic fracture, as recorded at least 12 months after their surgery. DESIGN Prospective noncomparative study. SETTING Tertiary referral centre for pelvic-and-acetabular reconstruction. PATIENTS AND PARTICIPANTS Cohort of patients attending a dedicated pelvic-and-acetabular reconstruction clinic because of blunt pelvic trauma, at a minimum of a year after their injury. INTERVENTION Operatively treated pelvic fractures and concomitant surgical interventions for associated injuries, if any, sustained by the patients after blunt trauma. MAIN OUTCOME MEASURES Sexual function questionnaires: IIEF (international index of erectile function) and FSFI (female sexual function index). Quality of life was assessed with the EuroQol-5D questionnaire. RESULTS Of a cohort of 110 patients, 80 patients (48 males and 32 females) consented to participate with a median age of 46 years (range, 19-65 years). Of the above cohort, 62.5% were a result of road traffic accidents and 52.5% were classified as lateral compression type fractures. Assessment occurred at a median period of 36 months after injury (range, 12-96). Overall, significant decrease of their quality of life (P < 0.0001) and sexual function were recorded (males, P < 0.00014; females, P < 0.001). Sexual dysfunction was identified in 43.8% of the female and 52.1% of the male patients, as per the validated gender-specific sexual function scores (female sexual function index and international index of erectile function, respectively). Regression analysis identified the presence of urinary tract injury (P < 0.049) and open surgical treatment (P < 0.047) as independent risk factors for sexual dysfunction. A near significant association with injury severity score (P = 0.05) was seen. Male gender (P < 0.006), abdominal injury (P < 0.0001), pelvic fracture severity (P < 0.049), pain (P < 0.0001), and sexual dysfunction (P < 0.034) were identified as significant independent risk factors for decreased quality of life. CONCLUSIONS All domains of female and male sexual function were significantly decreased at a minimum of a year after pelvic fracture. Quality of life was also significantly decreased in this group with sexual dysfunction shown to be an independent risk factor for decreased quality of life after injury. Further pivotal clinical studies should follow based on the provided evidence. High clinical suspicion and prompt engagement of appropriate multidisciplinary pathways, including urological, gynecological, and psychiatric consultations, is recommended. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Roetman B, Schildhauer TA. [Lumbopelvic stabilization for bilateral lumbosacral instabilities: indications and techniques]. Unfallchirurg 2013; 116:991-9. [PMID: 24233084 DOI: 10.1007/s00113-012-2338-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bilateral lumbopelvic instabilities are rare; for the affected patients, however, they mean a severe reduction in quality of life. Optimal results can only be achieved with a well-adapted therapy algorithm that balances surgery and non-surgical procedures. OBJECTIVES The present article addresses the indications, strategy, and techniques of bilateral lumbopelvic fixation in the operative treatment of bilateral lumbopelvic injuries and review of the literature and personal experience. RESULTS The overall incidence of lumbosacral instabilities is low and mainly caused by high energy trauma, osteoporotic insuffiencies (e.g., primarily or secondary after long segment lumbar instrumentation), and tumors. Dramatic soft tissue injuries can occur in addition to hidden neurological impairments, and therefore it is important to diagnose and evaluate all concomitant comorbidities. The keys to success are gaining stability in the lumbosacral junction possibly combined with neuronal decompression and meaningful coordination of all disciplines, certainly challenged by finding the correct moment for surgery which is between 2 days and 2 weeks. Based on the superficial anatomy of the bony structures in the lumbosacral junction, the surgical approach has to match the pathology and should be tissue saving. CONCLUSIONS Treatment of bilateral lumbopelvic instabilities requires an accurate examination, sophisticated therapy protocol, and a multidisciplinary approach. Surgery with a bilateral lumbopelvic fixation combined with neuronal decompression is an adequate treatment that creates early bony stability, thus, promising functional weight-bearing mobilization.
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Affiliation(s)
- B Roetman
- Klinik für Unfallchirurgie und Orthopädie, Märkische Kliniken, Klinikum Lüdenscheid, Paulmannshöher Straße 14, 58515, Lüdenscheid, Deutschland,
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Rommens PM, Wagner D, Hofmann A. Surgical management of osteoporotic pelvic fractures: a new challenge. Eur J Trauma Emerg Surg 2012; 38:499-509. [PMID: 23162670 PMCID: PMC3495273 DOI: 10.1007/s00068-012-0224-8] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 08/24/2012] [Indexed: 11/24/2022]
Abstract
The number and variety of osteoporotic fractures of the pelvis are rapidly growing around the world. Such fractures are the result of low-impact trauma. The patients have no signs of hemodynamic instability and do not require urgent stabilization. The clinical picture is dominated by immobilizing pain in the pelvic region. Fractures may be located in both the ventral and the dorsal pelvic ring. The current well-established classification of pelvic ring lesions in younger adults does not fully reflect the criteria for osteoporotic and insufficiency fractures of the pelvic ring. Most osteoporotic fractures are minimally displaced and do not require surgical therapy. However, in some patients, an insidious progress of bone damage leads to complex displacement and instability. Therefore, vertical sacral ala fractures, fracture dislocations of the sacroiliac joint, and spinopelvic dissociations are best treated with operative stabilization. Angular stable bridge plating, the insertion of a transsacral positioning bar, and iliolumbar fixation are operative techniques that have been adapted to the low bone mineral density of the pelvic ring and the high forces acting on it.
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Affiliation(s)
- P M Rommens
- Department of Trauma Surgery, Center of Musculoskeletal Surgery, University Medical Center, Johannes Gutenberg University, Langenbeckstrasse 1, 55131 Mainz, Germany
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Methodology and interpretation of radiographic outcomes in surgically treated pelvic fractures: a systematic review. J Orthop Trauma 2012; 26:474-81. [PMID: 22391403 DOI: 10.1097/bot.0b013e3182323aa2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To identify and evaluate previously described methods for the measurement, and interpretation, of radiographic outcomes of operatively treated pelvic fractures. DATA SOURCES A systematic review of the available literature was performed using all major databases (MEDLINE, EMBASE, MEDLINE IN-PROGRESS, and Cochrane Central) in August 2009. STUDY SELECTION Inclusion criteria were case series, cohort studies, or clinical trials regarding orthopaedic treatment of acute traumatic pelvic ring fractures treated surgically in adults, with at least 12 weeks of radiographic follow-up. Exclusion criteria were case reports or case series of <10 patients, review articles, foreign language articles, and series where time frame of outcome measurement was not stated were excluded. DATA EXTRACTION Modality, and timeline, of the radiographic assessment was recorded. Next, the description of the method of radiographic measurement technique used was scrutinized for standardization. The interpretation of the radiographic measurement was evaluated, and any grading scale used was recorded. The interpretation of the quality of the radiographic result as described by each author was recorded. Finally, a qualitative methodological analysis was performed. DATA SYNTHESIS Number of standardized radiographic assessment techniques used (3 of 31) and interpretation scales used (13 of 31) were calculated. Nonweighted mean follow-up time (30.6 months) and overall positive radiographic outcomes were calculated (78.6% good or excellent). CONCLUSIONS Reporting of radiographic outcomes in pelvic fractures has been done using largely unstandardized and universally untested measurement techniques. The interpretations of these measurements are also inconsistent and untested. Substantive future research is needed in this area.
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Harvey-Kelly KF, Kanakaris NK, Eardley I, Giannoudis PV. Sexual Function Impairment After High Energy Pelvic Fractures: Evidence Today. J Urol 2011; 185:2027-34. [DOI: 10.1016/j.juro.2011.01.076] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Indexed: 11/26/2022]
Affiliation(s)
- Katherine F. Harvey-Kelly
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Nikolaos K. Kanakaris
- Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Ian Eardley
- Department of Urology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Peter V. Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom
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Completely displaced S-1/S-2 growth plate fracture in an adolescent: case report and review of literature. J Orthop Trauma 2009; 23:734-8. [PMID: 19858983 DOI: 10.1097/bot.0b013e3181a23d8b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In children, pelvic fractures are not common, and therefore, sacral fractures are a rare occurrence. Sacral fractures are often associated with neurologic deficit. Using radiographs alone may not be adequate to diagnose sacral fractures, and computed tomography scanning and/or magnetic resonance imaging may be needed. Treatment of the sacral fracture is often controversial and can range from nonoperative management to surgical intervention. This article presents a case report of completely displaced S-1/S-2 growth plate fracture. It also describes our diagnostic and treatment approach based on similar previously reported cases.
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Crowther AJ, McMaster JM, Abercrombie J, Hahn DM. Sacral fracture associated with small bowel entrapment: a case report. J Orthop Trauma 2006; 20:580-3. [PMID: 16990732 DOI: 10.1097/01.bot.0000245002.75621.ff] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We report the third documented case of small bowel entrapment within a sacral fracture leading to small bowel obstruction. This important diagnosis is rare and difficult to make, even with current imaging methods. We report a case in which a segment of small bowel trapped in a Denis II fracture of the sacrum required laparotomy, small bowel resection, and an omental patch over the fracture site. In this case the outcome was favorable with no residual sequelae.
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Affiliation(s)
- A J Crowther
- University Hospital Nottingham, Queens Medical Centre, Department of Trauma and Orthopaedics, Nottingham, UK.
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Schildhauer TA, Bellabarba C, Nork SE, Barei DP, Routt MLC, Chapman JR. Decompression and lumbopelvic fixation for sacral fracture-dislocations with spino-pelvic dissociation. J Orthop Trauma 2006; 20:447-57. [PMID: 16891935 DOI: 10.1097/00005131-200608000-00001] [Citation(s) in RCA: 168] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To report results of sacral decompression and lumbopelvic fixation in neurologically impaired patients with highly displaced, comminuted sacral fracture-dislocations resulting in spino-pelvic dissociation. DESIGN Retrospective clinical study. SETTING Regional level one trauma center. PATIENTS Nineteen patients with highly displaced, comminuted, irreducible Roy-Camille type 2-4 sacral fractures with spino-pelvic instability patterns and cauda equina deficits were identified over a 6-year period, 18 of which met the 12-month minimum follow-up criterion. INTERVENTION All were treated with open reduction, sacral decompression, and lumbopelvic fixation. Radiographic and clinical results were evaluated. Neurological outcome was measured by Gibbons' criteria. MAIN OUTCOME MEASUREMENTS Radiographic evaluation with computed tomography scan and antero-posterior, lateral, and oblique views of the pelvis to assess alignment, hardware position and decompression. Clinical evaluation emphasizing neurological outcome as described by Gibbons' criteria. RESULTS Sacral fractures healed in all 18 patients without loss of reduction. Average sacral kyphosis improved from 43 to 21 degrees. Fifteen patients (83%) had full or partial recovery of bowel and bladder deficits, although only 10 patients (56%) had improved Gibbons scores. Average Gibbons score improved from 4 to 2.8 at 31-month average follow-up (range: 12 to 57 mo). Wound infection (16%) was the most common complication. Complete recovery of cauda equina function was more likely in patients with continuity of all sacral roots (86% vs. 0%, P = 0.00037) and incomplete deficits (100% vs. 20%, P = 0.024). Although not statistically significant, recovery of bowel and bladder function specifically was more closely associated with absence of any sacral root discontinuity (86% vs. 36%, P = 0.066) than on completeness of the injury (100% vs. 47%, P = 0.21). CONCLUSIONS Lumbopelvic fixation provided reliable fracture stability and allowed consistent fracture union without loss of alignment. Neurological outcome was, in part, influenced by completeness of injury and presence of sacral root disruption.
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Affiliation(s)
- Thomas A Schildhauer
- Chirurgische Klinik u Poliklinik, BG-Kliniken Bergmannsheil, Ruhr-Universität Bochum, Germany
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Petrisor B, Bhandari M. (i) Injuries to the pelvic ring: Incidence, classification, associated injuries and mortality rates. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/j.cuor.2005.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Dzupa V, Havránek P, Matousková E, Dittertová L. Surgical treatment the sacral fracture in childhood: case report and literature overview. Arch Orthop Trauma Surg 2005; 125:426-9. [PMID: 15843941 DOI: 10.1007/s00402-005-0819-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2005] [Indexed: 11/25/2022]
Abstract
Fractures of the sacrum in children are rare. In the 17 cases described in the past 25 years, surgery was indicated only for treatment of the consequences of the primary injury. We present the case of a 10-year-old girl who sustained the following injuries as a result of a fall from a swing: posterior angulation of S2/3 with suspected injury of anterior ligamentous structures, fracture of the proximal part of the S4 body with a displacement by the bone width anteriorly and contraction of 5 mm, posterior angulation of S5/Co1 also with a suspected injury of anterior ligamentous structures. After an unsuccessful attempt at closed reduction, open reduction and fixation by two K-wires was indicated. The fracture healed in 8 weeks. Two years after the treatment, the patient is without complaints and limitations. The question is whether surgery was necessary for treatment of this fracture or whether spontaneous healing and subsequent remodelling of the sacral bone in such a young patient may be expected which would be also fully satisfactory. In our view, the described surgical treatment was appropriate and is definitely indicated for patients with a similar injury associated with a neural lesion.
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Affiliation(s)
- Valér Dzupa
- Department of Orthopaedics and Centre for Integrated Study of Pelvis, 3rd Faculty of Medicine, Charles University, Srobárova 50, 10034 , Prague 10, Czech Republic.
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Abstract
We report on an unusual impalement injury to the sacrum in a 15-year-old adolescent patient. This open pelvic fracture resulted in a shattered sacrum with neurologic impairment including clinically absent anal sphincter tone and perineal sensation. Early debridement, wound revision, neural decompression, fracture reduction, and stable fixation using lumbopelvic fixation according to the principles of triangular osteosynthesis resulted in a favorable outcome with primary wound healing, return of bowel and bladder control, as well as immediate patient mobilization.
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Affiliation(s)
- Thomas A Schildhauer
- Chirurgische Klinik und Poliklinik, BG-Kliniken Bergmannsheil, Ruhr-Universität Bochum, Bürkle-de-la-Camp-Platz 1, D-44789 Bochum, Germany.
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Zelle BA, Gruen GS, Hunt T, Speth SR. Sacral fractures with neurological injury: is early decompression beneficial? INTERNATIONAL ORTHOPAEDICS 2004; 28:244-51. [PMID: 15103503 PMCID: PMC3456939 DOI: 10.1007/s00264-004-0557-y] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/03/2004] [Indexed: 11/25/2022]
Abstract
During a 6-year period, 177 patients with a displaced sacral fracture were treated at our level-one trauma centre. At the initial presentation, 13 patients demonstrated a neurological deficit as a result of their sacral fracture. Six patients underwent surgical decompression, and seven patients were managed without surgical decompression. All patients were re-assessed at an average follow-up of 27.1 (range 12-84) months using the modified SOFCOT Index and the SF-36. Patients undergoing surgical decompression had a significantly better neurological improvement as measured by the modified SOFCOT Index (p=0.014). Moreover, patients undergoing surgical decompression had a significantly better physical function than the patients that were managed without surgical decompression, as measured by the SF-36 (p=0.044). We therefore believe that patients undergoing surgical decompression achieve better neurological improvement and better functional results.
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Affiliation(s)
- B A Zelle
- Division of Orthopaedic Traumatology, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Kaufmann Building, Suite 1011, 3471 Fifth Avenue, PA 15213, USA.
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