Early open reduction and internal fixation of the disrupted pelvic ring

Evolution of the reduction technique for unstable pelvic ring fractures: a narrative review

Unstable pelvic ring fractures are associated with high mortality and morbidity, and the quality of reduction is critical to the prognosis. While previous reviews have examined general fracture reduction techniques, there is limited focus on the specific advancements and challenges in the reduction technique of unstable pelvic ring fractures. The pelvic fracture reduction technique has undergone a four-stage evolution: open reduction, conventional closed reduction, navigation-assisted closed reduction, and robot-assisted automatic closed reduction. This review discusses and compares the features, effectiveness, and safety of each reduction technique. Open reduction improves clinical outcomes compared to nonsurgical management; however, it is no longer commonly practiced due to its association with extensive soft tissue damage. Although conventional closed reduction is minimally invasive and reduces intraoperative blood loss, surgical duration, and the length of hospital stay, frequent fluoroscopy is required to assess the reduction position, imposing a high risk of radiation exposure. Computer-aided navigation technology has advanced closed reduction techniques by allowing better visualization of the fracture site and surgical instruments, thereby enhancing the quality of pelvic fracture reduction and reducing radiation exposure. The recently developed robot-assisted automatic reduction technique relieves the burden on orthopedic surgeons and further reduces intraoperative radiation exposure. Future advancements in the pelvic reduction technique may involve big data-based intelligent reduction to enable broader indications such as bilateral pelvic fractures.

Stability before and after percutaneous anterior medullary fixation of lateral compression 1 and 2 pelvic ring disruptions: Should surgeons prioritize the anterior ring?

PURPOSE

Surgical intervention for lateral compression (LC) 1 and 2 pelvic ring fractures is controversial. Posterior ring stabilization remains the most common mode of initial fixation. However, greater mechanical instability is observed in the anterior component of LC pelvic fractures. This study tested whether reduction and percutaneous superior ramus fixation will decrease the instability of LC pelvic fractures on intraoperative fluoroscopic imaging.

METHODS

All adult patients (≥ 18 years) presenting with either a Young-Burgess LC1 or LC2 pelvic ring disruption treated operatively with percutaneous anterior followed by posterior fixation by a single surgeon from July 2021 to June 2023 were retrospectively reviewed. Displacement of the anterior ring to intraoperative manual internal rotation stress examination under fluoroscopy was compared before and after anterior pelvic ring reduction and fixation and prior to posterior pelvic ring fixation. Pre- and post-operative visual analog scores (VAS) for pain were also compared.

RESULTS

Twenty-one patients with a mean age of 48.7 years were included. Fifteen patients (71.4%) presented with an LC1, and six (28.6%) with an LC2 injury patterns. Anterior pelvic fixation alone provided 7.5mm reduction in mean displacement of the anterior pelvic ring (pre-operative = 9.2 mm vs. post-operative = 1.6 mm, p < 0.001). VAS significantly decreased from 7.2 one-day pre-operatively to 2.2 twenty-four h post-operatively (p < 0.001).

CONCLUSIONS

Reduction and fixation of the anterior pelvic ring prior to posterior fixation for LC1 and LC2 pelvic ring disruptions substantially improves mechanical stability on intraoperative stress examination. Combination of percutaneous anterior and posterior fixation significantly decreased VAS above the MCID 24 h after stabilization.

Long-term musculoskeletal function after Open Pelvic ring fractures in Children (OPEC); a multicentre, retrospective case series with follow-up measurement

Background

The proportion of Open Pelvic fractures in the paediatric population is relatively high. While operative fixation is the primary approach for managing Open Pelvic fractures in adults, there is limited literature on treatment outcomes in Children, particularly regarding long-term musculoskeletal, neurological, and urogenital function.

Methods

This multicentre case series included paediatric patients (<18 years old) with Open Pelvic ring fractures treated at one of two major trauma centres in the Netherlands between January 1, 2001 and December 31, 2021. Data collection involved clinical records and long-term assessments, including musculoskeletal function, growth disorders, urogenital function, sexual dysfunction, and sensory motor function.

Results

A total of 11 patients were included, primarily females (73 %), with a median age at trauma of 12 years (P25-P75 7-14). Most patients had unstable Pelvic ring fractures resulting from high-energy trauma. Surgical interventions were common, with external fixation as the main initial surgical approach (n = 7, 70 %). Complications were observed in eight (73 %) patients. Musculoskeletal function revealed a range of issues in the lower extremity, daily activities, and mental and emotional domain. Long-term radiologic follow-up showed high rates of Pelvic malunion (n = 7, 64 %). Neurological function assessment showed motor and sensory function impairment in a subset of patients. Urogenital function was moderately affected, and sexual dysfunction was limited with most respondents reporting no issues.

Conclusion

Paediatric Open Pelvic fractures are challenging injuries associated with significant short-term complications and long-term musculoskeletal and urogenital issues. Further research is needed to develop tailored treatment strategies and improve outcomes of these patients.

Critical distance of the sacroiliac joint for open reduction using screw fixation for traumatic sacroiliac joint diastasis: a retrospective study

BACKGROUND

Osteosynthesis for sacroiliac joint (SIJ) diastasis using an iliosacral screw (ISS) and a trans-iliac-trans-sacral screw (TITSS) can be performed using a closed or an open method. However, no clear indication for open reduction has been established.

METHODS

Data on patients with unilateral traumatic SIJ diastasis who underwent ISS and TITSS fixation were retrospectively collected and separated into groups according to the reduction method: closed reduction group (C group) and open reduction group (O group). Demographic data and perioperative image assessments were compared between the groups. The critical distance of the SIJ was identified to elucidate the indication for open reduction of the diastatic SIJ.

RESULTS

Fifty-six patients met the inclusion criteria over a 3-year period. There was no significant difference in the reduction quality of pelvic ring injuries between the groups, according to Matta's and Lefaivre's criteria. The improvement in the SIJ distance was significantly greater in the O group than in the C group in the axial plane on multiplanar computed tomography (p = 0.021). This model predicted that a difference of > 3.71 mm between the injured and healthy SIJ was a recommended indication for open reduction, with an area under the curve of 0.791 (95% confidence interval 0.627-0.955, p = 0.004).

CONCLUSIONS

Open reduction for SIJ diastasis might achieve better reduction quality than does closed reduction in the axial plane in selected cases. When the difference between the injured and healthy SIJ was wider than 3.71 mm, open reduction was recommended for satisfactory radiological outcomes.

Early versus late surgical treatment of pelvic and acetabular fractures a five-year follow-up of 419 patients

BACKGROUND

Surgical treatment of pelvic and acetabular fractures is an advanced intervention with a high risk of subsequent complications. These patients are often polytrauma patients with multiple injuries in several organ systems. The optimal timing for the definitive surgery of these fractures has been debated. The primary aim of this study was to investigate the influence of timing of definitive surgery on the rate of unplanned reoperations. Secondary aims included its influence on the occurrence of adverse events and mortality.

METHODS

All patients from 18 years with a surgically treated pelvic or acetabular fracture operated at the Karolinska University Hospital in Sweden during 2010 to 2019 were identified and included. Data was collected through review of medical records and radiographs. Logistic regression analysis was performed to evaluate factors associated with unplanned reoperations and other adverse events.

RESULTS

A total of 419 patients with definitive surgical treatment within 1 month of a pelvic (n = 191, 46%) or an acetabular (n = 228, 54%) fracture were included. The majority of the patients were males (n = 298, 71%) and the mean (SD, range) age was 53.3 (19, 18-94) years. A total of 194 (46%) patients had their surgery within 72 h (early surgery group), and 225 (54%) later than 72 h (late surgery group) after the injury. 95 patients (23%) had an unplanned reoperation. There was no difference in the reoperation rate between early (n = 44, 23%) and late (n = 51, 23%) surgery group (p = 1.0). A total of 148 patients (35%) had any kind of adverse event not requiring reoperation. The rate was 32% (n = 62) in the early, and 38% (n = 86) in the late surgery group (p = 0.2). When adjusting for relevant factors in regression analyses, no associations were found that increased the risk for reoperation or other adverse events. The 30-day mortality was 2.1% (n = 4) for the early and 2.2% (n = 5) for the late surgery group (p = 1.0). The 1-year mortality was 4.1% (n = 8) for the early and 7.6% (n = 17) for the late surgery group (p = 0.2).

CONCLUSIONS

Early (within 72 h) definitive surgery of patients with pelvic or acetabular fractures seems safe with regard to risk for reoperation, other adverse events and mortality.

FFP: Indication for minimally invasive navigation technique

An 85-year-old female patient was transferred to our clinic for surgical treatment of a complex FFP IIc. She had suffered a ground level fall 10 days ago and was still living independently. The patient was initially treated conservatively with pain medication and immobilization in an outward hospital. Due to the clinical symptoms and complex fracture pattern a physiotherapeutic assisted mobilization was not possible. The clinical examination revealed severe bilateral pain at the anterior and posterior pelvic ring. We performed a minimally invasive and an image-guided surgical stabilization. After surgical treatment the patient was mobilized with crutches for short distances. On the third day after surgical intervention the patient was discharged from our hospital into rehabilitation. This case shows the successful use of minimally invasive and modern navigation technique for treatment of a complex FFP.

Advances in the Treatment of Implant-Associated Infections of the Pelvis: Eradication Rates, Recurrence of Infection, and Outcome

INTRODUCTION

Surgical site infections after operative stabilization of pelvic and acetabular fractures are rare but serious complications. The treatment of these infections involves additional surgical procedures, high health care costs, a prolonged stay, and often a worse outcome. In this study, we focused on the impact of the different causing bacteria, negative microbiological results with wound closure, and recurrence rates of patients with implant-associated infections after pelvic surgery.

MATERIAL AND METHODS

We retrospectively analyzed a study group of 43 patients with microbiologically proven surgical site infections (SSI) after surgery of the pelvic ring or the acetabulum treated in our clinic between 2009 and 2019. Epidemiological data, injury pattern, surgical approach, and microbiological data were analyzed and correlated with long-term follow-up and recurrence of infection.

RESULTS

Almost two thirds of the patients presented with polymicrobial infections, with staphylococci being the most common causing agents. An average of 5.7 (±5.4) surgical procedures were performed until definitive wound closure. Negative microbiological swabs at time of wound closure were only achieved in 9 patients (21%). Long-term follow-up revealed a recurrence of infection in only seven patients (16%) with an average interval between revision surgery and recurrence of 4.7 months. There was no significant difference of recurrence rate for the groups of patients with positive/negative microbiology in the last operative revision (71% vs. 78%). A positive trend for a correlation with recurrent infection was only found for patients with a Morel-Lavallée lesion due to run-over injuries (30% vs. 5%). Identified causing bacteria did not influence the outcome and rate of recurrence.

CONCLUSION

Recurrence rates after surgical revision of implant-associated infections of the pelvis and the acetabulum are low and neither the type of causing agent nor the microbiological status at the timepoint of wound closure has a significant impact on the recurrence rate.

Is Anterior Plating Superior to the Bilateral Use of Retrograde Transpubic Screws for Treatment of Straddle Pelvic Ring Fractures? A Biomechanical Investigation

Background: Fractures of the four anterior pubic rami are described as “straddle fractures”. The aim of this study was to compare biomechanical anterior plating (group 1) versus the bilateral use of retrograde transpubic screws (group 2). Methods: A straddle fracture was simulated in 16 artificial pelvises. All specimens were tested under progressively increasing cyclic loading, with monitoring by means of motion tracking. Results: Axial stiffness did not differ significantly between the groups, p = 0.88. Fracture displacement after 1000–4000 cycles was not significantly different between the groups, p ≥ 0.38; however, after 5000 cycles it was significantly less in the retrograde transpubic screw group compared to the anterior plating group, p = 0.04. No significantly different flexural rotations were detected between the groups, p ≥ 0.32. Moreover, no significant differences were detected between the groups with respect to their cycles to failure and failure loads, p = 0.14. Conclusion: The results of this biomechanical study reveal less fracture displacement in the retrograde transpubic screw group after long-term testing with no further significant difference between anterior plating and bilateral use of retrograde transpubic screws. While the open approach using anterior plating allows for better visualization of the fracture site and open reduction, the use of bilateral retrograde transpubic screws, splinting the fracture, presents a minimally invasive and biomechanically stable technique.

Comparison of lumbopelvic fixation and iliosacral screw fixation for the treatment of bilateral sacral fractures

Background

Bilateral sacral fractures result in traumatic disruption of the posterior pelvic ring. Treatment for unstable posterior pelvic ring fractures should aim for fracture reduction and rigid fixation to facilitate early mobilization. Iliosacral screw fixation (ISF) and lumbopelvic fixation (LPF) were recommended for the treatment of these injuries. No algorithm or gold standard exists for surgery of these fractures.

Purpose

The purpose of this study was to evaluate the differences between ISF and LPF in bilateral sacral fractures regarding intraoperative procedures, complications and postoperative mobilization. The secondary aim was to determine whether demographics influence surgical treatment.

Methods

Over a 4-year period (2016–2019), 188 consecutive patients with pelvic ring injuries were treated at one academic level 1 trauma center and retrospectively identified. Fractures were classified according to the AO/OTA classification system. Seventy-seven patients were treated with LPF or ISF in combination with internal fixation of pubic rami fractures and could be included in this study. Comparisons were made between demographic and perioperative data. Infection, hematoma and hardware malpositioning were used as complication variables. Mobilization with unrestricted weight bearing was used as outcome variable. Follow-up was at least 6 months postoperatively.

Results

Operative stabilization of bilateral posterior pelvic ring injuries was performed in 77 patients. Therefore, 29 patients (females 59%) underwent LPF whereas 48 patients (females 83%) had bilateral ISF. The ISF group was older (76 yrs.) compared to the LPF group (62 yrs.) (p = 0.001), but no differences regarding BMI or comorbidities were detected. Time for surgery was reduced for patients who were treated with ISF compared to lumbopelvic fixation (73 min vs. 165 min; respectively, p < 0.001). But this did not result in reduced fluoroscopic time or radiation exposure. Overall complication rate was not different between the groups. Patients with LPF had a greater length of stay (p = 0.008) but were all weight bearing as tolerated when discharged (p < 0.001).

Conclusion

Bilateral posterior pelvic ring injuries of the sacrum can be sufficiently treated by LPF or ISF. LPF allows immediate weight bearing which may benefit younger patients and patients with an elevated risk for pneumonia or other pulmonary complications. Treatment with ISF reduces operative time, length of stay and postoperative wound infection. Elderly patients may be better suited for treatment with ISF if there is concern that the patient may not tolerate the increased operative time.

Management of a Close-Range High-Velocity Gunshot Wound to the Pelvis with Posterior Pelvic Plating: A Case Report

CASE

A 31-year-old woman suffered a close-range, high-energy .30-rifle gunshot wound to her right ilium and sacrum resulting in an unstable pelvic ring injury with significant internal soft-tissue damage and bone loss. Given the limited amount of literature for managing this rare clinical scenario in a civilian setting, we described our protocol used on this patient to achieve a safe and effective result.

CONCLUSIONS

We present a civilian-inflicted high-velocity pelvic gunshot injury at close range. Although the patient had extensive pelvic bone loss and soft-tissue damage, she had excellent clinical results at 18-month follow-up after delayed posterior sacral bridge plating. Proper soft-tissue management and posterior sacral plating may yield good results for management of this type of injury.

Evolving concepts and strategies in the management of polytrauma patients

Major trauma is one of the leading causes of morbidity and mortality in young adults. The impact of disability on the quality of life and functionality in this younger population is worrisome. This remains a major public health concern across the globe. Immediate and early deaths account for nearly 80% of trauma deaths occurring within the first few hours of injury to the first few days, usually because of traumatic brain injury or major exsanguination and subsequently due to shock or hypoxia. Worldwide adoption of comprehensive trauma systems and evolving models of trauma care including prehospital interventions have led improvements in trauma and critical care over the last few decades. Resuscitation and damage control orthopaedics are two key pillars in the management of polytrauma patient. Trauma-related coagulopathy can be an emerging complication during resuscitation of such patients which should be recognized early so appropriate corrective measures can be undertaken. We describe the evolving models of care in the management of polytrauma and trauma associated coagulopathy.

Temporary External Fixation to Table as a Traction Reduction Aide in the Treatment of Unstable Pelvic Ring Injuries: A Technical Note

Displaced pelvic ring injuries can be challenging to even the experienced orthopedic traumatologist. A temporary external fixation to table construct provides a quick, simple, and accessible means of external skeletal fixation to reliably obtain and maintain stable hemipelvis reduction on the operating room table. The contralateral hemipelvis can be stabilized to the table by use of Steinman pins safely inserted into the subtrochanteric and anterior column regions and later connected to external fixator bars attached to the table. With rigid stabilization, the displaced contralateral pelvic fragment(s) can be reduced in a more vector intentional manner with greater force than the traditional means of pelvic reduction can allow. The skeletal-table fixation technique is presented along with two cases, a combined pelvic-acetabular injury and an isolated pelvic ring injury.

Vertical Shear Pelvic Ring Injury Adjacent to Retained Pelvic Hardware: A Case Report

CASE

A 47-year-old obese woman presented with a vertical shear (VS) pelvic ring injury after a motor vehicle accident around her previous posterior pelvic hardware. The patient underwent closed reduction with percutaneous posterior screw fixation using combined fluoroscopy and O-arm (Medtronic).

CONCLUSION

A rare case of VS pelvic injury with indwelling posterior pelvic hardware does not automatically preclude placement of percutaneous sacroiliac and transiliac-transsacral screws. Combining fluoroscopic imaging and O-arm enables safe screw placement, saving patients from invasive surgeries.

Fracture fixation in the polytrauma patient: Markers that matter

Timing and type of fracture fixation in the multiply-injured trauma patient have been important and controversial topics. Ideal care for these patients come from providers who communicate well with one another in a team fashion and view the whole person, rather than focusing on injury to individual systems. This group encompasses a wide range of musculoskeletal and other injuries, further complicated by the broad spectrum of patients, with variability in age, medical and social comorbidities, all of which may have profound impact upon outcomes. The concept of Early Total Care arose from the realization that early definitive fixation of femur fractures provided pulmonary and systemic benefits to most patients. However, insufficient assessment and understanding of the physiological status of polytraumatized patients at the time of major orthopaedic procedures, potentially with inclusion of multiple other procedures in the same setting resulted in more morbidity, swinging the pendulum of care toward initial Damage Control Orthopaedics to minimize surgical insult. More recently, iterative assessment of response to resuscitation using Early Appropriate Care guidelines, suggests definitive fixation of most axial and femoral injuries within 36 h after injury appears safe in resuscitated patients, as measured by improvement of acidosis.

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

PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Anterior Pelvic Ring: Introduction to Evaluation and Management

The evaluation and management of pelvic ring injuries continues to evolve. Historic treatment was primarily nonsurgical, which yielded to open surgical treatment as the benefits of restoring pelvic anatomy and stability became clear. The development of percutaneous techniques for pelvic ring fixation enabled surgeons to reduce and stabilize certain injuries without the need for large open surgical dissections. Although percutaneous iliosacral screw fixation of sacral fractures and sacroiliac disruptions is the standard for most posterior pelvic ring injuries, the evaluation and treatment of anterior pelvic ring disruptions remains a controversial topic among surgeons who treat these injuries. Universally accepted indications for anterior pelvic ring stabilization do not exist, and there is little comparative data to support one surgical technique over another. In fact, some believe that for many injuries, the anterior ring rarely requires fixation after stable fixation of the posterior pelvic ring. The purpose of this work is to present a brief history on management of the anterior pelvic ring as a component of pelvic ring disruptions and briefly review the anatomy of the anterior pelvic ring. Finally, we will introduce the current techniques available for anterior pelvic reduction/stabilization and present information on evaluation of anterior ring stability as a means of guiding treatment.

Predictors of Unplanned Reoperation After Operative Treatment of Pelvic Ring Injuries

OBJECTIVES

To evaluate the incidence of unplanned reoperations after pelvic ring injuries and to develop a risk prediction model.

DESIGN

Retrospective review.

SETTING

Level I Trauma Center.

PATIENTS

The medical records of 913 patients (644 male and 269 female patients; mean age, 39 years; age range, 16-89 years) with unstable pelvic ring fractures operatively treated at our center from 2003 to 2015 were reviewed.

INTERVENTION

Multiple logistic regression analysis was conducted to evaluate the relative contribution of associated clinical parameters to unplanned reoperations. A risk prediction model was developed to assess the effects of multiple covariates.

MAIN OUTCOME MEASUREMENTS

Unplanned reoperation for infection, fixation failure, heterotopic ossification, or bleeding complication.

RESULTS

Unplanned reoperations totaled 137 fractures, with an overall rate of 15% (8% infection, 6% fixation failure, <1% heterotopic ossification, and <1% bleeding complication). Reoperations for infection and fixation failure typically occurred within the first month after the index procedure. Four independent predictors of reoperation were open fractures, combined pelvic ring and acetabular injuries, abdominal visceral injuries, and increasing pelvic fracture grade. No independent association was shown between reoperation and patient, treatment, or other injury factors.

CONCLUSIONS

Unplanned reoperations were relatively common. Infection and fixation failure were the most common indications for unplanned reoperations. Factors associated with reoperation are related to severity of pelvic and abdominal visceral injuries. Our findings suggest that these complications might be inherent and in many cases unavoidable despite appropriate current treatment strategies.

LEVEL OF EVIDENCE

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

Early versus late intramedullary nailing for traumatic femur fracture management: meta-analysis

INTRODUCTION

There is no consensus yet on the impact of timing of femur fracture (FF) internal fixation on the patient outcomes. This meta-analysis was conducted to evaluate the contemporary data in patients with traumatic FF undergoing intramedullary nail fixation (IMN).

METHODS

English language literature was searched with publication limits set from 1994 to 2016 using PubMed, Scopus, MEDLINE (OVID), EMBASE (OVID), Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL). Studies included randomized controlled trials (RCTs), prospective observational or retrospective cohort studies, and case-control studies comparing early versus late femoral shaft fractures IMN fixation. Variable times were used across studies to distinguish between early and late IMN, but 24 h was the most frequently used cutoff. The quality assessment of the reviewed studies was performed with two instruments. Observational studies were assessed with the Newcastle-Ottawa Quality Assessment Scale. RCTs were assessed with the Cochrane Risk of Bias Tool.

RESULTS

We have searched 1151 references. Screening of titles and abstracts eliminated 1098 references. We retrieved 53 articles for full-text screening, 15 of which met study eligibility criteria.

CONCLUSIONS

This meta-analysis addresses the utility of IMN in patients with FF based on the current evidence; however, the modality and timing to intervene remain controversial. While we find large pooled effects in favor of early IMN, for reasons discussed, we have little confidence in the effect estimate. Moreover, the available data do not fill all the gaps in this regard; therefore, a tailored algorithm for management of FF would be of value especially in polytrauma patients.

Safe Zone Quantification of the Third Sacral Segment in Normal and Dysmorphic Sacra

OBJECTIVE

To quantify the osseous anatomy of the dysmorphic third sacral segment and assess its ability to accommodate internal fixation.

DESIGN

Retrospective chart review of a trauma database.

SETTING

University Level 1 Trauma Center.

PATIENTS

Fifty-nine patients over the age of 18 with computed tomography scans of the pelvis separated into 2 groups: a group with normal pelvic anatomy and a group with sacral dysmorphism.

MAIN OUTCOME MEASUREMENTS

The sacral osseous area was measured on computed tomography scans in the axial, coronal, and sagittal planes in normal and dysmorphic pelves. These measurements were used to determine the possibility of accommodating a transiliac transsacral screw in the third sacral segment.

RESULTS

In the normal group, the S3 coronal transverse width averaged 7.71 mm and the S3 axial transverse width averaged 7.12 mm. The mean S3 cross-sectional area of the normal group was 55.8 mm. The dysmorphic group was found to have a mean S3 coronal transverse width of 9.49 mm, an average S3 axial transverse width of 9.14 mm, and an S3 cross-sectional area of 77.9 mm.

CONCLUSIONS

The third sacral segment of dysmorphic sacra has a larger osseous pathway available to safely accommodate a transiliac transsacral screw when compared with normal sacra. The S3 segment of dysmorphic sacra can serve as an additional site for screw placement when treating unstable posterior pelvic ring fractures.

Fractures of the pelvic ring

Traumatic disruptions of the pelvic ring are high energy life threatening injuries. Management represents a significant challenge, particularly in the acute setting in the presence of severe haemorrhage. Initial management is focused on preserving life by controlling haemorrhage and associated injuries. Advances in prehospital care, surgery, interventional radiology and the introduction of treatment algorithms to streamline decision making have improved patient survival. As more patients with unstable pelvic injuries survive, the poor results associated with nonoperative management and increasing patient expectations of outcome are making surgical management of these fractures increasingly common. The aim of operative fracture fixation is to correct deformity and restore function. The advent of percutaneous fixation techniques has reduced the morbidity previously associated with large operative exposures and internal fixation.

Sacroiliac Joint Treatment Personalized to Individual Patient Anatomy Using 3-Dimensional Navigation

During the past 10 years, the sacroiliac (SI) joint has evolved from being barely recognized as a source of pain, to being a joint treated only nonsurgically or with great surgical morbidity, to currently being a joint treated with minimally invasive techniques that are personalized to the individual patient. The complex 3-dimensional anatomy of the SI joint and lack of parallel to traditional imaging planes requires a thorough understanding of the structures within and around the SI joint that may be at risk of injury. Thus, the SI joint is ideally suited for intraoperative 3-dimensional imaging and surgical navigation when being treated minimally invasively.

Computed tomography-based three-dimensional visualisation of bone corridors and trajectories for screws in open reduction and internal fixation of symphysis diastasis: a retrospective radiological study

INTRODUCTION

Typical stabilisation of pelvic open book injuries consists of plate fixation of the symphysis. No previous literature has been published about the evaluation of screw placement and their trajectory with four oblique 4.5 mm screws using a four-hole plate in symphysis diastasis. The aim of this study was to define insertion points and angles of trajectory for crossed screw placement regardless of any plate design based on an analysis of three-dimensional computed tomography data sets.

METHODS

One hundred human pelvic CT data sets were collected. Unilateral and bilateral placements of crossed 4.5 mm screws were simulated. Primary outcome measure was successful simulated screw placement without cortical breach. Secondary outcome measures included the anatomical measurements of the screw positions.

RESULTS

Simulated screw placement of two oblique screws on each side of the pubic symphysis without cortical breach was achieved in all (100 %) cases. There were a total of 400 screw simulations. Medial screws were longer, lateral screws had higher coronal angles, and the distance between both screws was higher on the right side (p < 0.001 each). The lengths of the right lateral, right medial, left lateral, and left medial screws were 44.9, 65.8, 45.4, and 67.4 mm, respectively. The sagittal angles to the dorsal surface area of the pubic rami were 10.5°, 11.1°, 9.0°, and 11.0°. The coronal angles to the vertical axis of the symphysis measured 39.5°, 16.0°, 33.8°, and 16.8°. The distances between these screws and the medial edge of the pubic crest were 33.5, 8.6, 29.5, and 7.3 mm. Furthermore, certain sex- and side-related differences were noted.

CONCLUSIONS

This series provides results about the feasibility and a detailed anatomical description of crossed screw placement. This is of special interest in pelvic surgery for choosing the entry points, safe screw channel parameters, and trajectories.

Treatment of Unstable Posterior Pelvic Ring Fracture with Pedicle Screw-Rod Fixator Versus Locking Compression Plate: A Comparative Study

Background

The aim of this study was to assess the clinical results of treatment for unstable posterior pelvic fractures using a pedicle screw-rod fixator compared to use of a locking compression plate.

Material/Methods

A retrospective study was performed between June 2010 and May 2014 and the data were collected from 46 patients with unstable posterior pelvic ring fractures. All patients were treated using either a pedicle screw-rod fixator (study group, 24 patients) or locking compression plate (control group, 22 patients). In these patients, causes of injury included traffic accidents (n=27), fall from height (n=12), and crushing accidents (n=7). The quality of reduction and radiological grading were assessed. Clinical assessments included the operation time, times of X-ray exposures, bleeding volume during operation, incision length, and Majeed postoperative functional evaluation.

Results

No iatrogenic neurovascular injuries occurred during the operations in these 2 groups. The average follow-up time was 24.5 months. All fractures were healed. The significant differences (P<0.05) between the 2 groups were operation duration, size of incision, and intraoperative bleeding volume. Statistically significant differences in the Majeed postoperative functional evaluation and times of X-ray exposures were not found between the 2 groups.

Conclusions

Similar clinical effects were achieved in treating the posterior pelvic ring fractures using the pedicle screw-rod fixator and the locking compression plate. However, the pedicle screw-rod fixator has the advantages of smaller incision, shorter duration of the operation, and less bleeding volume compared to using the locking compression plate.

Multiple Procedures in the Initial Surgical Setting: When Do the Benefits Outweigh the Risks in Patients With Multiple System Trauma?

OBJECTIVES

To compare single versus multiple procedures in the same surgical setting. We hypothesized that complication rates would not be different and length of stay would be shorter in patients undergoing multiple procedures.

DESIGN

Prospective, cohort.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

A total of 370 patients with high-energy fractures were treated after a standard protocol for resuscitation to lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥-5.5 mmol/L. Fractures included femur (n = 167), pelvis (n = 74), acetabulum (n = 54), and spine (n = 107).

MAIN OUTCOME MEASUREMENTS

Complications, including pneumonia, acute respiratory distress syndrome, infections, deep venous thrombosis, pulmonary embolism, sepsis, multiple organ failure, and death, and length of stay.

RESULTS

Definitive fixation was performed concurrently with another procedure in 147 patients. They had greater ISS (29.4 vs. 24.6, P < 0.01), more transfusions (8.9 U vs. 3.6 U, P < 0.01), and longer surgery (4:22 vs. 2:41, P < 0.01) than patients with fracture fixation only, but no differences in complications. When patients who had definitive fixation in the same setting as another procedure were compared only with other patients who required more than 1 procedure performed in a staged manner on different days (n = 71), complications were fewer (33% vs. 54%, P = 0.004), and ventilation time (4.00 vs. 6.83 days), intensive care unit (ICU) stay (6.38 vs. 10.6 days), and length of stay (12.4 vs. 16.0 days) were shorter (all P ≤ 0.03) for the nonstaged patients.

CONCLUSIONS

In resuscitated patients, definitive fixation in the same setting as another procedure did not increase the frequency of complications despite greater ISS, transfusions, and surgical duration in the multiple procedure group. Multiple procedures in the same setting may reduce complications and hospital stay versus additional surgeries on other days.

LEVEL OF EVIDENCE

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

A Quantitative Exposure Planning Tool for Surgical Approaches to the Sacroiliac Joint

OBJECTIVES

To aid in surgical planning by quantifying and comparing the osseous exposure between the anterior and posterior approaches to the sacroiliac joint.

METHODS

Anterior and posterior approaches were performed on 12 sacroiliac joints in 6 fresh-frozen torsos. Visual and palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J.

RESULTS

The average surface areas of exposed bone were 44 and 33 cm for the anterior and posterior approaches, respectively. The anterior iliolumbar ligament footprint could be visualized in all anterior approaches, whereas the posterior aspect could be visualized in all but one posterior approach. The anterior approach provided visual and palpable access to the anterior superior edge of the sacroiliac joint in all specimens, the posterior superior edge in 75% of specimens, and the inferior margin in 25% and 50% of specimens, respectively. The inferior sacroiliac joint was easily visualized and palpated in all posterior approaches, although access to the anterior and posterior superior edges was more limited. The anterior S1 neuroforamen was not visualized with either approach and was more consistently palpated when going posterior (33% vs. 92%).

CONCLUSIONS

Both anterior and posterior approaches can be used for open reduction of pure sacroiliac dislocations, each with specific areas for assessing reduction. In light of current plate dimensions, fractures more than 2.5 cm lateral to the anterior iliolumbar ligament footprint are amenable to anterior plate fixation, whereas those more medial may be better addressed through a posterior approach.

Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue

OBJECTIVES

We hypothesized that a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay.

DESIGN

Prospective consecutive series.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Two hundread and fifty-three adult patients with a mean age of 40.7 years and mean Injury Severity Score of 26.0.

INTERVENTION

Femur, pelvis, or spine fractures treated surgically.

MAIN OUTCOME MEASUREMENTS

Hospital and professional charges and collections were analyzed. Fixation was defined as early (<36 hours) or delayed. Complications and hospital stay were recorded.

RESULTS

Mean charges were US $180,145 with a mean of US $66,871 collected (37%). The revenue multiplier was US $59,882/$6989 (8.57), indicating hospital collection of US $8.57 for every professional dollar, less than half of which went to orthopaedic surgeons. Delayed fracture care was associated with more intensive care unit (4.5 vs. 9.4) and total hospital days (9.4 vs. 15.3), with mean loss of actual revenue US $6380/patient delayed (n = 47), because of the costs of longer length of stay. Complications were associated with the highest expenses: mean of US $291,846 charges and US $101,005 collections, with facility collections decreased by 5.1%. An uncomplicated course of care was associated with the most favorable total collections: (US $60,017/$158,454 = 38%) and the shortest mean stay (8.7 days).

CONCLUSIONS

Facility collections were nearly 9 times more than professional collections. Delayed fixation was associated with more complications, and facility collections decreased 5% with a complication. Furthermore, delayed fixation was associated with longer hospital stay, accounting for US $300K more in actual costs during the study. A standardized protocol to expedite definitive fixation enhances the profitability of the trauma service line.

LEVEL OF EVIDENCE

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

The Effect of Implant Failure After Symphyseal Plating on Functional Outcome and General Health

OBJECTIVES

To relate the incidence of implant failure after internal anterior fixation of the pelvic ring to functional outcome and the health-related quality of life in patients.

DESIGN

Retrospective chart and radiographic review.

SETTING

Level I Trauma center.

METHODS

We retrospectively identified all patients who were treated with symphyseal plating for traumatic symphyseal diastasis between January 2003 and December 2013. Patients were asked to complete 2 questionnaires, the SF-36 and the Majeed score. A retrospective chart and radiographic control review were performed on all patients. The following data were collected: demographic data and details regarding the pelvic surgery. Computed tomograms were used to determine fracture classification and quality of reduction. Conventional radiographic follow-up were used to detect implant failure.

RESULTS

A total of 37 patients enrolled the study. Implant failure occurred in 11 (30%) patients resulting in the identification of 2 groups, "implant failure" (n = 11) and "intact implants" (n = 26). The baseline characteristics were equal in both groups. The analysis of the questionnaires revealed that the SF-36 score was not significantly different in any of the dimensions between the both groups. Patients in the implant failure group scored higher on all of the Majeed items, including the total Majeed score, but the difference did not reach statistical significance of P < 0.05.

CONCLUSIONS

Our study showed comparable results regarding the general health measured by the SF-36 for both groups and higher Majeed scores for patients with implant failure compared with patients with intact implants.

LEVEL OF EVIDENCE

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

History of pelvic fracture management: a review

High-energy pelvic fractures represent potentially life-threatening injuries due to the risk of acute exsanguinating retroperitoneal hemorrhage. The first report of a severe pelvic ring disruption dates back to Charles Hewitt Moore’s seminal publication from 1851. Significant advantages in the understanding of injury mechanisms and treatment concepts of pelvic ring injuries evolved in the 20^th century, and provided the basis to current classification-guided treatment and life-saving “damage control” concepts. However, there is a paucity of reports in the current literature focused on the historic background on the treatment of pelvic ring injuries. The present review was designed to summarize the history and evolution of our current understanding of the mechanisms and management strategies for severe pelvic ring injuries (excluding acetabular fractures which represent a different entity outside of the scope of this article).

A Nationwide Analysis of Pelvic Ring Fractures: Incidence and Trends in Treatment, Length of Stay, and Mortality

BACKGROUND

Previous studies evaluating the epidemiology of pelvic ring fractures and predictors of mortality are largely based upon non-US populations, potentially limiting their generalizability. This study sought to analyze trends of pelvic ring fractures and associated complications in the United States using the largest and most recent national data set available. The specific aims of this study were to determine whether the incidence of pelvic ring fractures changed over time, whether in-hospital mortality following pelvic ring fracture changed over time, whether hospital length of stay following pelvic ring fracture changed over time, and whether there are independent predictors of in-hospital mortality, adverse events, or nonroutine discharge following pelvic fracture.

METHODS

The National Hospital Discharge Survey was queried to identify all patients admitted to US hospitals with pelvic ring fractures between 1990 and 2007. A cohort representative of 1 464 458 patients was identified, and multivariable logistic regression was used to find independent predictors of mortality, adverse events, and nonroutine discharge to another inpatient facility.

RESULTS

Between 1990 and 2007, the population-adjusted incidence of pelvic ring fractures increased from 27.24 to 34.30 per 100 000 capita (P < .001). Mortality declined from 4.2% to 2.8% (P < .001) paralleling an increase in the proportion of patients treated with surgical fixation (7.22%-10.36%). All forms of internal fixation were associated with decreased odds of mortality, while external fixation was associated with increased odds of mortality. Internal fixation was also associated with lower odds of adverse events and nonroutine discharge to inpatient facilities. The average in-hospital length of stay decreased from 11.2 days to 6.5 days (P < .001).

CONCLUSION

This study provides the largest and most comprehensive epidemiologic analysis of pelvic ring fractures in the United States. Knowledge of the increasing incidence of pelvic fractures and prognostic factors associated with poor outcomes may improve outcomes.

Teamwork in Trauma: System Adjustment to a Protocol for the Management of Multiply Injured Patients

OBJECTIVES

We developed a protocol to determine the timing of definitive fracture care based on the adequacy of resuscitation. Inception of this project required a multidisciplinary group, including physicians from anesthesiology, general trauma and critical care, neurosurgery, orthopaedic spine, and orthopaedic trauma. The purposes of this study were to review our initial experience with adherence to protocol recommendations and to assess barriers to implementation.

DESIGN

Prospective.

SETTING

Level 1 trauma center.

INTERVENTION

Definitive fixation of pelvis, acetabulum, spine, and femur fractures within 36 hours of injury, based on laboratory parameters for acidosis.

MAIN OUTCOME MEASUREMENTS

Three hundred five consecutive skeletally mature patients with Injury Severity Score ≥ 16 (mean, 26.4) and 346 fractures of the proximal or diaphyseal femur (n = 152), pelvic ring (n = 56), acetabulum (n = 44), and/or spine (n = 94) were treated surgically. Adherence to the protocol was defined as definitive fixation within 36 hours of injury in resuscitated patients. All patients were adequately resuscitated within that time. Patient demographic and injury characteristics, date and time of presentation, and reasons for delay were recorded.

RESULTS

Two hundred fifty-one patients (82%) with 287 fractures were treated according to the protocol, whereas 54 patients (18%) with 59 fractures were definitively stabilized on a delayed basis (mean, 90 hours). Delay was not related to patient age, Injury Severity Score, day of week, or time of presentation. Before implementation of this protocol, 76% were treated on a delayed basis, demonstrating improvement for each fracture type: spine (79% of previous patients with delay), pelvis (57%), acetabulum (72%), and femur (22%); all P < 0.0001 for more frequently delayed surgery before the protocol. Surgeon choice to delay the procedure accounted for 67% of reasons for delay. Other reasons included intensivist choice (13%), operating room availability (7.4%), patient choice (3.7%), severe head injury (5.6%), or cardiac issues (3.7%). Our trauma center and surgeons became more accustomed to the protocol and had fewer delays over time; 10% were delayed 2 years after implementation.

CONCLUSIONS

Management of trauma patients with injury to multiple systems requires teamwork among providers from related specialties and hospital support, in terms of operating room access, with appropriate ancillary personnel and equipment. Our system adjusted quickly to the protocol. Surgeon preference was the most common reason for delayed fixation, but within 24 months, only 10% of fractures were treated on a delayed basis, as long as patients were resuscitated.

Complications are reduced with a protocol to standardize timing of fixation based on response to resuscitation

BACKGROUND

Our group developed a protocol, entitled Early Appropriate Care (EAC), to determine timing of definitive fracture fixation based on presence and severity of metabolic acidosis. We hypothesized that utilization of EAC would result in fewer complications than a historical cohort and that EAC patients with definitive fixation within 36 h would have fewer complications than those treated at a later time.

METHODS

Three hundred thirty-five patients with mean age 39.2 years and mean Injury Severity Score (ISS) 26.9 and 380 fractures of the femur (n = 173), pelvic ring (n = 71), acetabulum (n = 57), and/or spine (n = 79) were prospectively evaluated. The EAC protocol recommended definitive fixation within 36 h if lactate <4.0 mmol/L, pH ≥7.25, or base excess (BE) ≥-5.5 mmol/L. Complications including infections, sepsis, DVT, organ failure, pneumonia, acute respiratory distress syndrome (ARDS), and pulmonary embolism (PE) were identified and compared for early and delayed patients and with a historical cohort.

RESULTS

All 335 patients achieved the desired level of resuscitation within 36 h of injury. Two hundred sixty-nine (80%) were treated within 36 h, and 66 had protocol violations, treated on a delayed basis, due to surgeon choice in 71%. Complications occurred in 16.3% of patients fixed within 36 h and in 33.3% of delayed patients (p = 0.0009). Hospital and ICU stays were shorter in the early group: 9.5 versus 17.3 days and 4.4 versus 11.6 days, respectively, both p < 0.0001. This group of patients when compared with a historical cohort of 1443 similar patients with 1745 fractures had fewer complications (16.3 versus 22.1%, p = 0.017) and shorter length of stay (LOS) (p = 0.018).

CONCLUSIONS

Our EAC protocol recommends definitive fixation within 36 h in resuscitated patients. Early fixation was associated with fewer complications and shorter LOS. The EAC recommendations are safe and effective for the majority of severely injured patients with mechanically unstable femur, pelvis, acetabular, or spine fractures requiring fixation.

Treatment of Unstable Pelvic Ring Injuries

Pelvic fractures are classified according to the stability of the pelvic ring. Unlike stable pelvic fractures, which heal without complications, unstable fractures may lead to pelvic ring deformities, which cause severe complications. An orthopedic surgeon must determine the stability of the pelvic ring by radiography and physical examination of the patient in order to ensure early, prompt treatment. This article includes anatomy of the pelvic ring, classification of pelvic ring injuries, its treatment algorithm, and corresponding cases involving unstable pelvic ring injury.

[Polytrauma with pelvic fractures and severe thoracic trauma: does the timing of definitive pelvic fracture stabilization affect the clinical course?]

BACKGROUND

The aim of this study was to investigate the influence of the surgical timing in patients with pelvic fractures and severe chest trauma on the clinical course, especially on postoperative lung function.

METHODS

A total of 47 patients were included in a prospective dual observational study. The study investigated the clinical course depending on the time of operation based on the functional lung parameters, SAPS II, SOFA and total hospital stay.

RESULTS

The average ISS was 32±6, PTS was 34±11 and TTSS was 9±3 points. The pelvic fractures were stabilized definitively after an average of 7±2 days. The early stabilization correlated significantly with a lower TTSS and SAPS II on admission (p<0.05), shorter time of ventilation (p<0.05) and stay in the intensive care unit (p<0.01) as well as the decreased need for packed red blood cells (p<0.01).

CONCLUSIONS

In this study patients with pelvic fractures and thoracic trauma benefited positively from an earlier definitive pelvic fracture stabilization with respect to a shorter time of ventilation and stay in the intensive care unit due to a lower need for red cell concentrates.

Combined acetabulum and pelvic ring injuries

Combined fractures of the acetabulum and pelvic ring are more common than previously believed, with an incidence as high as 15.7%. Recent series that include combined injuries indicate that the incidence of lateral compression and anteroposterior compression pelvic ring injuries is similar and that transverse and both-column acetabular fractures are the most common acetabular fracture patterns. Combined injuries most often are the result of high-energy mechanisms, and, compared with patients who present with isolated pelvic or acetabular injury, patients with combined injury typically have higher injury severity scores, higher transfusion requirements, and lower systolic blood pressure, with reported mortality rates of 1.5% to 13%. Treatment requires a multidisciplinary approach. The first priority is resuscitation following the Advanced Trauma Life Support protocols. Once the patient is stable, acetabular fractures and pelvic ring injuries should be assessed individually, and the most appropriate treatment for each should be outlined. These treatments should then be integrated to develop the most appropriate overall treatment strategy. Although outcomes data are available for isolated acetabulum and pelvic ring disruptions, no such data currently exist for combined injuries.

The posterior approach to pelvic ring injuries: A technique for minimizing soft tissue complications

Surgical techniques and fixation strategies for the treatment of unstable posterior pelvic ring injuries continue to evolve. The safety of the posterior surgical approach in particular has been questioned due to historically high rates of wound related complications. More contemporary studies have shown lower infection rates, however concern still persists. These concerns for infection and wound necrosis have led, in part, to increased interest in closed reduction and percutaneous fixation for treatment of these injuries but an open posterior approach remains the optimal strategy in some injury patterns. We describe herein a modified posterior approach to the pelvis designed to minimize wound related complications and present our clinical results demonstrating wound complication rates consistent with contemporary publications.

Timing of orthopaedic surgery in multiple trauma patients: development of a protocol for early appropriate care

OBJECTIVES

The purpose was to define which clinical conditions warrant delay of definitive fixation for pelvis, femur, acetabulum, and spine fractures. A model was developed to predict the complications.

DESIGN

Statistical modeling based on retrospective database.

SETTING

Level 1 trauma center.

PATIENTS

A total of 1443 adults with pelvis (n = 291), acetabulum (n = 399), spine (n = 102), and/or proximal or diaphyseal femur (n = 851) fractures.

INTERVENTION

All fractures were treated surgically.

MAIN OUTCOME MEASUREMENTS

Univariate and multivariate analysis of variance assessed associations of parameters with complications. Logistic predictive models were developed with the incorporation of multiple fixed and random effect covariates. Odds ratios, F tests, and receiver operating characteristic curves were calculated.

RESULTS

Twelve percent had pulmonary complications, with 8.2% overall developing pneumonia. The pH and base excess values were lower (P < 0.0001) and the rate of improvement was also slower (all Ps < 0.007), with pneumonia or any pulmonary complication. Similarly, lactate values were greater with pulmonary complications (all Ps < 0.02), and lactate was the most specific predictor of complications. Chest injury was the strongest independent predictor of pulmonary complication. Initial lactate was a stronger predictor of pneumonia (P = 0.0006) than initial pH (P = 0.047) or the rate of improvement of pH over the first 8 hours (P = 0.0007). An uncomplicated course was associated with the absence of chest injury (P < 0.0001) and definitive fixation within 24 (P = 0.007) or 48 hours (P = 0.005). Models were developed to predict probability of complications with various injury combinations using specific laboratory parameters measuring residual acidosis.

CONCLUSIONS

Acidosis on presentation is associated with complications. Correction of pH within 8 hours to >7.25 was associated with fewer pulmonary complications. Presence and severity of chest injury, number of fractures, and timing of fixation are other significant variables to include in a predictive model and algorithm development for Early Appropriate Care. The goal is to minimize complications by definitive management of major skeletal injury once the patient has been adequately resuscitated.

Do patients with multiple system injury benefit from early fixation of unstable axial fractures? The effects of timing of surgery on initial hospital course

OBJECTIVES

We hypothesized that early definitive management (within 24 hours of injury) of mechanically unstable fractures of the pelvis, acetabulum, femur and spine would reduce complications and shorten length of stay.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

1005 skeletally mature patients with Injury Severity Score (ISS) ≥18 with pelvis (n = 259), acetabulum (n = 266), proximal or diaphyseal femur (n = 569), and/or thoracolumbar spine (n = 98) fractures. Chest (n = 447), abdomen (n = 328), and head (n = 155) injuries were present.

INTERVENTION

Definitive surgery was within 24 hours in 572 patients and after 24 hours in 433.

MAIN OUTCOME MEASUREMENTS

Complications related to the initial trauma episode included infections, sepsis, pneumonia, deep venous thrombosis, pulmonary embolism, acute respiratory distress syndrome (ARDS), organ failure, and death.

RESULTS

Days in intensive care unit (ICU) and total hospital stay were lower with early fixation (5.1 ± 8.8 vs. 8.4 ± 11.1 ICU days (P = 0.006); 10.5 ± 9.8 versus 14.3 ± 11.4 total days (P = 0.001), after adjusting for ISS and age. Fewer complications (24.0% vs. 35.8%, P = 0.040), ARDS (1.7% vs. 5.3%, P = 0.048), pneumonia (8.6% vs. 15.2%, P = 0.070), and sepsis (1.7% vs. 5.3%, P = 0.054) occurred with early versus delayed fixation. Logistic regression was used to account for differences in age and ISS between the early and delayed groups. Adjustment for severity of chest injury was included when analyzing pulmonary complications including pneumonia and ARDS.

CONCLUSIONS

Definitive fracture management within 24 hours resulted in shorter ICU and hospital stays and fewer complications and ARDS, after adjusting for age and associated injury types and severity. Surgical timing must be determined with consideration of the physiology of the patient and complexity of surgery. Parameters should be established within which it is safe to proceed with fixation. These data will serve as a baseline for comparison with prospective evaluation of such parameters in the future.

LEVEL OF EVIDENCE

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

Management of pubic symphysis diastasis with locking plates: a report of 11 cases

INTRODUCTION

The optimal method of fixation of symphyseal disruptions in pelvic ring injuries and post-operative rehabilitation is still debated. Options include two-hole, multi-hole and multiplanar plates. Post-operative rehabilitation can range from non-weight bearing bilaterally to full weight-bearing with crutches. Locking symphyseal plates have recently been introduced. There is a paucity of literature evaluating their use in such injuries. We present the first clinical case series of symphyseal diastasis managed with locking plates.

METHODS

A retrospective analysis of a single centre case series between August 2008 and December 2011 was conducted. A total of 11 patients; 2 females and 9 males with a mean age of 42 years were included. The mean radiological follow up was 27 weeks. Radiological failure and need for revision were evaluated.

RESULTS

4 patients sustained their injury as a result of a motorcycle accident, 3 patients following a car accident, 2 fell from a height and 2 had crush injuries. 9 patients had other concomitant injuries. The mechanism of injury was classified as anterior-posterior compression injury in 6 patients, vertical shear in 4 patients and combined mechanism in 1 patient. 6 patients required posterior pelvic fixation. Patients were mobilised fully or partially weight bearing. One patient had a significant radiological failure. All patients were asymptomatic at last follow-up and none required revision surgery.

CONCLUSION

Our series represents the first published clinical series of patients with symphyseal diastasis managed with locking plates. We have found the use of locking plates across the pubic symphysis to be safe with low complication rates despite early weight bearing.

An evaluation of three-dimensional image-guided technologies in percutaneous pelvic and acetabular lag screw placement

BACKGROUND

Percutaneous stabilization using three-dimensional (3D) navigation system is a promising treatment for pelvic and acetabular fractures. However, there are still some controversies regarding the use of 3D navigation to treat pelvic and acetabular fractures. The purpose of this study was to compare the Iso-C(3D) fluoroscopic navigation, standard fluoroscopy, and two-dimensional (2D) fluoroscopic navigation in placing percutaneous lag screws in pelvic specimens to better understand the merits of 3D navigation techniques.

METHODS

Fifty-four instrumentation procedures were performed in this study using six cadaveric pelvic specimens. Three groups were designated for different procedures and tests: group I, standard fluoroscopy; group II, 2D fluoroscopic navigation; and group III, Iso-C(3D) fluoroscopic navigation. Nine screws were placed in each pelvis, including four screws placed bilaterally through the ilium into S1 and S2 vertebrae, four screws placed bilaterally through anterior and posterior columns of acetabulum, and one screw placed through the pubic symphysis. 3D fluoroscopic techniques were evaluated to determine the accuracy of screw position, instrumentation time, and fluoroscopic time. The data were statistically analyzed using SPSS 13.0.

RESULTS

The malposition rate was 38.89%, 22.22%, and 0% in standard fluoroscopy, 2D fluoroscopic navigation, and Iso-C(3D) fluoroscopic navigation groups, respectively. There was no significant difference between standard fluoroscopy and 2D fluoroscopic navigation. Compared with Iso-C(3D) fluoroscopic navigation, there were significant differences (analysis of variance [ANOVA], P < 0.05). The mean instrumentation operating time using Iso-C(3D) fluoroscopic navigation technique was 15.4 ± 4.5 min. There were significant differences compared with standard fluoroscopy (31.5 ± 6.2 min) and 2D fluoroscopic navigation (26.3 ± 7.5 min; ANOVA, post hoc Scheffe, P < 0.01). The mean fluoroscopic time of Iso-C(3D) fluoroscopic navigation was 66 ± 4.8 min. Compared with standard fluoroscopy (132.8 ± 7.3 min) and 2D fluoroscopic navigation (47.7 ± 5.6 min), there were significant differences (ANOVA, post hoc least significant difference, P < 0.01).

CONCLUSIONS

In the present study, we compared Iso-C(3D) fluoroscopic navigation, 2D fluoroscopic navigation, and standard fluoroscopy. Iso-C(3D) fluoroscopic navigation showed a higher accuracy rate in positioning and a shorter instrumentation operating time. The fluoroscopic time was longer in Iso-C(3D) fluoroscopic navigation than that in standard fluoroscopy, indicating that radiation exposure can be moderately reduced in Iso-C(3D) fluoroscopic navigation operation, although the fluoroscopic time was the shortest in 2D fluoroscopic navigation.

Percutaneous iliosacral screw fixation in unstable pelvic ring lesions: the interest of O-ARM CT-guided navigation

INTRODUCTION

The reference surgical treatment for unstable posterior pelvic fracture is percutaneous iliosacral screw fixation, isolated or in association with other techniques. As there is a risk of passage outside the bone when performing screw fixation under fluoroscopy, new image-guidance techniques have been developed: fluoronavigation, peroperative 3D navigation, CT-linked navigation, etc. Since September 2011, our department has performed iliosacral screw fixation under CT control linked to navigation so as to optimize screw positioning. This innovative technology has been used in neurosurgery in our center since 2007, for disc implants, spinal fracture, vertebral arthrodesis and intracerebral localization.

MATERIAL AND METHODS

Six patients were treated by iliosacral screw fixation for posterior pelvic ring fracture lesion. The O-ARM (Medtronic(®)) computer-assisted surgical navigation system was used, combining surgical navigation and peroperative 3D imaging. This kind of osteosynthesis is suitable for non-displaced or prereduced fracture. A radiation dose report is drawn up at end of surgery.

DISCUSSION

Postoperative course does not differ from other percutaneous osteosynthesis techniques, combing the advantages of a percutaneous approach (reduced infection and blood-loss rates, etc.) while optimizing iliosacral screw positioning. To date, no radiation overexposure has been found.

CONCLUSION

The precision and safety of iliosacral screw fixation are now unequalled, meeting the basic computer-assisted surgery principles of reduced morbidity without overexposure to ionizing radiation. Indications for computer-assisted surgery should therefore be extended to iliosacral pathologies (arthritic, tumoral and inflammatory), non-displaced acetabular fracture, etc.

The outcome of surgically treated traumatic unstable pelvic fractures by open reduction and internal fixation

BACKGROUND

This study was performed to evaluate functional and radiological results of pelvic ring fractures treatment by open reduction and internal fixation.

METHODS

Thirty eight patients with unstable pelvic fractures, treated from 2002 to 2008 were retrospectively reviewed. The mean patients' age was 37 years (range 20 to 67). Twenty six patients were men (4 patients with type B and 22 patients with type C fracture) and 12 women (7 patients with type B and 5 patients with type C fracture). The commonest cause was a road traffic accident (N=37, about 97%). Internal fixation was done by plaque with ilioinguinal and Kocher-Langenbeek approaches for anterior, posterior pelvic wall and acetabulum fracture respectively. Quality of reduction was graded according to Majeed score system.

RESULTS

There were 11 type-C and 27 type-B pelvic fractures according to Tile's classification. Thirty six patients sustained additional injuries. The commonest additional injury was lower extremity fracture. The mean follow-up was 45.6 months (range 16 to 84 months).The functional outcome was excellent in 66%, good in 15%, fair in 11% and poor in 7% of the patients with type B pelvic fractures and functional outcome was excellent in 46%, good in 27%, fair in 27% and poor in 0% of the patients with type C pelvic fractures. There were four postoperative infections. No sexual functional problem was reported. Neurologic problem like Lateral cutaneous nerve of thigh injury recovered completely in 2 patients and partially in 2 patients. There was no significant relation between functional outcome and the site of fracture (P greater than 0.005).

CONCLUSIONS

Unstable pelvic ring fracture injuries should be managed surgically by rigid stabilization. It must be carried out as soon as the general condition of the patient permits, and even up to two weeks.

Surgical technique: a percutaneous method of subcutaneous fixation for the anterior pelvic ring: the pelvic bridge

BACKGROUND

Management of pelvic ring injuries using minimally invasive techniques may be desirable if reduction and stability can be achieved. We present a new technique, the anterior pelvic bridge, which is a percutaneous method of fixing the anterior pelvis through limited incisions over the iliac crest(s) and pubic symphysis.

DESCRIPTION OF TECHNIQUE

An incision is made over each anterior iliac crest and a 6- to 8-cm incision is centered over the symphysis. Either a locking reconstruction plate or a spinal rod is placed through a subcutaneous tunnel overlying the external oblique fascia in the subcutaneous tissue, and fixation into the iliac crest and pubis is achieved to effect stability.

METHODS

A randomized controlled trial comparing anterior pelvic external fixation (APEF) versus anterior pelvic internal fixation (APIF) for unstable pelvic ring injuries was begun in October 2010. Patients with unstable pelvic ring injuries were enrolled and followed with respect to fracture reduction, surgical pain, complications, and functional outcome scores.

RESULTS

As of January 2012, 23 patients met inclusion; however, 12 patients refused participation because of the possibility of external fixation, leaving 11 patients (four male, seven female) enrolled. At 6-month followup, there was a single pin tract infection in the APEF cohort and no complications or pain in the APIF cohort.

CONCLUSIONS

This clinical experience lends support to the use of a new minimally invasive technique to stabilize the anterior pelvis, particularly given the resistance on the part of patients to consider external fixation.

LEVEL OF EVIDENCE

Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Can lumbopelvic fixation salvage unstable complex sacral fractures?

BACKGROUND

Traditional screw or plate fixation options can be used to fix the majority of sacral fractures. However, these techniques are unreliable with dysmorphic upper sacral segments, U-fractures, osseous compression of neural elements, and previously failed fixation. Lumbopelvic fixation can potentially address these injuries but is a technically demanding procedure requiring spinal and pelvic fixation and it is unclear whether it reliably corrects the deformity and restores function.

QUESTIONS/PURPOSES

We therefore assessed reduction quality and loss of fixation, pain related to prominent hardware, subjective dysfunction measured by the Short Musculoskeletal Function Assessment (SMFA), and complications.

METHODS

We retrospectively reviewed 15 patients with unstable sacral fractures treated with lumbopelvic fixation between 2002 and 2010. Patients had radiographic monitoring regarding reduction quality and loss of fixation and clinical followup using the SMFA. The minimum followup was 12 months (mean, 23 months; range, 12-41 months).

RESULTS

Posterior reduction quality was 11 of 15 with less than 5 mm persistent displacement and four of 15 with 5 to 10 mm displacement. Loss of fixation was observed in one patient as a result of a technical error. Prominent hardware resulted in greater pain. Despite daily activity and bother subscores improving over time, we found long-term dysfunction in the SMFA. Eleven of the 15 patients were able to return to previous work or activities.

CONCLUSION

Complex posterior pelvic ring injuries of the sacrum not amenable to traditional fixation options can be salvaged with adherence to the technical details of lumbopelvic fixation. Hardware prominence and pain are markedly reduced with screw head recession. Long-term impairment is noted in patients with complex pelvic ring injuries requiring lumbopelvic fixation compared with normative data.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Persistent impairment after surgically treated lateral compression pelvic injury

BACKGROUND

Recently, fixation of lateral compression (LC) pelvic fractures has been advocated to improve patient comfort and to allow earlier mobilization without loss of reduction, thus minimizing adverse systemic effects. However, the degree of acceptable deformity and persistence of disability are unclear.

QUESTIONS/PURPOSES

We determined if (1) injury pattern; (2) demographics; (3) final posterior displacement; (4) L5/S1 involvement; (5) associated injuries; and (6) time influence outcome measurements, sexual dysfunction, and pain.

METHODS

We retrospectively reviewed 119 patients with unstable LC injuries treated surgically between 2000 and 2010. There were 52 males and 67 females; mean age was 39 years with a mean body mass index of 27 kg/m(2). All patients underwent clinical examination and radiographic imaging for instability and accompanying injuries. We obtained Short Musculoskeletal Function Assessment (SMFA). The minimum followup was 12 months (mean, 33 months; range, 12-100 months).

RESULTS

SMFA subscores were not affected by injury pattern and demographics. Posterior reduction was less than 5 mm with persistent displacement in 99 of 119 (83%). Displacement of 5 to 10 mm did not affect any SMFA subscore at any time interval. Patients with additional lower extremity injuries had worse SMFA scores. Function improved with time. A visual analog scale pain score of 4 or more at 6 months predicted pain and overall SMFA score at last followup.

CONCLUSIONS

Unstable LC pelvic ring injuries result in persistent disability based on validated outcome measurements. Near anatomical reduction can be achieved and maintained. While our findings need to be confirmed in studies with high rates of followup, patients with unstable LC pelvic injuries should be counseled concerning the possibility of some degree of persistent disability.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

What is the infection rate of the posterior approach to type C pelvic injuries?

BACKGROUND

Pelvic ring injuries with complete disruption of the posterior pelvis (AO/OTA Type C) benefit from reduction and stabilization. Open reduction in early reports had high infectious complications and many surgeons began using closed reduction and percutaneous fixation. Multiple smaller studies have reported low infection rates after a posterior approach, but these rates are not confirmed in larger series of diverse fractures.

QUESTIONS/PURPOSES

We therefore determined (1) the incidence of surgical site infectious complications after a posterior approach to the pelvis; and (2) whether secondary procedures other than surgical débridement are necessary as a result of the approach-related complications.

METHODS

We retrospectively reviewed all 236 patients (268 surgical approaches) with C type injuries treated with a posterior approach at six institutions before 1998 and at one institution from 1998 to 2005. Posterior injuries were classified anatomically as described by Letournel and the AO/OTA system. We recorded wound complications after surgery.

RESULTS

Surgical site infection occurred in eight of the 236 patients (3.4%) in the multicenter analysis. Treatment consisted of surgical débridement, wound closure, and antibiotics. No patients required soft tissue reconstruction as a result of the approach or infection.

CONCLUSION

Our data suggest with proper patient selection and the described surgical technique, there should be minimal risk for catastrophic wound complications or high infection rates as reported by others.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Surgical management of U-shaped sacral fractures: a systematic review of current treatment strategies

PURPOSE

U-shaped sacral fractures usually result from axial loading of the spine with simultaneous sacral pivoting due to a horizontal fracture which leads to a highly unstable spino-pelvic dissociation. Due to the rarity of these fractures, there is lack of an agreed treatment strategy.

METHODS

A thorough literature search was carried out to identify current treatment concepts. The studies were analysed for mechanism of injury, diagnostic imaging, associated injuries, type of surgery, follow-up times, complications, neurological, clinical and radiological outcome.

RESULTS

Sixty-three cases were found in 12 articles. No Class I, II or III evidence was found in the literature. The most common mechanism of injury was a fall or jump from height. Pre-operative neurological deficit was noted in 50 (94.3%) out of 53 cases (not available in 10 patients). The most used surgical options were spino-pelvic fixation with or without decompression and ilio-sacral screws. Post-operative complications occurred in 24 (38.1%) patients. Average follow-up time was 18.6 months (range 2-34 months). Full neurological recovery was noted in 20 cases, partial recovery in 14 and 9 patients had no neurological recovery (5 patients were lost in follow-up). Fracture healing was mentioned in 7 articles with only 1 case of fracture reduction loss.

CONCLUSION

From the current available data, an evidence based treatment strategy regarding outcome, neurological recovery or fracture healing could not be identified. Limited access and minimal-invasive surgery focussing on sacral reduction and restoration seems to offer comparable results to large spino-pelvic constructs with fewer complications and should be considered as the method of choice. If the fracture is highly unstable and displaced, spino-pelvic fixation might offer better stability.