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Pan Z, Qin L, Shi X, Hu F, Li Y, Li M, Chen M, Huang W, Li Y, Yang Z, Zhao J, Liu W. Plate fixation of inferior ramus in pubis-ischium ramus improves mechanical stability in Tile B pelvic injures: a cadaveric biomechanical analysis and early clinical experience. Biomed Eng Online 2024; 23:66. [PMID: 38997736 PMCID: PMC11241975 DOI: 10.1186/s12938-024-01262-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Management of inferior ramus of the pubis-ischium ramus remains controversial, and related research is sparse. The main intention of this study is to describe the biomechanical and clinical outcomes of pubis-ischium ramus fractures in Tile B pelvic injuries and to identify the feasibility and necessity of fixation of the inferior ramus of the pubis-ischium ramus. METHODS This study comprised two parts: a biomechanical test and a retrospective clinical study. For the biomechanical tests, Tile B-type pelvic injuries were modeled in six cadaver specimens by performing pubis-ischium osteotomies and disruption of the anterior and interosseous sacroiliac ligaments. The superior and/or inferior rami of the pubis-ischium ramus were repaired with reconstruction plates and separated into three groups (A, B, and C). Specimens were placed in the standing position and were loaded axially with two-leg support for three cycles at 500 N. The displacements of sacroiliac joints at osteotomy were measured with Vernier calipers and compared using statistical software. To investigate the clinical outcomes of this technique, 26 patients were retrospectively analyzed and divided into a superior ramus fixation group (Group D) and a combined superior and inferior ramus of the pubis-ischium ramus fixation group (Group E). The main outcome measures were time of operation, blood loss, postoperative radiographic reduction grading, and functional outcomes. RESULTS In the vertical loading test, Group E showed better pelvic ring stability than Group D (P < 0.05). However, the shift of the sacroiliac joints was almost identical among the three groups. In our clinical case series, all fractures in Group E achieved bony union. Group E demonstrated earlier weight-bearing functional exercise (2.54 ± 1.45 vs 4.77 ± 2.09; P = 0.004), earlier bony union (13.23 ± 2.89 vs 16.55 ± 3.11; P = 0.013), and better functional outcomes (89.77 ± 7.27 vs 82.38 ± 8.81; P = 0.028) than Group D. The incidence of sexual dysfunction was significantly lower in Group E than that in Group D (2/13 vs 7/13; P = 0.039). Bone nonunion occurred in two patients in Group D, and two patients in Group E had heterotopic ossification. None of the patients exhibited wound complications, infections, implant failures, or bone-implant interface failures. CONCLUSIONS Fixation of the inferior ramus of a pubis-ischium ramus fracture based on conventional fixation of the anterior pelvic ring is mechanically superior in cadaveric Tile B pelvic injury and shows rapid recovery, good functional outcomes, and low incidence of complications.
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Affiliation(s)
- Zhongjie Pan
- Department of Orthopedic Trauma & Hand and Foot Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Trauma Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Orthopaedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Lili Qin
- Department of Orthopedic Trauma & Hand and Foot Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiaorong Shi
- Department of Orthopaedic Joint Surgery and Sports Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Feng Hu
- Department of Orthopedic Trauma & Hand and Foot Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Trauma Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yuquan Li
- Department of Orthopedic Trauma & Hand and Foot Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Muwen Li
- Department of Orthopedics, The Peoples Hospital of Yudu County of Jiangxi Province, Ganzhou, Jiangxi, China
| | - Min Chen
- Department of Orthopedic Trauma & Hand and Foot Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wengui Huang
- Department of Orthopedic Trauma & Hand and Foot Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yuanjun Li
- Department of Orthopedic Trauma & Hand and Foot Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Zhi Yang
- Department of Orthopaedic Joint Surgery and Sports Medicine, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
| | - Jinmin Zhao
- Department of Orthopaedics Trauma and Hand Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
| | - Wei Liu
- Department of Orthopedic Trauma & Hand and Foot Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
- Department of Trauma Surgery, The Second Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
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Tripathy SK, Goyal T, Sen RK. Nonunions and malunions of the pelvis. Eur J Trauma Emerg Surg 2015; 41:335-42. [PMID: 26037993 DOI: 10.1007/s00068-014-0461-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 10/20/2014] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Neglected pelvic fractures manifesting as pelvic nonunion or malunion are usually due to inadequate initial fixation or negligence of the injury because of increased attention towards other associated life-threatening conditions. The management of such injuries is complex. A systematic review was conducted to spot the clinical manifestations, evaluation, management and outcome of pelvic nonunion and malunion. MATERIALS AND METHODS Two databases ("Pubmed" and "Google scholar") were searched to look for relevant literature on pelvic non-union and malunion. The search was limited to 'English language' and 'Human being'. RESULTS A total of 500 articles found, of which 10 articles were only reviewed which met the inclusion criteria. These articles discussed the clinical management and treatment of pelvic malunion and non-union following trauma without associated acetabular injury. CONCLUSION The usual presentations of pelvic non-union and malunion are pain, deformity, gait abnormality or instability. A detailed preoperative evaluation is essential as a majority of them have associated hip and spine injury which may be the cause of symptoms. Radiographs and 3D CT scans have helped surgeons in deciding the best way of management. The surgeries are usually complex and may need multiple-staged procedures. Soft tissue release, multiple osteotomies to achieve anatomical or near-anatomical reduction, augmentation of healing process using bone graft and stabilizing the nonunion/ osteotomy site using plates/screws/rods is the basic principle of surgery. Per-operative use of somato-sensory evoked potential evaluation helps the surgeon in preventing iatrogenic nerve injury. Despite these precautions and surgeries, most of the patients do not regain their preinjury functional activity.
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MESH Headings
- Female
- Fracture Fixation, Internal/adverse effects
- Fracture Fixation, Internal/methods
- Fracture Healing/physiology
- Fractures, Bone/diagnostic imaging
- Fractures, Bone/surgery
- Fractures, Malunited/diagnostic imaging
- Fractures, Malunited/etiology
- Fractures, Malunited/surgery
- Fractures, Ununited/diagnostic imaging
- Fractures, Ununited/etiology
- Fractures, Ununited/surgery
- Humans
- Male
- Pelvic Bones/diagnostic imaging
- Pelvic Bones/injuries
- Pelvic Bones/surgery
- Postoperative Complications/epidemiology
- Postoperative Complications/surgery
- Prognosis
- Radiography
- Risk Assessment
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Affiliation(s)
- S K Tripathy
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhubaneswar, 751019, India,
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Sacral Fracture Nonunion Treated by Bone Grafting through a Posterior Approach. Case Rep Orthop 2013; 2013:932521. [PMID: 23738173 PMCID: PMC3657433 DOI: 10.1155/2013/932521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 04/12/2013] [Indexed: 11/18/2022] Open
Abstract
Nonunion of a sacral fracture is a rare but serious clinical condition which can cause severe chronic pain, discomfort while sitting, and significant restriction of the level of activities. Fracture nonunions reportedly occur most often after nonoperative initial treatment or inappropriate operative treatment. We report a case of fracture nonunion of the sacrum and pubic rami that resulted from non-operative initial treatment, which was treated successfully using bone grafting through a posterior approach and CT-guided percutaneous iliosacral screw fixation combined with anterior external fixation. Although autologous bone grafting has been the gold standard for the treatment of pelvic fracture nonunions, little has been written describing the approach. We utilized a posterior approach for bone grafting, which could allow direct visualization of the nonunion site and preclude nerve root injury. By this procedure, we were able to obtain the healing of fracture nonunion, leading to pain relief and functional recovery.
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Kanakaris NK, Angoules AG, Nikolaou VS, Kontakis G, Giannoudis PV. Treatment and outcomes of pelvic malunions and nonunions: a systematic review. Clin Orthop Relat Res 2009; 467:2112-24. [PMID: 19184260 PMCID: PMC2706342 DOI: 10.1007/s11999-009-0712-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Accepted: 01/09/2009] [Indexed: 02/07/2023]
Abstract
UNLABELLED Although acute management of pelvic fractures and their long-term functional outcome have been widely documented, important information regarding malunion and nonunion of these fractures is sparse. Despite their relative rarity, malunions and nonunions cause disabling symptoms and have major socioeconomic implications. We analyzed the factors predisposing a pelvic injury to develop malunion/nonunion, the clinical presentation of these complications, and the efficacy of the reported operative protocols in 437 malunions/nonunions of 25 clinical studies. Treatment of these demanding complications appeared effective in the majority of the cases: overall union rates averaged 86.1%, pain relief as much as 93%, patient satisfaction 79%, and return to a preinjury level of activities 50%. Nevertheless, the patient should be informed about the incidence of perioperative complications, including neurologic injury (5.3%), symptomatic vein thrombosis (5.0%), pulmonary embolism (1.9%), and deep wound infection (1.6%). For a successful outcome, a thorough preoperative plan and methodical operative intervention are essential. In establishing effective evidence-based future clinical practice, the introduction of multicenter networks of pelvic trauma management appears a necessity. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nikolaos K. Kanakaris
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospital, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, Leeds, LS1 3EX UK
| | - Antonios G. Angoules
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospital, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, Leeds, LS1 3EX UK
| | - Vassilios S. Nikolaou
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospital, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, Leeds, LS1 3EX UK
| | - George Kontakis
- Department of Trauma and Orthopaedic Surgery, University Hospital of Crete, Crete, Greece
| | - Peter V. Giannoudis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospital, School of Medicine, University of Leeds, Leeds General Infirmary, Clarendon Wing, Level A, Great George Street, Leeds, LS1 3EX UK
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Rousseau MA, Laude F, Lazennec JY, Saillant G, Catonné Y. Two-stage surgical procedure for treating pelvic malunions. INTERNATIONAL ORTHOPAEDICS 2006; 30:338-41. [PMID: 16568330 PMCID: PMC3172769 DOI: 10.1007/s00264-006-0089-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Accepted: 02/04/2006] [Indexed: 11/30/2022]
Abstract
When surgically treated, pelvic-ring deformities due to post-traumatic malunions in adults usually require invasive three-stage (prone/supine/prone or supine/prone/supine) procedures. A standardised two-stage prone/supine procedure was developed by the authors. Technical points and first clinical results are presented. Malunuions related to Tile B and C types of fracture were successfully corrected.
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Affiliation(s)
- Marc-Antoine Rousseau
- Department of Orthopaedic Surgery, Hôpital Pitié - Salpétrière, 47 bd de l'Hôpital, 75013 Paris, France.
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Abstract
Whereas the initial treatment of pelvic fractures and their long-term outcomes have been well researched, little has been written concerning the surgical management of late pelvic malunions and nonunions causing residual pain and deformity. The available literature describes osteotomies usually done in multiple stages. The authors report the case of a progressive lateral compression pelvic disability treated in a unique one-stage procedure. This one-stage anterior approach allowed excellent correction of the deformity. In cases in which the deformity is purely one of internal or external rotation or medial or lateral displacement with no vertical migration, the authors think it is possible to adequately mobilize the pelvis to an anatomic reduction in a single-stage anterior approach. In cases in which vertical migration of the hemipelvis causes symptoms, it is probably necessary to approach the patient posteriorly to safely mobilize and adequately reduce the hemipelvis. With these factors in mind, the authors think a one-stage anterior approach can be an effective treatment for appropriately selected pelvic malunions.
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Affiliation(s)
- V A Frigon
- Department of Orthopaedic Surgery, Tulane University, New Orleans, Louisiana, USA
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