Functional outcome of internal fixation for pelvic ring fractures

Intelligent robot-assisted fracture reduction system for the treatment of unstable pelvic fractures

BACKGROUND

Precise and minimally invasive closed reduction is the premise of minimally invasive internal fixation. This paper aims to explore the safety and efficacy of a robot-assisted fracture reduction system (RAFR) in the treatment of pelvic fractures and to analyze its clinical advantages and existing problems.

METHODS

The RAFR system intelligently designed the optimal reduction path and target position based on a preoperative three-dimensional(3D) CT scan of the patient. The reduction robotic arm automatically reduced the affected hemipelvis according to the pre-planned reduction path.

RESULTS

The average residual displacement was the 6.65 ± 3.59 mm. According to Matta's criteria, there were 7 excellent, 10 good, and 3 fair, and the excellent and good rate was 85%. No postoperative complications occurred.

CONCLUSION

In our study, the RAFR system could complete accurate and minimally invasive closed reduction for most patients with unstable pelvic fractures, which could achieve good fracture reduction quality and short-term efficacy.

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

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

Effects of Iliosacral Joint Immobilization on Walking after Iliosacral Screw Fixation in Humans

BACKGROUND

Pelvis fractures are commonly stabilized by surgical implants to facilitate their healing. However, such implants immobilize the iliosacral joint for up to a year until removal. We report how iliosacral joint immobilization affects the walking of patients.

METHODS

The gaits of patients with immobilized sacroiliac joints after unstable pelvic fracture (n = 8; mean age: 45.63 ± 23.19; five females and three males) and sex- and age-matched healthy control individuals (n = 8; mean age: 46.50 ± 22.91; five females and three males) were recorded and analyzed using a motion capture system. The forces between the tread and feet were also recorded. Standard gait parameters as well as dynamic patterns of joint angles and moments of the lower extremities were analyzed using the simulation software OpenSim.

RESULTS

With the exception of hip extensor strength, the monitored joint parameters of the patients showed task-dependent deviations during walking, i.e., plantarflexor force was increased when stepping on an elevated surface, as were hip flexion and extensor moments, knee flexion and extensor moments, as well as ankle dorsiflexion and the associated negative plantarflexor force during stance on the elevated surface.

CONCLUSIONS

Iliosacral joint fixation causes reduced forward and upward propulsion and requires an extended range of hip motion in the sagittal plane. Patients show significant mobility limitation after iliosacral screw fixation.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality of Life from Return to Work and Sport Activities to Sexual Dysfunction after Surgical Treatment of Pelvic Ring Fractures

BACKGROUND

Pelvic ring fractures are life-threatening injuries that have a severe impact on patients' lives. The aim of this clinical study was to evaluate the outcome of surgical treatment in terms of Quality of Life (QoL), return to work, functional results and sport activities, and post-operative sexual dysfunction.

METHODS

A retrospective study with patients retrieved from a Level 1 Trauma Center was performed. Minimum patient follow-up was 12 months: QoL was evaluated with the SF-12 (Short Form Survey) questionnaire, return to work with the Workplace Activity Limitation Survey (WALS), functional outcomes and sport activities with the Harris Hip Score and Tegner activity score, respectively, and sexual function damage with a 0-10 NRS.

RESULTS

Seventy-six patients (41 males and 35 females) were enrolled, with a mean age at surgery of 56.4 years (18-89 years). Overall, their quality of life remained significantly affected, with male patients reporting worse WALS outcomes (p = 0.036), sexual damage (p = 0.001), and SF-12 Bodily Pain (p = 0.046) than females. In particular, 70.7% of men and 45.7% of women reported sexual limitations, and only 53.7% returned to their job, with 35.2% losing their job as a consequence of the pelvic ring disruption.

CONCLUSIONS

An important deterioration in general health state, return to work, and sexual function was documented in patients treated surgically for pelvic trauma, especially in male patients. There are disabling secondary sequels at all levels beyond the mere functional scores, and both patients and clinicians should be aware and have the correct expectations.

Intelligent robot-assisted minimally invasive reduction system for reduction of unstable pelvic fractures

OBJECTIVE

Currently, minimally invasive internal fixation is recommended for the surgical treatment of unstable pelvic fractures. The premise and difficulty of minimally invasive internal fixation are minimally invasive reduction of fractures. This review aimed to investigate the indications, surgical strategy and techniques, safety, and efficacy of intelligent robot-assisted fracture reduction (RAFR) system of pelvic ring injuries.

METHODS

This retrospective study reviewed a case series from March 2021 to November 2021. A total of 22 patients with unstable pelvic fracture injuries underwent minimally invasive internal fixations. All pelvic ring fractures were reduced with our intelligent RAFR system. The robot system intelligently designs the optimal position and reduction path based on the patient's preoperative 3D CT. During the operation, the three-dimensional visualization of the fracture is realized through image registration, and the Robot completes the automatic reduction of the fracture. The global 3D point cloud error between the preoperative planning results and the actual postoperative reduction results was calculated. The postoperative reduction results of residual displacement were graded by the Matta Criteria.

RESULTS

Minimally invasive closed reduction procedures were completed in all 22 cases with our RAFR system. The average global 3D point cloud reduction error between the preoperative planning results and the actual postoperative reduction results was 3.41mm±1.83mm. The mean residual displacement was 4.61mm±3.29mm. Given the Matta criteria, 16 cases were excellent, five were good, and one was fair, with an excellent and good rate of 95.5%.

CONCLUSION

Our new pelvic fracture reduction robot system can complete intelligent and minimally invasive fracture reduction for most patients with unstable pelvic fractures. The system has intelligent reduction position and path planning and realizes stable pelvis control through a unique holding arm and a robotic arm. The operation process will not cause additional damage to the patient, which fully meets the clinical requirements. Our study demonstrated the safety and effectiveness of our robotic reduction system and its applicability and usability in clinical practice, thus paving the way towards Robot minimally invasive pelvic fracture surgeries.

Sacral osteotomy combined with triangular osteosynthesis in the treatment of malunion and nonunion of vertically displaced pelvic fractures

Background

Malunion and nonunion of vertically displaced pelvic fractures result in lower limb length discrepancies, claudication, and pain. There have been few previous reports of this type of corrective surgery for these old pelvic fractures. We present a surgical technique of sacral osteotomy combined with triangular osteosynthesis in the treatment of malunion and nonunion of vertically displaced pelvic fractures and report on its short-term clinical results.

Methods

We retrospectively reviewed nine patients (five males and four females) with malunion or nonunion of vertically displaced pelvic fractures treated with sacral osteotomy and triangular osteosynthesis from April 2015 to January 2020. The age ranged from 14 to 45 years (average, 30.7 years). The time from injury to deformity correction surgery ranged from 3 months to 5 years (average, 12.8 months). The vertical displacement of a unilateral hemipelvis was 3.0–4.5 cm (average, 3.80 cm). According to AO/OTA classification at the initial fracture, there are eight cases in type C1.3 and one case in type C3.3. Sacral osteotomy and triangular osteosynthesis were used in all nine patients. The degree of unilateral hemipelvic reduction was assessed postoperatively based on measurements from the anteroposterior (AP) X-ray. Majeed score and pain visual analog scale (VAS) were used to assess the therapeutic effect of the patients during follow-up.

Results

In all nine patients, postoperative AP X-ray showed correction displacement of 1.7–3.9 cm (average, 3.20 cm). All the patients were followed up for 6–36 months (average, 12.7 months). At the last follow-up, the Majeed score of pelvic fracture increased from an average of 53.9 points (30–84 points) preoperatively to 87.0 points (72–94 points), and the VAS score for pain decreased from an average of 6.0 points (4–8 points) preoperatively to 1.2 points (0–3 points). None had complications like infection, implant broken, screw loosening, iatrogenic nerve, and blood vessel injury.

Conclusion

Sacral osteotomy combined with triangular osteosynthesis for the treatment of pelvic malunion and nonunion caused by sacral fractures can correct significantly vertical displacement of a unilateral pelvis, prolong limb length, and reconstruct the stability of a pelvic ring, achieving good clinical results.

Pelvic Malunion: A Systematic Review, Dichotomy of Definitions and Treatment

Background and Objectives: Pelvic nonunion and malunion have been documented as rare complications in pelvic fractures and literature describing these topics is severely limited. Articles dedicated solely to pelvic malunion are nearly nonexistent. We conducted a literature search with the goal of providing a summary of the definition, causes, treatment strategies, and outcomes of pelvic malunion correction. Materials and Methods: An initial review of the literature was performed using the PubMed, ScienceDirect, and Cochrane Database of Systematic Reviews databases. Search terms used were “malunion” AND “pelvic” OR “pelvis”. Duplicate articles, non-English language articles without translations available and non-human subject studies were excluded. Results: Eleven original publications were found describing experiences with pelvic malunion. Seven of the articles were exclusively dedicated to the topic of pelvic fracture malunion, and only two reported on a series of patients treated for malunion with variably staged procedures. Most reports define pelvic pain as the main indication for surgical correction, along with gait disturbance, standing or sitting imbalance, and urinary or sexual dysfunction. Radiographically, vertical displacement of one to two centimeters and rotation of the hemipelvis of fifteen degrees or more have been described in defining malunion. No treatment algorithms exist, and each patient is treated with a unique work-up and operative plan due to the complexity of the problem. Only one series reported a patient satisfaction rate of 75% following malunion treatment. Conclusions: Pelvic malunion is a rare complication of pelvic ring injury and is seldom discussed in the literature. We found two small case series reporting exclusively on malunion treatment and complications. While some of the combination studies made the distinction in the diagnosis of malunion and nonunion, they rarely differentiated the treatment outcomes between the two categories. This paper describes pelvic malunion and highlights the need for more research into surgical outcomes of treatment specifically regarding functionality, patient satisfaction, and recurrence of preoperative symptoms.

Preclinical evaluation of a prototype freehand drill video guidance system for orthopedic surgery

Purpose: Internal fixation of pelvic fractures is a challenging task requiring the placement of instrumentation within complex three-dimensional bone corridors, typically guided by fluoroscopy. We report a system for two- and three-dimensional guidance using a drill-mounted video camera and fiducial markers with evaluation in first preclinical studies. Approach: The system uses a camera affixed to a surgical drill and multimodality (optical and radio-opaque) markers for real-time trajectory visualization in fluoroscopy and/or CT. Improvements to a previously reported prototype include hardware components (mount, camera, and fiducials) and software (including a system for detecting marker perturbation) to address practical requirements necessary for translation to clinical studies. Phantom and cadaver experiments were performed to quantify the accuracy of video-fluoroscopy and video-CT registration, the ability to detect marker perturbation, and the conformance in placing guidewires along realistic pelvic trajectories. The performance was evaluated in terms of geometric accuracy and conformance within bone corridors. Results: The studies demonstrated successful guidewire delivery in a cadaver, with a median entry point error of 1.00 mm (1.56 mm IQR) and median angular error of 1.94 deg (1.23 deg IQR). Such accuracy was sufficient to guide K-wire placement through five of the six trajectories investigated with a strong level of conformance within bone corridors. The sixth case demonstrated a cortical breach due to extrema in the registration error. The system was able to detect marker perturbations and alert the user to potential registration issues. Feasible workflows were identified for orthopedic-trauma scenarios involving emergent cases (with no preoperative imaging) or cases with preoperative CT. Conclusions: A prototype system for guidewire placement was developed providing guidance that is potentially compatible with orthopedic-trauma workflow. First preclinical (cadaver) studies demonstrated accurate guidance of K-wire placement in pelvic bone corridors and the ability to automatically detect perturbations that degrade registration accuracy. The preclinical prototype demonstrated performance and utility supporting translation to clinical studies.

Effect of Percutaneous Posterior Pelvic Ring Reduction and Fixation on Patient-Reported Outcomes

OBJECTIVES

The purpose of this study was to assess patient outcomes using Patient-Reported Outcomes Measurements Information System (PROMIS) scores after closed reduction and percutaneous fixation (CRPF) of the posterior pelvic ring and determine whether quality of reduction affects the outcomes.

DESIGN

This is a retrospective cohort study.

SETTING

The study involved a Level I trauma center.

PATIENTS

The study included 46 adult patients with operatively treated pelvic ring injuries (63% OTA/AO 61-B) who underwent CRPF between 2014 and 2018 at a single institution.

INTERVENTION

The intervention involved closed reduction and percutaneous posterior pelvic ring fixation.

MAIN OUTCOME MEASUREMENTS

The main outcome measurements were postoperative patient PROMIS scores, including physical function, pain interference, anxiety, and depression, and radiographic measurements of postoperative displacement and pelvic deformity.

RESULTS

After CRPF, PROMIS scores of physical function, pain interference, and anxiety were significantly improved at the time of final follow-up when compared with the first postoperative visit. The amount of malreduction or pelvic deformity did not significantly affect outcome scores; however, results were limited by small sample size.

CONCLUSIONS

CRPF of posterior pelvic ring injuries results in good functional and radiographic outcomes. Degree of malreduction may not affect outcomes as much as previously believed.

LEVEL OF EVIDENCE

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

Management of LC Type I (LC-1) Pelvic Injuries with Complete Sacral Fracture: Comparison of Solitary Anterior Fixation with Combined Anterior-Posterior Fixation

BACKGROUND

Management of LC-1 type pelvic injuries, particularly in patients with complete sacral fracture (LC-1 PICSF, OTA type 61-B2.1), remains controversial. Specific indications for solitary fixation remain unclear, and there is a paucity of outcomes data in comparison to combined fixation. We undertook a retrospective study in patients with LC-1 PICSFs to compare outcomes between solitary anterior fixation and combined anterior-posterior fixation.

METHODS

A retrospective cohort study was conducted with enrollment from 2016 to 2018 at a single tertiary-referral center in China. Adults with operatively managed LC-1 PICSFs were enrolled. Patients with sacral displacement < 1 cm as assessed by axial CT received solitary anterior ring fixation (group A); patients with displacement ≥ 1 cm received combined fixation of both the anterior and posterior rings (group B). Reduction was confirmed by manipulation under anesthesia. Patients followed up for at least 24 months postoperatively. Primary outcome was function (Majeed score). Secondary outcomes included intraoperative characteristics, pain (VAS score), quality of fracture reduction (Tornetta and Matta radiographic grading), rate of nonunion, early weight-bearing status, and complication rate.

RESULTS

68 (89%) of 76 enrolled patients completed follow-up. Patients in group A exhibited improved operative times, less time under fluoroscopy, and less blood loss as compared to group B. There were no significant differences between groups A and B regarding quality of fracture reduction, rate of union, functional outcomes, or rate of complications. Notably, group B patients were more likely to achieve full early weight-bearing.

CONCLUSION

LC-1 PFCSFs can get benefits from ORIF; the treatment algorithm should be differently made following the degree of the sacral fractures displacement. Less than 1 cm sacral fracture displacement may get good functional outcomes from solitary anterior fixation. However, for the sacral fractures displacement greater or equal to 1 cm, both the anterior and posterior pelvic rings should be surgical stabilization.

Cross-Cultural Adaptation and Psychometric Properties of the Lithuanian Version of the Majeed Pelvic Score

Background and Objectives: There are no valid patient-based pelvic ring function assessment tools in Lithuania. The most widely used instrument is the Majeed Pelvic Score (MPS), which is proven to be an effective tool for assessing pelvic function after pelvic injuries. The aims of our study were: (1) the translation and cross-cultural adaptation of the MPS for the Lithuanian-speaking population, (2) to test the psychometric properties of the Lithuanian version of the MPS (MPS-LT) at follow-up two-time points after pelvic fractures. Materials and Methods: The MPS was translated and culturally adapted. Psychometric properties of the MPS-LT were determined in one patient group (n = 40) at two time-points during follow-up examination from 1.5 to 3 months (mean 2 months) and from 11 to 20 months (mean 12 months). Results: At the mean time of 2 months after trauma, Cronbach’s α of the MPS-LT was 0.65. Correlation of the MPS-LT with the Iowa Pelvic Score (IPS) was r = 0.84 (p < 0.001), and with the Lithuanian SF-36, PCS was r = 0.53 (p < 0.001). At the mean time follow-up of 12 months, Cronbach’s α was 0.86, correlation with the IPS was r = 0.92 (p < 0.001), and with the Lithuanian SF-36, PCS – r = 0.82 (p < 0.001). At the 2-month follow-up, neither floor nor ceiling effects were reached, but at 12 months, 27.5% of patients reached the ceiling effect, while none reached the floor effect. The effect size of the MPS-LT was 1.66. Conclusions: The MPS-LT has limited ability to measure functional outcomes at 2 months after pelvic fracture. In contrast, at the 12-month follow-up examination, the MPS-LT had a good ability to assess pelvic function, and it was sensitive to health changes. The MPS-LT can be used as a pelvic function assessment tool after pelvic fractures for the Lithuanian-speaking population.

Deep infection following reconstruction of pelvic fractures: prevalence, characteristics, and predisposing risk factors

Purpose

To identify the incidence, risk factors, and treatment course of patients who developed deep infection following fixation of pelvic fractures.

Methods

Over a period of 8 years patients who underwent pelvic reconstruction in our institution and developed postoperative infection were included. Exclusion criteria were pathological fractures and infections that were not secondary to post-traumatic reconstruction. The mean time of follow-up was 43.6 months (33–144). For comparison purposes, we randomly selected patients that underwent pelvic fracture fixation from our database (control group). A logistic regression was fitted to patient characteristics including age, sex, ISS, and diabetic status.

Results

Out of 858 patients, 18 (2.1%) (12 males), with a mean age of 41 (18–73) met the inclusion criteria. The control group consisted of 82 patients with a mean age of 41 years (18–72). The mean ISS was 27.7 and 17.6 in the infection and control group, respectively. The mean time from pelvic reconstruction to the diagnosis of infection was 20 days (7–80). The median number of trips to theatre was 3 (1–16). Methicillin-resistant Staphylococcus aureus (MRSA) was the most frequently isolated organism in the years prior to 2012. Eradication was achieved in 93% of the patients. The most important risk factors for deep infection were ISS (OR 1.08, 1.03–1.13), posterior sacral approach (OR 17.03, 1.49–194.40), and diabetes (OR 36.85, 3.54–383.70).

Conclusion

In this retrospective case–control study, deep infection following pelvic trauma was rare. A number of patient-, injury- and surgery-related factors have shown strong correlation with this serious complication.

Comparison of One-Year Functional Outcomes and Quality of Life between Posterior Pelvic Ring Fixation and Combined Anterior-Posterior Pelvic Ring Fixation after Lateral Compression (B2 Type) Pelvic Fracture

Background and Objectives: The treatment algorithm of lateral compression B2 type pelvic fractures are still under debate. Some authors advocate conservative treatment, while others recommend surgical approach. The clear indications for isolated anterior or posterior ring fixation or combined anterior-posterior pelvic ring fixation of B2 type fractures remain unclear. The aim of this study was to compare the functional outcomes and quality of life after isolated posterior pelvic ring fixation and combined anterior-posterior pelvic ring fixation for the treatment of B2 pelvic fractures. Materials and Methods: Patients aged 18 to 65 years with B2 type pelvic fracture hospitalized in a single trauma centre over a period of 3 years were included in the research. Based on the attending surgeon’s preference, patients were treated with isolated posterior or combined anterior-posterior pelvic fixation. The quality of life and pelvic function were assessed using SF-36 and Majeed questionnaires, respectively. Patients filled in the questionnaires twice: during the first hospitalization (concerning their pre-trauma state—timepoint I) and one-year after the injury (timepoint II). Results: A cohort of 32 patients with B2 type pelvic fracture was enrolled in the analysis: 23 (72%) were female and 9 (28%) were male. The mean age was 35.3 ± 11.9 years. In this cohort 13 (41%) patients underwent isolated posterior pelvic ring fixation (group I) and 19 (59%) patients underwent combined anterior-posterior pelvic ring fixation (group II). No statistically significant differences were observed between the groups in both timepoints concerning Majeed, SF-36 PCS and MCS scores. However, in both groups Majeed and SF-36 PCS scores were statistically significantly lower one year after pelvic fracture compared with pre-trauma state, while SF-36 MCS scores did not differ. Conclusions: No differences were found in quality of life and functional outcomes between isolated posterior pelvic ring fixation and combined anterior-posterior fixation for the treatment of B2 type pelvic fractures.

Drill-mounted video guidance for orthopaedic trauma surgery

Purpose: Percutaneous fracture fixation is a challenging procedure that requires accurate interpretation of fluoroscopic images to insert guidewires through narrow bone corridors. We present a guidance system with a video camera mounted onboard the surgical drill to achieve real-time augmentation of the drill trajectory in fluoroscopy and/or CT. Approach: The camera was mounted on the drill and calibrated with respect to the drill axis. Markers identifiable in both video and fluoroscopy are placed about the surgical field and co-registered by feature correspondences. If available, a preoperative CT can also be co-registered by 3D-2D image registration. Real-time guidance is achieved by virtual overlay of the registered drill axis on fluoroscopy or in CT. Performance was evaluated in terms of target registration error (TRE), conformance within clinically relevant pelvic bone corridors, and runtime. Results: Registration of the drill axis to fluoroscopy demonstrated median TRE of 0.9 mm and 2.0 deg when solved with two views (e.g., anteroposterior and lateral) and five markers visible in both video and fluoroscopy-more than sufficient to provide Kirschner wire (K-wire) conformance within common pelvic bone corridors. Registration accuracy was reduced when solved with a single fluoroscopic view ( TRE = 3.4    mm and 2.7 deg) but was also sufficient for K-wire conformance within pelvic bone corridors. Registration was robust with as few as four markers visible within the field of view. Runtime of the initial implementation allowed fluoroscopy overlay and/or 3D CT navigation with freehand manipulation of the drill up to 10    frames / s . Conclusions: A drill-mounted video guidance system was developed to assist with K-wire placement. Overall workflow is compatible with fluoroscopically guided orthopaedic trauma surgery and does not require markers to be placed in preoperative CT. The initial prototype demonstrates accuracy and runtime that could improve the accuracy of K-wire placement, motivating future work for translation to clinical studies.

Percutaneous triangular stabilization of type 3 and type 4 fragility fractures of the pelvis usually leads to fracture healing despite high revision rates

This is a monocentric, retrospective study to analyze radiological findings as well as perioperative and postoperative complications in patients who underwent percutaneous triangular stabilization of type 3 and type 4 fragility fractures of the pelvis. From August 2017 to December 2018, 20 patients were treated surgically. Thirteen patients (65%) were followed-up and received a CT scan of the pelvis after an average time of 14.8 months. A total of 5 patients (38%) had to undergo revision surgery, 2 patients (15%) immediately, 3 patients (23%) in the interval. In 84.6% no fracture line was visible in the sacrum. Fracture healing of the anterior pelvic ring was observed in all cases. Our results show that percutaneous triangular stabilization of type 3 and type 4 fragility fractures of the pelvis usually leads to fracture healing. Radiological signs of loosening were observed in 62%, an implant removal due to symptomatic loosening was necessary in 23%.

Factors affecting quality of life after pelvic fracture

INTRODUCTION

Functional outcome and health-related quality of life (HRQOL) after pelvis fracture is suboptimal; majority of the patients do not return to their preinjury activities. Many researchers reported that late morbidity in pelvis fracture is associated with severity of the fracture, associated trauma, pelvic fracture-related complications and methods of treatment.

MATERIAL AND METHODS

One hundred and twelve patients with pelvis fracture who were treated either conservatively (n = 88) or surgically (n = 24) with a minimum of two years follow up were evaluated clinically and radiologically. The clinical outcome was evaluated using Majeed score and self-reported Short Musculoskeletal Function Assessment (SMFA). Their HRQOL was evaluated using the 36-item Short Form Survey (SF-36) and WHOQOL-BREF questionnaires. The fracture-displacement in the anterior or posterior pelvis ring was measured from the anteroposterior radiograph or inlet/outlet view.

RESULTS

The average Majeed score was 76.65 ± 14.73 (range, 36 to 96). There were 81 patients with good to excellent outcomes and 31 patients with poor to fair outcomes. The average SF-36 Physical Component Summary (PCS) score was 47.71 ± 7.88 (range, 27.3 to 61.5) and SF-36 Mental Component Summary (MCS) was 49.20 ± 9.37 (range, 23.1 to 56.8). The functional level of the general population in the physical and mental domain was achieved in 48.23% and 65.3% of pelvic-fractured patients respectively. General population norms were achieved in 56.3%, 63.4%, 65.2% and 84.8% of patients in WHOQOL-BREF domain one, two, three and four respectively. The patients had significantly worse functional outcome and HRQOL if residual displacement was > 1 cm. Age, sex, associated injuries and injury mechanism were not affecting the HRQOL in patients with acceptable residual displacement of ≤ 1 cm.

CONCLUSION

Pelvic fracture with the residual displacement of ≤ 1 cm in the sacroiliac joint/symphysis pubis result in better functional outcome and HRQOL. Injury mechanism and associated injury have no impact on the HRQOL if the residual displacement is within the acceptable limit.

Calibration and Registration of a Freehand Video-Guided Surgical Drill for Orthopaedic Trauma

Pelvic trauma surgical procedures rely heavily on guidance with 2D fluoroscopy views for navigation in complex bone corridors. This "fluoro-hunting" paradigm results in extended radiation exposure and possible suboptimal guidewire placement from limited visualization of the fractures site with overlapped anatomy in 2D fluoroscopy. A novel computer vision-based navigation system for freehand guidewire insertion is proposed. The navigation framework is compatible with the rapid workflow in trauma surgery and bridges the gap between intraoperative fluoroscopy and preoperative CT images. The system uses a drill-mounted camera to detect and track poses of simple multimodality (optical/radiographic) markers for registration of the drill axis to fluoroscopy and, in turn, to CT. Surgical navigation is achieved with real-time display of the drill axis position on fluoroscopy views and, optionally, in 3D on the preoperative CT. The camera was corrected for lens distortion effects and calibrated for 3D pose estimation. Custom marker jigs were constructed to calibrate the drill axis and tooltip with respect to the camera frame. A testing platform for evaluation of the navigation system was developed, including a robotic arm for precise, repeatable, placement of the drill. Experiments were conducted for hand-eye calibration between the drill-mounted camera and the robot using the Park and Martin solver. Experiments using checkerboard calibration demonstrated subpixel accuracy [-0.01 ± 0.23 px] for camera distortion correction. The drill axis was calibrated using a cylindrical model and demonstrated sub-mm accuracy [0.14 ± 0.70 mm] and sub-degree angular deviation.

Inaccuracies in the Use of the Majeed Pelvic Outcome Score: A Systematic Literature Review

OBJECTIVES

To evaluate the accuracy with which the Majeed Pelvic Score has been reported in the English literature.

DATA SOURCES

Databases used to search for literature were PubMed, Embase, and Ovid, restricted to English language from inception to October 2, 2018.

STUDY SELECTION

Search words used were: Majeed, pelvis, and outcome.

DATA EXTRACTION

Articles were assessed for descriptions of scoring and proper reporting of Majeed Pelvic Outcome Score.

DATA SYNTHESIS

Descriptive statistics were used to report the outcome of our findings.

CONCLUSIONS

Ninty-two English articles were identified. Twenty-four (26%) articles were identified as including methodology related to the use and scoring of the Majeed Pelvic score. The remaining 68 presented mean Majeed scores with no methodological information. None (0/92) discussed how the range of possible scores for the most severe function was applied. Six (7%) reported adjusted scores for patients not working. Three (3%) included a discussion of the scores as adjusted for patients working before injury compared with those not working. Ten (11%) addressed the categorization of scores by excellent to poor describing what raw scores defined those categories. We observed poor accuracy and notable inconsistency in the use and reporting of the Majeed Pelvic Outcome Score in the literature. These data demonstrate that interpretation and comparison of research reporting this score should be done cautiously. Future studies should include specific information as to how the Majeed instrument calculated to allow for verification of the presented scores and subsequent conclusions.

The Longitudinal Short-, Medium-, and Long-Term Functional Recovery After Unstable Pelvic Ring Injuries

OBJECTIVES

Describe the trajectory of functional recovery for patients with surgically treated unstable pelvic ring injuries from baseline to 5 years.

DESIGN

Prospective cohort study.

SETTING

Level I Trauma Center.

PATIENTS/PARTICIPANTS

One hundred eight adult patients with surgically treated pelvic fractures (72% OTA/AO 61 B1-B3 and 28% OTA/AO 61 C1-C3) were enrolled into the institutions orthopaedic trauma database between 2004 and 2015. The cohort was 78% men with a mean age of 44.9 years and injury severity score of 16.9.

INTERVENTION

Surgical pelvic stabilization.

MAIN OUTCOME MEASUREMENTS

Function was measured at baseline and prospectively at 6 months, 1, and 5 years postoperatively using the Short Form-36 Physical Component Score (SF-36 PCS). The trajectory was mapped, and the proportion of patients achieving a minimal clinically important difference (MCID) between time points was determined.

RESULTS

The mean SF-36 PCS improved for the entire group between 6 and 12 months (P = 0.001) and between 1 and 5 years (P = 0.02), but did not return to baseline at 5 years (P < 0.0001). The proportion of patients achieving a MCID between 6 and 12 months and 1 and 5 years was 75% and 60%, respectively. The functional level was similar between type B and C groups at baseline (P = 0.5) and 6 months (P = 0.2); however, the type B cohort reported higher scores at 1 year (P = 0.01) and 5 years (P = 0.01). Neither group regained their baseline function (P < 0.0001).

CONCLUSIONS

Functional recovery for patients with surgically treated pelvic fractures is characterized by an initial decline in function, followed by sharp improvement between 6 and 12 months, and continued steady improvement between 1 and 5 years. Type B injuries show better early recovery than type C and reach a higher level of function at the final follow-up. Despite the proportion of patients achieving MCID, patients do not regain the preinjury level of function.

LEVEL OF EVIDENCE

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

CT-guided fixation of pelvic fractures after high-energy trauma, by interventional radiologists: technical and clinical outcome

OBJECTIVE

The aim of our study was to evaluate screw placement accuracy, safety, complications, and clinical outcomes including functional and pain score, in 32 patients treated with CT-guided pelvic ring fixation after high-energy trauma.

MATERIALS AND METHODS

Consecutive patients who were treated by CT-guided fixation of sacral or acetabular fractures after high-energy trauma were included. All procedures were performed under general anesthesia, with dual CT and fluoroscopic guidance, by interventional radiologists. Fractures were minimally displaced or reduced unstable posterior pelvic ring disruptions, with or without sacroiliac disjunction (Tile B or C) and minimally displaced acetabular fractures. The primary outcome evaluated was screw accuracy. Secondary outcomes included patient radiation exposure, duration of the procedure, complications, clinical functional score (Majeed score), and pain scale (VAS, visual analog scale) evaluation during a follow-up period from 4 to 30 months postoperatively.

RESULTS

Thirty-two patients were included (mean age 46) and 62 screws were inserted. Screw placement was correct in 90.3% of patients (95% of screws). Mean procedure duration was 67 min and mean patient radiation exposure was 965 mGy cm. Mean follow-up was 13 months and no complications were observed. The mean Majeed score at final follow-up was 84/100 and the mean VAS was 1.6/10.

CONCLUSION

This technique is an effective and safe procedure in specific cases of pelvic ring and acetabulum fractures. It allows accurate screw placement in a minimally invasive manner, leading to effective management of poly-traumatized patients.

KEY POINTS

• CT-guided pelvic ring fixation, including sacroiliac and acetabular fractures, is an effective and safe procedure. • It allows accurate and minimally invasive screw placement, leading to effective management of poly-traumatized patients. • Multidisciplinary cooperation is essential to ensure efficiency and safety.

Patient-reported Outcome in Surgically Treated Pelvic Ring Injuries at 5 Years Post-surgery

BACKGROUND AND AIMS

Long-term prospective data on patient-reported outcome after surgical treatment of pelvic ring injuries are scarce. This study aimed at describing results at 5 years post-surgery using validated outcome measures.

PATIENTS AND METHODS

Patients admitted for surgical treatment of pelvic ring injuries were prospectively included and asked to report their outcome at 1, 2 and 5 years post-surgery using two patient-reported outcome measures: the generic Short-Form 36 and the condition-specific pelvic discomfort index. Data were evaluated using mixed-effects linear models.

RESULTS

There were 108 patients (68 males and 40 females), mean age 38 years. Injury type according to the AO/OTA-classification was B-type in 68 patients and C-type in 40 patients. No domain of the Short-Form 36 reached norm values at 5 years post-surgery. Females reported a worse outcome than males concerning general health (p < 0.01) at 5 years. Recovery of physical function (p < 0.01), mental health (p = 0.04), and pain (p = 0.01) was observed for males at 5 years compared to earlier assessments, while females on the contrary described more pain at this time-point (p = 0.03). Mean pelvic discomfort index at 5 years was 27, indicating moderate residual pelvic discomfort overall. Males reported less pelvic discomfort than females at 5 years (p = 0.02) and improved when compared to results at 2 years (p = 0.02), while females did not. Influence of age, fracture type, and presence of associated injuries on patient-reported outcome was limited.

CONCLUSION

Surgically treated pelvic ring injuries are associated with long-standing negative effects on patient-reported outcome. Males report a better outcome than females at 5 years post-surgery.

Quality of life after pelvic ring fractures: Long-term outcomes. A multicentre study

AIMS

This study was conducted to determine long-term (5-10 years) health-related quality of life (HRQOL) and ceiling effects in patients with a pelvic ring fracture.

PATIENTS AND METHODS

We identified all patients with pelvic ring fractures after high-energy trauma admitted at two level 1 trauma centres in the Netherlands from 2006 to 2011. Patients were asked to complete the Majeed Pelvic Score (MPS), EuroQol-5D (EQ-5D) and Short Musculoskeletal Function Assessment (SMFA) questionnaires. HRQOL analysis used a multiple linear regression model.

RESULTS

In total, 136 patients returned the questionnaires. The median follow-up period was 8.7 years. The mean MPS and EQ-5D-VAS scores were 85.1 and 74, respectively. The mean EQ-5D index scores were 0.87, 0.81 and 0.82 in Tile B, A and C patients, respectively. The mean SMFA index was 24. A ceiling effect was observed for 1/3 of the patients. After multiple linear regression analysis, no differences were identified among the various fracture types for each questionnaire, with the exception of 2 subscales of the MPS.

CONCLUSION

Patients who suffer pelvic ring fractures generally have good HRQOL outcomes after 5-10 years. No significant differences were found among different fracture types. Long-term follow-up of patients with Tile C fractures is warranted.

Differences in the Majeed Pelvic Score Between Injured and Uninjured Patients

OBJECTIVES

To investigate the differences in the Majeed Pelvic Score (MPS) between injured and uninjured patients. Discriminative power and applicability of the MPS in elderly are also investigated, and a norm score for the MPS in the Netherlands is provided.

DESIGN

Cross-sectional cohort study.

SETTING

Urban level 1 trauma center.

PATIENTS/PARTICIPANTS

One hundred ninety-five patients with pelvic ring disruptions; 101 61A, 67 61B, and 27 61C (OTA/AO classification; 6%, 27%, and 82% surgically treated, respectively); mean follow-up 29 months (range 6-61); 554 adults from the Longitudinal Internet Studies for the Social Sciences panel (control group). Participants were divided into 2 age groups: <65 and ≥65 years (respectively, maximum MPS: 100 and 80 points).

MAIN OUTCOME MEASUREMENTS

Majeed Pelvic Score.

RESULTS

Patients <65 years of age (81.6) scored lower on the MPS when compared with the control group (88.3, P < 0.001). Patients ≥65 years of age (68.1) scored lower on the MPS when compared with the control group (72.0, P = 0.006). In the <65 group, the patient group scored worse on the sexual function, work, and standing dimensions (P < 0.001). In the ≥65 group, the patient group scored worse on the dimensions sitting (P = 0.03) and standing (P < 0.001) and better on the dimension pain (P = 0.001).

CONCLUSIONS

Compared with the general population, patients with pelvic ring disruption in both age groups perceived some health problems in almost all MPS domains. The MPS discriminates well enough to provide information about the mobility of elderly patients.

LEVEL OF EVIDENCE

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

Long-Term Patient-Reported Functional Outcome of Polytraumatized Patients With Operatively Treated Pelvic Fractures

OBJECTIVES

To report the long-term functional outcome of a cohort of patients with operatively treated unstable pelvic fractures using validated patient-reported outcome measures.

DESIGN

Long-term observational study using prospective and retrospective data.

SETTING

Tertiary referral pelvic trauma center, Bristol, United Kingdom.

PATIENTS

Seventy-four polytraumatized patients with operatively treated unstable pelvic ring injuries (50 OTA/AO type B and 24 OTA/AO type C, mean Injury Severity Score 17) treated between 1994 and 2005.

INTERVENTION

Sixty-four (86%) patients were treated with internal fixation. The remaining 10 patients (14%) were treated with either combined percutaneous posterior fixation and anterior external fixation or external fixation in isolation.

MAIN OUTCOME

Patient-reported functional outcome.

MEASUREMENTS

Short Form-36, with UK norm-based comparator scores and EQ-5D-3L.

RESULTS

Patients were between 11 and 22 years after injury (mean 15 years). We found no significant association between fracture classification and outcome score, but compared with age- and sex-matched scores for a UK population, differences were statistically significant in 3 of the 8 domains of health: physical function (P = 0.04), bodily pain (P = 0.001), and vitality (P = 0.001). The level of disability remained constant for these patients compared with their patient-reported outcome measure scores reported 8 years previously.

CONCLUSION

Patients who sustain an unstable pelvic fracture continue to have significant functional limitations compared with an uninjured population. These changes were not found to be related to age, injury pattern, genitourinary injury, or neurological injury. Functional outcome scores did not change over the 2 long-term time points.

LEVEL OF EVIDENCE

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

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

Background

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

Methods

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

Results

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

Limitations

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

Conclusion

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

How to cite this article

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

A novel hybrid fixation (percutaneous anterior pelvic bridge with K-wire) for the treatment of traumatic pelvic ring injury: A prospective study

BACKGROUND

The aim of the study was to introduce a novel percutaneous technique for the treatment of pelvic ring injuries using a percutaneous anterior pelvic bridge (PAPB) with K-wire.

METHODS

From December 2010 to November 2016, a prospective study of 86 patients with anterior pelvic ring fracture (42 utilizing PAPB with K-wire and 44 utilizing PAPB). Patient data was retrieved from electronic charts. Radiological results were assessed based on the Matta criteria system to evaluate the quality of the reduction and time to union. Functional outcomes were evaluated using the Majeed scoring system. Postoperative complications were also recorded.

RESULTS

Age, sex, cause of injury, type of fracture, functional recovery, American Society of Anesthesiologists classification, union time, Majeed scoring and complications did not differ significantly between the two groups. The quality of the reduction and pain scoring differed between groups (all p-values < 0.05). Group A got better reduction and less pain scoring.

CONCLUSIONS

The novel percutaneous technique with hybrid fixation using PAPB with K-wire is a successful alternative for the treatment of pelvic ring injuries, which results in better quality of reduction and less pain scoring outcomes comparing to PAPB. May the PAPB + K-wire could provide more stability.

Biomechanical evaluation of location and mode of failure in three screw fixations for a comminuted transforaminal sacral fracture model

Background

Pelvic ring–comminuted transforaminal sacral fracture injuries are rotationally and vertically unstable and have a high rate of failure.

Objective

Our study purpose was to use three-dimensional (3D) optical tracking to detect onset location of bone–implant interface failure and measure the distances and angles between screws and line of applied force for correlation to strength of pelvic fracture fixation techniques.

Methods

3D relative motion across sacral–rami fractures and screws relative to bone was measured with an optical tracking system. Synthetic pelves were used. Comminuted transforaminal sacral–rami fractures were modelled. Each pelvis was stabilised by either (1) two iliosacral screws in S1, (2) one transsacral screw in S1 and one iliosacral screw in S1 and (3) one trans-alar screw in S1 and one iliosacral screw in S1; groups 4–6 consisted of fixation groups with addition of anterior inferior iliac pelvic external fixator. Eighteen-instrumented pelvic models with right ilium fixed simulate single-leg stance. Load was applied to centre of S1 superior endplate. Five cycles of torque was initially applied, sequentially increased until permanent deformation occurred. Five cycles of axial load compression was next applied, sequentially increased until permanent deformation occurred, followed by axial loading to catastrophic failure. A Student t test was used to determine significance (p < 0.05).

Results

The model, protocol and 3D optical system have the ability to locate how sub-catastrophic failures initiate. Our results indicate failure of all screw-based constructs is due to localised bone failure (screw pull-in push-out at the ipsilateral ilium–screw interface, not in sacrum); thus, no difference was observed when not supplemented with external fixation.

Conclusion

Inclusion of external fixation improved resistance only to torsional loading.

Translational Potential of this Article

Patients with comminuted transforaminal sacral–ipsilateral rami fractures benefit from this fixation.

Patient-related quality of life after pelvic ring fractures in elderly

PURPOSE

Pelvic ring fractures, occurring in elderly patients are a challenging problem. Little known is about the patient-related outcome after these injuries. The primary objective of this study is to evaluate the quality of life after pelvic ring injuries in patients aged over 60 years.

METHODS

Patients (≥ 60 years) with pelvic ring fractures treated in our trauma department between 2004 and 2014 were included. Next to patient data, injury-related details as well as treatment details were assessed. After a follow-up of at least two years, the survival rate and the patient-related outcome were evaluated using the SF-36 and the EQ-5D score.

RESULTS

One hundred ninety-six patients (138 women; 58 men; mean age 75.3 ± 7.8 years) were identified. Ninety-six patients were treated operatively, 100 patients conservatively. The overall complication rate was significantly lower for conservatively compared to operatively treated patients (conservatively 18% vs. operatively 33%; p = 0.014). The total mortality rate over 2 years is 29% with no significant difference of the two-year survival rate (2-year survival rate: operatively 77% vs. non-operatively 65%; p = 0.126). Fifty-five patients completed the SF-36 and EQ-5D score after a mean follow-up of 4.2 ± 2.9 years. The mean physical component score of the SF-36 is 33.6 ± 8.3, and the mean mental component score is 45.3 ± 8.4. The mean EQ-5D VAS reached 62.5 ± 27.9.

CONCLUSION

Elderly patients with pelvic ring fractures show a high mortality rate and a limited patient-related outcome. While the complication rate of conservatively treated patients is lower compared to operated patients, the two year survival rate is steady.

Robot-assisted percutaneous screw placement combined with pelvic internal fixator for minimally invasive treatment of unstable pelvic ring fractures

Purpose

The purpose of this study was to investigate the safety and efficacy of the combination of robot‐assisted percutaneous screw placement and pelvic internal fixator (INFIX) for minimally invasive treatment of unstable anterior and posterior pelvic ring injuries.

Methods

From September 2016 to June 2017, twenty‐four patients with unstable anterior and posterior pelvic ring injuries were treated with TiRobot‐assisted percutaneous sacroiliac cannulated screw fixation on the posterior pelvic ring combined with robot‐assisted pedicle screw placement in the anterior inferior iliac spine along with INFIX on the anterior pelvic ring. The results of the treatment, including surgery duration, fluoroscopy frequency, total drilling, amount of blood loss, fracture healing time, and postoperative functional outcomes were recorded and compared with another 21 similar patients who underwent conventional manual positioning surgery.

Results

The TiRobot group incurred significantly shorter duration of surgery; less fluoroscopy frequency, intraoperative bleeding, and total drilling than in the conventional group (P < 0.05). Postoperative radiological follow‐up showed that all screws were in the safe area and no screw penetrated the cortex. All wounds healed by primary intention and no iatrogenic damage to the blood vessels, nerves, and organs occurred. Patients showed good tolerance to INFIX and reported no discomfort. The mean follow‐up duration was 5.4 months; the fractures were all healed, no loss of reduction occurred, and the mean Majeed score at the last follow‐up did not show any difference.

Conclusion

TiRobot‐assisted percutaneous screw placement combined with INFIX for the anterior and posterior pelvic ring injuries is accurate, safe, less invasive, and shows satisfactory efficacy, suggesting it is a better method for minimally invasive treatment of unstable pelvic ring fractures.

Quality of life after pelvic ring fractures: A cross-sectional study

BACKGROUND

Pelvic ring fractures might have consequences for health-related quality of life (HrQoL). The main purpose of this study was to evaluate patients' HrQoL after a pelvic ring fracture, considering the patients' characteristics. A cross-sectional study was conducted using the EuroQoL-5D (EQ-5D) and the Majeed pelvic score (MPS).

METHODS

One hundred ninety-five patients (86%) with pelvic ring fractures who were conservatively or surgically treated in a level 1 trauma centre between 2011 and 2015 were included in this study (mean follow up: 29 months, range 6-61). A telephone survey of all patients was conducted. Multiple logistic and linear regression analyses were used for statistical assessment with the EQ-5D and the MPS. The MPS results were split into two age groups with a cut-off point of 65 years.

RESULTS

EQ-5D: The mean EQ-5D Visual Analogue Scale (VAS) for Tiles A-C was, respectively, 74 (SD 18), 74 (SD 19) and 67 (SD 21), and the mean EQ-5D index score was, respectively, 0.81 (SD 0.23), 0.77 (SD 0.30) and 0.71 (SD 0.26). Compared with Tile A, patients in Tile C experienced significantly more pain (odds ratio 6.28 (1.73-22.82 95% CI), P < 0.01). Clinically relevant differences in EQ-5D scores between Tile A and Tile C were seen in the domains of usual activities and anxiety and in the index score. MPS: The mean MPS of Tiles A-C patients in the <65 group was, respectively, 86 (SD 15), 81 (SD 17), and 74 (SD 16), and in the ≥65 group, it was, respectively, 69 (SD 15), 68 (SD 15) and 66 (SD 9). In the <65 group, significant differences in MPS results between the Tile groups regarding pain (P < 0.01) and the total MPS score (P = 0.04) were seen. Neither significant regression coefficients nor clinically relevant differences were found in the ≥65 group.

CONCLUSIONS

In conclusion, our study showed that pain was increased in patients with Tile C fractures, compared with Tiles A and B. Furthermore, Tile C patients had significantly lower EQ-5D index and total MPS scores. However, these problems were not seen in the ≥65 group.

Patient-related outcome of unstable pelvic ring fractures stabilized with a minimal invasive screw-rod system

Background

Clinical and radiological outcomes of operatively treated unstable pelvic ring fractures are well documented, whereas little is known about the patient’s related outcome. The purpose of this study is to evaluate the patient-reported outcome after minimal invasive treatment of pelvic ring fractures using the SF-36 and EQ-5D medical outcome scores.

Methods

Patients with unstable pelvic ring fractures treated in our trauma department with a minimal invasive screw-rod system between 01/2004 and 12/2014 were included. Next to patient data (sex, age), injury related details (fracture type, additional injuries, Injury Severity Score (ISS)) as well as operation details (method, time to operation, general complications, adverse events associated with the surgical procedure, revision surgery, fracture reduction) were assessed. The patient related outcome was evaluated using the SF-36 and the EQ-5D score.

Results

A total of 105 patients (57 men; 48 women; mean age 56 ± 21 years) were identified as candidates for the study. 60 patients completed the SF-36 and EQ-5D score after a mean follow-up of five years (60.5 months (14-142 months)). Of these patients 77% were multiply injured with a mean ISS of 26 ± 19. Within the respondent group 22% showed type B and 78% type C pelvic ring fractures. In 82% the dorsal pelvic ring fracture was stabilized using a minimally invasive transiliac internal fixator, in 18% an iliolumbar fixation was performed respectively. The mean physical component score of the SF-36 was 37.9 ± 12.0, the mean mental component score was 49.8 ± 12.5. The mean EQ-5D VAS reached 70.5 ± 24.4.

Conclusion

Patients being multiply injured and treated with minimal invasive treated dorsal pelvic ring fractures were suffering more especially concerning physical domains compared to the healthy reference population. Nevertheless, the overall patient-related outcome is comparable to pelvic ring fractures in general.

Trial Registration Number

Clinical Trial Registry University of Regensburg Z-2017-0878-3. Registered 22. July 2017. Retrospectively registered.

Management of the open book APC II pelvis: Survey results from pelvic and acetabular surgeons in the United Kingdom

The results of this questionnaire show that the opinion of pelvic and acetabular surgeons in the UK and Republic of Ireland vary as to the best method of fixation for APC II pelvic injuries. A single anterior plate and single sacroiliac joint (SIJ) screw was the most popular fixation method, chosen by 34%. 74% favour a single, opposed to two orthogonal anterior plates. Posterior fixation supplementing anterior plating is preferred by 63% of surgeons, 58% use a single versus 42% two SIJ screws. Case by case assessment and intraoperative screening to assess stability is essential when considering whether to stabilise the SIJ.

Percutaneous iliosacral screw fixation in unstable pelvic fractures

Surgical treatment of unstable pelvic fractures Type C, has a vertical instability that is not controlled by traction and supine; therefore, orthopedic and functional treatments undertaken by default are sources of complications. The closed reduction with percutaneous sacroiliac fixation solves the problem of vertical instability; but at the cost of learning the method. Five patients with unstable pelvic fractures; were treated by percutaneous sacroiliac fixation. This reliable and useful method in the stabilization of unstable pelvic fractures. Good functional results are predictable based on the severity of pelvic fractures and associated injuries. The low rates of complications and the minimally invasive nature are the advantages of this method.

Does MRI help in the pre - operative evaluation of pelvic fracture urethral distraction defect? - A pilot study

Objectives

To study the usefulness of MRI in preoperative evaluation of PFUDD. Can MRI provide additional information on urethral distraction defect (UDD) and cause of erectile dysfunction (ED)?

Materials and Methods

In this prospective study, consecutive male patients presenting with PFUDD were included from Feb 2011 till Dec 2012. Those with traumatic spinal cord injury and pre-existing ED were excluded. Patients were assessed using IIEF questionnaire, retrograde urethrogram and micturating cystourethrogram (RGU+MCU) and MRI pelvis. Primary end point was erectile function and secondary end point was surgical outcome.

Results

Twenty patients were included in this study. Fourteen patients (70%) were ≤40years; fifteen patients (75%) had ED, seven patients (35%) had severe ED. MRI findings associated with ED were longer median UDD (23mm vs. 15mm, p=0.07), cavernosal injury (100%, p=0.53), rectal injury (100%, p=0.53), retropubic scarring (60%, p=0.62) and prostatic displacement (60%, p=0.99). Twelve patients (60%) had a good surgical outcome, five (25%) had an acceptable outcome, three (15%) had a poor outcome. Poor surgical outcome was associated with rectal injury (66.7%, p=0.08), cavernosal injury (25%, p=0.19), retropubic scarring (18.1%, p=0.99) and prostatic displacement (16.7%, p=0.99). Five patients with normal erections had good surgical outcome. Three patients with ED had poor outcome (20%, p=0.20).

Conclusions

MRI did not offer significant advantage over MCU in the subgroup of men with normal erections. Cavernosal injury noted on MRI strongly correlated with ED. Role of MRI may be limited to the subgroup with ED or an inconclusive MCU.

Late reconstruction of severe open-book deformities of the pelvis - tips and tricks

BACKGROUND

The primary goal of treatment for open book pelvic injuries after high-energy trauma is to control haemorrhage and to close the pelvic ring anatomically. Less commonly, patients may present late with malunion or non-union.

METHODS

We reviewed five operatively treated patients with delayed severe open book deformities who had a diastasis of more than 6 cm. We describe the pre-operative workup, surgical strategy and challenges experienced. They specifically include: extensive scar and contracture formation, malunion, urogenital prolapse and difficult reduction of vertical shear element. A 5 to 15-point clinical scoring system based on quality of life regarding pain, ambulation, social function, continence control and presence of prolapse is proposed.

RESULTS

One elderly patient had early mortality after surgery. The other four patients had quality of life improvement by 3 to 5 points after one year. Correction is often clinically successful despite technical challenges and unpredictable radiological results.

CONCLUSION

External fixator and the C-clamp are good reduction tools. Powerful implants should be used and fixation of the posterior ring is mandatory. Staged urogenital and pelvic floor reconstruction is recommended before bony reconstruction to minimize the risk of wound contamination. Patients receiving this complex procedure have a good chance for improvement in pain and functional status.

Chronic low back pain after lumbosacral fracture due to sagittal and frontal vertebral imbalance

PROBLEM AND HYPOTHESIS

Over time, some patients with unilateral or bilateral lumbosacral injuries experience chronic low back pain. We studied the sagittal and frontal balance in a population with these injuries to determine whether mismatch in the pelvic and lumbar angles are associated with chronic low back pain.

PATIENTS AND METHODS

Patients with posterior pelvic ring fractures (Tile C1, C2, C3 and A3.3) that had healed were included. Foreign patients and those with an associated spinal or acetabular fracture or nonunion were excluded. The review consisted of subjective questionnaires, a clinical examination, and standing A/P and lateral stereoradiographic views. The pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), measured lumbar lordosis (LLm), T9 sagittal offset, leg discrepancy (LD) and lateral curvature (LC). The expected lumbar lordosis (LLe) was calculated using the formula LLe=PI+9°. We defined lumbopelvic mismatch (LPM) as the difference between LLm and LLe being equal or greater than 25% of LLe.

RESULTS

Fifteen patients were reviewed after an average follow-up of 8.8 years [5.4-15]. There were four Tile C1, five Tile C2, five Tile C3 and one Tile A3.3 fracture. Ten of the 15 patients had low back pain. The mean angles were: LLm 49.6° and LLe 71.9° (P=0.002), PT 21.3°, SS 44.1°, PI 62.9° in patients with low back pain and LLm 57.4° and LLe 63.2° (P=0.55), PT 13°, SS 43.1°, PI 54.2° in those without. LPM was present in 9 patients, 8 of who had low back pain (P=0.02). Six patients, all of whom had low back pain, had a mean LC of 7.5° [4.5-23] (P=0.02). The mean LD was 0.77cm.

DISCUSSION

The findings of this small study suggest that patients who experience low back pain after their posterior arch of the pelvic ring fracture has healed, have a lumbopelvic mismatch. Early treatment of these patients should aim to reestablish the anatomy of the pelvic base relative to the frontal and sagittal balance.

LEVEL OF EVIDENCE

IV.

Functional outcome of patients with unstable pelvic ring fracture

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

The Effect of Transiliac-Transsacral Screw Fixation for Pelvic Ring Injuries on the Uninjured Sacroiliac Joint

OBJECTIVE

To evaluate the functional outcomes and pain in patients with unilateral posterior pelvic ring injuries treated with transiliac-transsacral screw fixation compared with unilateral iliosacral screw fixation.

DESIGN

Retrospective comparative study.

SETTING

Three academic level 1 trauma centers.

PATIENTS/PARTICIPANTS

From a group of 866 patients with pelvic ring injuries treated surgically, 86 patients with unilateral pelvic ring injuries treated with transiliac-transsacral screws and 97 patients treated with unilateral iliosacral screws were identified. Thirty-six patients treated with transiliac-transsacral fixation and 26 patients treated with unilateral iliosacral screws met the inclusion criteria and participated.

INTERVENTION

Patients were treated surgically for unstable pelvic ring injuries with either unilateral iliosacral screws or transiliac-transsacral screws at the discretion of the treating surgeon.

MAIN OUTCOME MEASUREMENT

Majeed Pelvic Score.

RESULTS

There was no significant difference in Majeed Pelvic Scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws (72.8 ± 23.7 vs. 70.4 ± 19.0, P = 0.66). There was no difference in side-specific Numeric Rating Scale pain scores between patients treated with transiliac-transsacral screws and those treated with unilateral iliosacral screws on the injured side (2.5 ± 3.1 vs. 2.0 ± 2.4, P = 0.46) or the uninjured side (1.7 ± 2.8 vs. 0.8 ± 1.7, P = 0.12). Mean follow-up was greater than 3 years with no difference between the groups (mean 1270 vs. 1242 days, P = 0.84).

CONCLUSIONS

Treatment of unilateral pelvic ring injuries with transiliac-transsacral screws does not adversely affect or improve patient outcomes or subjective pain scores when compared with those treated with unilateral iliosacral screws.

LEVEL OF EVIDENCE

Therapeutic Level III. 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.

Are work return and leaves of absence predictable after an unstable pelvic ring injury?

Background

Resuming work after surgical treatment of an unstable pelvic ring injury is often impeded because of residual disability. The aim of this study was to test which factors influence return to work, ability to return to the same job function as before the injury, leaves of absence, and incapacitation after sustaining a pelvic fracture.

Materials and methods

We performed a retrospective study on patients with surgically treated pelvic fractures. Medical records were reviewed to document patients’ demographic data, the extent of follow-up care, diagnosis of the injury (according to the Tile system of classification), type of surgical treatment, injury severity, and the time from trauma to definitive surgery. We also recorded the classification of patients’ physical status according to the American Society of Anesthesiologists (ASA) and details about admission to the intensive care unit (ICU). Patients were interviewed to note the number of days before returning to work and their ability to maintain their previously held jobs.

Results

Fifty patients were included in the study, and their mean age was 46.3 ± 12.6 years. The median time to return to work was 195 days. Twelve patients (24 %) lost their jobs and 17 (34 %) resumed their previous job with a change of tasks. ICU admission and time from trauma to definitive surgery were negatively correlated with return to the previously held job. Returning to the same job tasks was not associated with any of the factors investigated. Polytrauma, ICU admission, and time from trauma to definitive surgery were associated with longer leaves of absence.

Conclusions

Work reintegration after pelvic ring injuries is a major issue for patients and health care systems: 58 % of patients were not able to return to or lost their job. Factors correlated with leaves of absence were injury severity, delayed definitive fixation, and ICU admission.

Level of evidence

IV (case series).

Percutaneous iliosacral screw fixation after osteoporotic posterior ring fractures of the pelvis reduces pain significantly in elderly patients

INTRODUCTION

Osteoporotic posterior ring fractures of the pelvis are common injuries in the elderly, but the treatment of these fractures still remains controversial. Percutaneous iliosacral screw fixation is one surgical option if conservative treatment cannot provide sufficient pain reduction. The aim of this study is to provide short-term results of elderly patients with percutaneous screw fixation.

METHODS

30 patients with posterior ring fractures were treated between 12/2009 and 01/2014 with percutaneous iliosacral screw fixation. Patients' mean age was 78.4 years. Concerning short-term outcome, we focused on initial pain level and postoperative pain reduction together with intra- and postoperative complications.

RESULTS

The average hospital stay was 23.7 days, with surgical treatment performed after an average of 9.2 days. 90% of our patients were female. All 30 patients had a lower level of pain at discharge compared with admission or immediately prior to surgery. The difference in pain level at admission compared with the pain level upon discharge showed a mean reduction from 6.8 to 1.8 with a statistically significant change (P≤0.001). 24 of 30 patients had no registered complications, one screw malpositioning with postoperative nerve irritation occurred.

DISCUSSION

Conventional percutaneous iliosacral screw fixation is a successful operative treatment for elderly patients with persistent lower back pain after unstable posterior ring fractures of the pelvis. Intra- and postoperative complications are rare, so this treatment can be regarded as a safe procedure.

LEVEL OF EVIDENCE

IV (retrospective study).

Simultaneous occurrence of a severe Morel-Lavallée lesion and gluteal muscle necrosis as a sequela of transcatheter angiographic embolization following pelvic fracture: a case report

Introduction

Morel-Lavallée lesions are posttraumatic hemolymphatic collections caused by disruption of the interfascial planes between the subcutaneous soft tissue and muscle. Severe peripelvic Morel-Lavallée lesions have rarely been reported in the literature. By contrast, a number of cases of gluteal muscle necrosis following transcatheter angiographic embolization for pelvic fracture have been reported. Each entity can result in severe infection and sepsis, and the mortality rate in such cases is quite high. However, to date, no previous reports have described a case in which these life-threatening entities occurred simultaneously.

Case presentation

A 32-year-old Asian man simultaneously developed severe peripelvic Morel-Lavallée lesions and gluteal muscle necrosis with sepsis following transcatheter angiographic embolization after an unstable pelvic fracture. Extremely large skin and soft tissue defects, which were untreatable with any commonly used flaps, were generated after repeated debridement. In addition, a deep-bone infection was suspected in his left fractured iliac bone, while motor function was almost completely lost in his left leg, possibly as a sequela of transcatheter angiographic embolization. As a result of his condition, a left hemipelvectomy was unavoidable. A pedicled fillet flap from his sacrificed left limb was used for the treatment of the defects and to provide a durable base for a prosthesis. Our patient survived and returned to his previous job 24 months after the surgery wearing a prosthetic left leg.

Conclusion

As illustrated by the present case, severe peripelvic Morel-Lavallée lesions and gluteal muscle necrosis following transcatheter angiographic embolization can occur simultaneously after unstable pelvic fractures. Physicians should recognize that these entities can result in life-threatening sepsis and, therefore, should attempt to detect them as early as possible. When hemipelvectomy is unavoidable, a pedicled upper and lower leg in-continuity fillet flap may provide satisfactory outcomes.

Patient-reported health minimum 8 years after operatively treated displaced sacral fractures: a prospective cohort study

OBJECTIVES

To assess long-term patient-reported health (PRH) after displaced sacral fractures, its association with clinical outcomes, and changes over time.

DESIGN

Prospective, longitudinal single-cohort study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

From 1996 to 2001, 31 consecutive patients with operatively treated displaced sacral fractures participated in a 1-year follow-up. Twenty-eight of them were available for the present long-term follow-up of mean 10.7 years (range, 8.1-13.4) postinjury.

INTERVENTION

Surgical treatment with open or closed reduction and internal fixation.

MAIN OUTCOME MEASURES

PRH was the main outcome, determined by the Short Form-36 (SF-36). Data were also collected on pain (using a visual analog scale), bladder function, neurologic deficits in the lower extremities, bowel function, sexual function, activities of daily living, and employment status. SF-36 scores from the present study were compared with norm-based scores for the Norwegian general population and 1-year scores.

RESULTS

At the present follow-up, mean 10.7 years (range, 8.1-13.4) postinjury, SF-36 scores were significantly lower than norm-based scores for all domains except mental health. No significant changes were observed between 1-year scores and scores from the present study. Pain correlated significantly with poor scores in the domains physical functioning (P = 0.05), role physical (P = 0.01), bodily pain (P = 0.003), general health (P = 0.007), and role emotional (P = 0.006). Sexual dysfunction correlated with poor social functioning (P = 0.013) and poor role emotional (P = 0.04); and bowel dysfunction with bodily pain (P = 0.02) and poor role emotional (P = 0.03). No correlations were found between SF-36 scores and bladder dysfunction or neurologic deficits.

CONCLUSIONS

Patients with displaced sacral fractures reported poor PRH, mean 10.7 years after the initial injury, with no significant improvement compared with 1-year follow-up. A significant association was found between pain and PRH.

LEVEL OF EVIDENCE

Therapeutic level IV. description of levels of evidence.