Functional outcomes in women after high-energy pelvic ring injury

Does Fracture Pattern Really Predict Displacement of LC1 Sacral Fractures?

BACKGROUND

Operative management of minimally displaced lateral compression type-1 (LC1) pelvic ring injuries remains controversial. We aimed to assess the proportion of LC1 pelvic fractures that displaced following nonoperative management as a function of specific ring fracture patterns, and we quantified the magnitude of this displacement.

METHODS

A retrospective review of the billing registry of a level-I trauma center was performed. Two hundred and seventy-three patients with a high-energy LC1 pelvic ring fracture and <5 mm of sacral displacement were included. The fracture pattern was characterized with use of computed tomography (CT) scans and radiographs. Absolute and interval pelvic ring displacement were quantified with use of previously described methodology.

RESULTS

Thirty-five pelvic ring injuries (13%) were displaced. The rate of displacement was 31% (15 of 49) for LC1 injuries involving a complete sacral fracture and bilateral ramus fractures, 12% (7 of 58) for injuries involving a complete sacral fracture and a unilateral ramus fracture, and 10% (5 of 52) for injuries involving an incomplete sacral fracture and bilateral ramus fractures. In displaced injuries, the average interval displacement was 4.2 mm (95% confidence interval [CI], 1.8 to 6.8) and the final displacement was 9.9 mm ± 4.2 mm.

CONCLUSIONS

Our study suggests that fracture characteristics can be used to predict the likelihood of displacement of LC1 fractures that are treated without surgery. To our knowledge, the present study is the first to describe the magnitude of displacement that may occur in association with LC1 pelvic ring injuries that are treated nonoperatively; however, further studies are needed to determine the clinical impact of this displacement.

LEVEL OF EVIDENCE

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

Unstable pelvic fractures in women: implications on obstetric outcome

PURPOSE

Obstetric outcomes in women following pelvic injuries requiring surgical fixation is not thoroughly known. We aimed to evaluate if radiographic measurements (RMs) can be used to provide information on delivery methods outcome after these injuries, and to evaluate if metal work removal is required prior to delivery.

METHOD

A retrospective study in a level 1 trauma centre of female patients with pelvic fractures treated operatively, aged 16-45 at the time of injury. Participants completed a questionnaire regarding their obstetric history. RM evaluating pelvic symmetry, displacement, and pelvimetry were conducted on postoperative radiographs and CT scans. Patients who gave birth after the injury were divided to two groups according to the delivery method: vaginal delivery (VD) and caesarean section (CS). These two groups RM were compared.

RESULTS

Forty-four patients were included, comparison of the RM of patients who delivered by CS (9) and patients who had only VD (11) showed no significant difference between the groups. Two patients underwent a trial of VD who subsequently underwent urgent CS due to prolonged labour, their RM were below the average and their pelvimetry measurements were above the cut-off for CS recommendation. Eleven patients had uncomplicated VD, all had retained sacroiliac screws at the time of delivery and one patient had an anterior pubic plate.

CONCLUSION

Postoperative RM did not show an effect on delivery method of women after pelvic fracture fixation. A relatively high number of patients who underwent normal vaginal delivery had retained sacroiliac screws. These findings can form the foundation for larger cohort studies.

Retrospective observational study correlating traumatic pelvic fractures and their associated injuries according to the Tile classification

INTRODUCTION

Pelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification.

METHODS

Retrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016.

RESULTS

A total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P = .032), and Tile B with sacral fractures (P = .033) and visceral injuries (P = .049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock.

CONCLUSIONS

Tile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.

Bony Sacral Volume after Sacro-Iliac Screw Fixation of Pelvic Fractures Is Dependent on Reduction of the Anterior Pelvic Ring

Pelvic ring injuries are uncommon but serious injuries. Percutaneous sacro-iliac screw fixation (SSF) is the standard treatment for posterior stabilization of pelvic fractures. Compression forces of the SSF might cause deformity of the sacrum and the pelvic ring. The aim of this radio-volumetric study is to evaluate the morphometry of the sacrum and pelvic ring in SSF for posterior pelvic fractures. (1) Methods: We conducted a radio-volumetric study measuring the bony sacral volume before and after SSF for a pelvic fracture based on a three-dimensional reconstruction of the pre- and postoperative computed tomography scan of 19 patients with a C-type pelvic fracture. In addition to the bony sacral volume, we assessed the pelvic deformity and the load bearing axis. We compared the results of patients without anterior stabilization (Group A) to patients who had additional ORIF of the anterior pelvic ring. (2) Results: Median age of the patients was 41.2 years (±17.8). All patients received percutaneous SSF with partially threaded 7.3 mm screws. The sacral volume decreased from 202.9 to 194.3 cm3 in group A (non-operative treatment anterior, n = 10) and an increase of sacral volume from 229.8 to 250.4 cm3 in group B (anterior ORIF; n = 9). Evaluation of the pelvic deformity also reflected this trend by a decrease of the ipsilateral load-bearing angle in group A (37.0° to 36.4°) and an increase of this angle in group B (36.3 to 39.9°). (3) Conclusions: Bony sacral volume and pelvic deformity after sacro-iliac screw fixation in pelvic fractures depend on treatment of the anterior pelvic ring. Reduction and fixation of the anterior fracture shows an increase of the bony sacral volume and the load bearing angle leading to a closer to normal reconstruction of the pelvic anatomy.

Unilateral Sacral Fractures Demonstrate Slow Recovery of Patient-Reported Outcomes Irrespective of Treatment

OBJECTIVES

To report functional outcomes of unilateral sacral fractures treated both operatively and nonoperatively.

DESIGN

Prospective, multicenter, observational study.

SETTING

Sixteen Level 1 trauma centers.

PATIENTS/PARTICIPANTS

Skeletally mature patients with unilateral zone 1 or 2 sacral fractures categorized as displaced nonoperative (DN), displaced operative (DO), nondisplaced nonoperative (NN), and nondisplaced operative (NO).

MAIN OUTCOME MEASUREMENTS

Pelvic displacement was documented on injury plain radiographs. Short Musculoskeletal Function Assessment (SMFA) scores were obtained at baseline and at 3, 6, 12, and 24 months after injury. Displacement was defined as greater than 5 mm in any plane at the time of injury.

RESULTS

Two hundred eighty-six patients with unilateral sacral fractures were initially enrolled, with a mean age of 40 years and mean injury severity score of 16. One hundred twenty-three patients completed the 2-year follow-up as follows: 29 DN, 30 DO, 47 NN, and 17 NO with 56% loss to follow-up at 2 years. Highest dysfunction was seen at 3 months for all groups with mean SMFA dysfunction scores: 25 DN, 28 DO, 27 NN, and 31 NO. The mean SMFA scores at 2 years for all groups were 13 DN, 12 DO, 17 NN, and 17 NO.

CONCLUSIONS

All groups (operative/nonoperative and displaced/nondisplaced) reported worst function 3 months after injury, and all but (DN) continued to recover for 2 years after injury, with peak recovery for DN seen at 1 year. No functional benefit was seen with operative intervention for either displaced or nondisplaced injuries at any time point.

LEVEL OF EVIDENCE

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

Functional outcomes more than 5 years following acetabulum fracture

Objectives:

The purposes of this project were to evaluate functional outcomes more than 5 years after acetabulum fracture and to determine factors related to function.

Methods:

This retrospective study consisted of 205 adult patients treated for acetabulum fracture who completed the Musculoskeletal Function Assessment (MFA) a minimum of 5 years following injury. The MFA includes survey of daily activities, gross and fine mobility, social and work function, sleeping, and mood. Higher scores indicate worse function.

Results:

Two hundred five patients with 210 fractures, 69.3% of whom were male, with mean age of 45.7 and mean body mass index 30.1 were included after mean 128 months follow-up. Fracture patterns included OTA/AO 62A (37.1%), 62B (40.5%), or 62C (22.4%), and 80.0% were treated surgically. Late complications were noted in 35.2%, including posttraumatic arthrosis (PTA: 19.5%), osteonecrosis and/or heterotopic ossification. Mean MFA of all patients was 31.4, indicating substantial residual dysfunction. Worse MFA scores were associated with morbid obesity (body mass index >40: 42.3, P>.09), and current tobacco smoking history vs former smoker vs nonsmoker (45.2 vs 36.1 vs 23.0, P < .002). Patients with late complications had worse mean MFA scores (38.7 vs 27.7, P = .001); PTA was the most common late complication, occurring in 19.5%.

Conclusions:

More than 5 years following acetabulum fracture, substantial residual dysfunction was noted, as demonstrated by mean MFA. Worse outcomes were associated with late complications and tobacco smoking. While fracture pattern was not associated with outcome, those patients who had late complications, mostly PTA, had worse outcomes.

Which general functional outcome measure does a better job of capturing change in clinical status in pelvic and acetabular fracture patients? An analysis of responsiveness over the first year of recovery

OBJECTIVE

To compare the responsiveness of the Short Form-36 (SF-36) physical component score (PCS) to the Short Musculoskeletal Function Assessment (SMFA) dysfunction index (DI) in pelvic and acetabular fracture patients over multiple time points in the first year of recovery.

DESIGN

Prospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Four hundred seventy-three patients with surgically treated pelvic and acetabular fractures (Orthopaedic Trauma Association B or C-type pelvic ring disruption or acetabular fracture) were enrolled into the center's prospective orthopaedic trauma database between January 2005 and February 2015. Functional outcome data were collected at baseline, 6 months, and 12 months.

MAIN OUTCOME MEASUREMENTS

Evaluation was performed using the SF-36 Survey and Short Musculoskeletal Function Assessment. Responsiveness was assessed by calculating the standard response mean (SRM), the minimal clinically important difference (MCID), and floor and ceiling effects.

RESULTS

Three hundred five patients had complete data for both outcome scores. SF-36 PCS and SMFA DI scores showed strong correlation for all time intervals (r = -0.55 at baseline, r = -0.78 at 6 months, and r = -0.85 at 12 months). The SRM of the SF-36 PCS was greater in magnitude than the SRM of SMFA DI at all time points; this was statistically significant between baseline and 6 months (P < .001), but not between 6 and 12 months (P = .29). Similarly, the proportion of patients achieving MCID in SF-36 PCS was significantly greater than the proportion achieving MCID in SMFA DI between baseline and 6 months (84.6% vs 69.8%, P < .001), and between 6 and 12 months (48.5% vs 35.7%, P = .01). There were no ceiling or floor effects found for SF-36 PCS at any time intervals. However, 16.1% of patients achieved the highest level of functioning detectable by the SMFA DI at baseline, along with smaller ceiling effects at 6 months (1.3%) and 12 months (3.3%).

CONCLUSIONS

SF-36 PCS is a more responsive measure of functional outcome than the SFMA DI over the first year of recovery in patients who sustain a pelvic ring disruption or acetabular fracture. This superiority was found in using the SRM, proportion of patients meeting MCID, and ceiling effects. Furthermore, the SF-36 PCS correlated with the more disease-specific SMFA DI.

LEVEL OF EVIDENCE

Prognostic Level II.

Genitourinary complications in orthopaedic surgery

Genitourinary complications following orthopaedic intervention are uncommon but well-described occurrences and exist on a spectrum of severity. These complications vary depending on the anatomic location and surgical approach, with surgery of the spine, hip, and pelvis of particular concern. Injuries to the urinary tract may present acutely with urinary retention or hematuria. However, they often have a delayed presentation with severe complications such as urinary fistula and recurrent infection. Delayed presentations may place the onus of timely and proper diagnosis on the orthopaedic provider, who may serve as the patient's primary source of long-term follow-up. Detailed knowledge of anatomy and at-risk structures is key to both preventing and identifying injury. Although iatrogenic injury is not always avoidable, early identification can help to facilitate timely evaluation and management to prevent long-term complications such as bladder dysfunction, obstructive renal injury, sexual dysfunction, and chronic pain.  Keywords: urologic injury, bladder injury, genitourinary injury, hip arthroplasty, pelvic ring injuries, spine surgery.

Patient-reported physical functioning and quality of life after pelvic ring injury: A systematic review of the literature

BACKGROUND

Pelvic ring injuries are one of the most serious traumatic injuries with large consequences for the patients' daily life. During recent years, the importance of the patients' perception of their functioning and quality of life following injury has increasingly received attention. This systematic review reports on self-reported physical functioning and quality of life after all types of pelvic ring injuries.

METHODS

The online databases MEDLINE-PubMed and Ovid-EMBASE were searched for studies published between 2008 and 2019 to identify published evidence of patient-reported physical functioning and quality of life after which they were assessed for their methodological quality.

RESULTS

Of the 2577 articles, 46 were reviewed in full-text, including 3049 patients. Most studies were heterogeneous, with small cohorts of patients, a variety of injury types, treatment methods and use of different, often non-validated, outcome measures. The overall methodological quality was moderate to poor. Nine different PROMs were used, of which the Majeed Pelvic Score (MPS), SF-36 and EQ-5D were the most widely used. Mean scores respectively ranged from 75-95 (MPS), 53-69 (SF-36, physical functioning) and 0.63-0.80 (EQ-5D).

CONCLUSIONS

Physical functioning and quality of life following pelvic ring injuries seem fair and tend to improve during follow-up. However, differences in patient numbers, injury definition, treatment strategy, follow-up duration and type of PROMs used between studies hampers to elucidate the actual effects of pelvic ring injuries on a patient's life.

IMPLICATIONS OF KEY FINDINGS

Physicians and researchers should use valid and reliable patient-reported outcome instruments on large cohorts of patients with properly defined injuries to truly evaluate physical functioning and quality of life after pelvic ring injuries.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO International prospective register of systematic reviews; registration number CRD42019129176.

Long-term outcomes of major trauma with unstable open pelvic fractures: A population-based cohort study

Aims

The aims of this study were to describe the profile and longer-term outcomes of major trauma patients with unstable open pelvic fractures.

Patients and methods

An observational study was performed using data from the population-based Victorian State Trauma Registry. Adult (≥16 years) major trauma patients who had sustained an unstable open pelvic fracture between 1 July 2010 and 30 June 2017 in Victoria (Australia) were included. Patient demographics, injury event, severity and management data were extracted. Patients were followed up at 6, 12 and 24 months post-injury to collect information about health status, function and return to work.

Results

There were 67 patients. The mean (SD) age was 41.4 (18.3) years, and 66% were male. Seventy-six per cent were road traffic injuries, 96% were managed at Level 1 trauma centres and all were multi-trauma patients. A third were Tile C fractures and 80% underwent surgical stabilisation of the pelvic injury. Eighty per cent were admitted to intensive care. The in-hospital mortality rate was 9%. Most (89%) survivors were discharged to an inpatient rehabilitation facility. The proportion classified as ‘severe disability’ on the Glasgow Outcome-Scale Extended declined from 38% at 6 months to 19% at 24 months. The overall three-level EuroQoL five-dimensional instrument score increased with time indicating better health status, and 50% of patients returned to work by 24 months.

Conclusions

Major trauma with unstable, open pelvic fracture is rare. Low in-hospital mortality was observed. Most survived to hospital discharge and outcomes improved with time post-injury, but 75% of patients experienced persistent pain and ongoing mobility and activity restrictions.

Prognostic factors and quality of life after pelvic fractures. The Brabant Injury Outcome Surveillance (BIOS) study

Introduction

Pelvic fractures can have long-term consequences for health-related quality of life (HRQoL). The main purpose of this study is to provide insight into short-term HRQoL in the first year after pelvic injury and to identify short-term prognostic factors of decreased outcome.

Methods

This is a prospective, observational, multicenter, follow-up cohort study in which HRQoL and functional outcomes were assessed during 12-month follow-up of injured adult patients admitted to 1 of 10 hospitals in the county of Noord-Brabant, the Netherlands. The data were collected by self-reported questionnaires at 1 week (including preinjury assessment) and 1, 3, 6 and 12 months after injury. The EuroQoL-5D (EQ-5D), visual analog scale (VAS), Merle d’Aubigné Hip Score (MAHS) and Majeed Pelvic Score (MPS) were used. Multivariable mixed models were used to examine the course of the HRQoL and the prognostic factors for decreased HRQoL and functional outcomes over time.

Results

A total of 184 patients with pelvic fractures were identified between September 2015–September 2016; the fractures included 71 Tile A, 44 Tile B and 10 Tile C fractures and 59 acetabular fractures. At the pre-injury, 1 week, and 1, 3, 6 and 12 months after injury time points, the mean EQ-5D Index values were 0.90, 0.26, 0.45, 0.66, 0.77 and 0.80, respectively, and the mean EQ-VAS values were 83, 45, 57, 69, 75 and 75, respectively. At 6 and 12 months after injury, 22 and 25% of the MPS < 65 year group, 38 and 47% of the MPS ≥ 65 year group and 34 and 51% of the MAHS group, respectively, reached the maximum score. Pre-injury score, female gender and high Injury Severity Score (ISS) were important prognostic factors for a decreased HRQoL, and the EQ-5D VAS β = 0.43 (95% CI: 0.31 − 0.57), -6.66 (95% CI: -10.90 − -0.43) and -7.09 (95% CI: -6.11 − -5.67), respectively.

Discussion

Patients with pelvic fractures experience a reduction in their HRQoL. Most patients do not achieve the HRQoL of their pre-injury state within 1 year after trauma. Prognostic factors for decreased HRQoL are a low pre-injury score, high ISS and female gender. We do not recommend using the MAHS and MPS in mid- or long-term follow-up of pelvic fractures because of ceiling effects.

Trial registration number NCT02508675.

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.

Nerve Injury With Acetabulum Fractures: Incidence and Factors Affecting Recovery

OBJECTIVES

To determine factors associated with nerve injury after acetabulum fracture and to evaluate recovery and outcomes.

DESIGN

Retrospective cohort study.

SETTING

Level 1 trauma center.

PATIENTS AND PARTICIPANTS

Nine hundred seventy-five skeletally mature patients with acetabulum fracture.

INTERVENTION

Operative and nonoperative management.

MAIN OUTCOME MEASUREMENTS

Nerve injuries, categorized as traumatic or iatrogenic, recovery (none, partial, or complete), and patient-reported functional outcomes with the Musculoskeletal Function Assessment (n = 353, 36.2%).

RESULTS

Thirty-two patients (3.3%) experienced nerve injury with 24 (78%) resulting from trauma and 23 with an associated posterior hip dislocation. Eight injuries (25%) were iatrogenic. Thirty-one (97%) occurred in patients with operative fractures (n = 738). The most common fracture pattern associated with nerve injury was transverse posterior wall (31% of injuries). Obesity was more common in patients with nerve injuries (59% vs. 30% in those without nerve injury (P = 0.001), but was not related to age or sex. Sixty-five percent of sciatic nerve injuries were to the common peroneal division only, while none were isolated to the tibial division. All iatrogenic injuries occurred after the ilioinguinal approach (P < 0.001). Overall, 50% experienced partial nerve recovery and 22% had complete recovery. However, 24% of patients with sciatic or common peroneal injuries had no recovery. Thirty-three percent of tobacco smokers experienced no recovery (vs. 26% of nonsmokers). Average Musculoskeletal Function Assessment scores for patients with nerve injuries was 32, similar to those without (33).

CONCLUSIONS

Posterior acetabulum fracture dislocations are associated with traumatic nerve injury, although 25% of nerve injuries were iatrogenic. Nerve injuries are more common in obese patients. More than one-quarter of patients had no recorded nerve recovery.

LEVEL OF EVIDENCE

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

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.

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.

The Influence of Musculoskeletal Conditions, Behavioral Health Diagnoses, and Demographic Factors on Injury-Related Outcome in a High-Demand Population

BACKGROUND

The extent to which musculoskeletal injuries and sociodemographic factors impact long-term outcome remains unknown. The purpose of this study was to provide a prognostic analysis of the influence of musculoskeletal conditions, behavioral health diagnoses, and patient-based characteristics on outcomes among a longitudinal cohort.

METHODS

This is a longitudinal observational study of the population of an Army brigade deployed to Iraq from 2006 to 2007. The 4087 soldiers who survived the deployment were followed for forty-eight months and were observed for the development of chronic musculoskeletal conditions, behavioral health disorders, and inability to remain in active service as indicated by the findings of the Physical Evaluation Board. The influence of demographic factors, behavioral health conditions, and deployment-related musculoskeletal injuries on the capacity to remain in the military was assessed using Poisson multivariate analysis and receiver operating characteristic curves.

RESULTS

The mean age of the cohort was twenty-seven years (range, eighteen to fifty-two years). One hundred and sixty-three soldiers sustained combat-related musculoskeletal trauma, and 587 soldiers had musculoskeletal injuries not related to battle. Three hundred and seventy-four soldiers (9%) were found to be unfit by the Physical Evaluation Board, with 236 soldiers (63%) referred for at least one musculoskeletal condition. Of these 236 soldiers, 116 (49%) also had a behavioral health diagnosis. Multivariate regression analysis revealed that junior enlisted rank (incidence rate ratio, 9.7 [95% confidence interval, 3.1 to 30.3]), senior enlisted rank (incidence rate ratio, 5.6 [95% confidence interval, 1.8 to 17.7]), behavioral health diagnosis (incidence rate ratio, 7.4 [95% confidence interval, 5.6 to 9.6]), age of eighteen to twenty-three years (incidence rate ratio, 1.6 [95% confidence interval, 1.2 to 2.3]), and male sex (incidence rate ratio, 2.5 [95% confidence interval, 1.2 to 5.0]) were significant predictors of referral to the Physical Evaluation Board for a musculoskeletal condition. A prognostic model developed using receiver operating characteristic curves and the risk factors of musculoskeletal injury, presence of a psychiatric condition, and lower rank explained 78% (95% confidence interval, 77% to 80%) of the risk of being found unfit by the Physical Evaluation Board.

CONCLUSIONS

Musculoskeletal conditions, psychological diagnoses, and lower rank (socioeconomic status) were identified as potent predictors of inferior outcome in this study. Targeting at-risk patients within populations may improve results.

LEVEL OF EVIDENCE

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

Urogenital disorders after pelvic ring injuries

Introduction

The close anatomical relationship between the skeletal and connective systems of the pelvis, neurological, and vascular structures and pelvic organs are predisposing factors for structural and functional damages of the urogenital system.

Materials and methods

We performed PUBMED and MEDLINE search using terms “pelvic ring trauma/disruption, bladder injury, urethral injury, sexual dysfunction”.

Results

The probability of damage of the pelvic organs increases along with the degree of disturbance of integrity of the pelvic ring. The most important risk factor of urogenital injuries is the rupture of the symphyseal joint. Patients with lesions of the urogenital system have a higher risk of mortality compared with patients without lesions of the urogenital system. Sexual dysfunctions along with urinary incontinence are a common consequence of the pelvic fracture in men and women.

Conclusions

Injuries of the urogenital organs during pelvic ring fractures have an important negative prognostic value in terms of morbidity and quality of life. A prerequisite for a successful therapeutic outcome in case of pelvic fractures with disturbance of pelvic ring integrity is cooperation of orthopedists and urologists, with possible early diagnosis and treatment of injuries of the urogenital organs.