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Xing B, Shen X, Ma L, Qi X. TiRobot-Assisted Percutaneous Cannulated Screw Fixation for Elderly Patients with Fragility Fractures of the Pelvis: A Retrospective Study. Orthop Surg 2024; 16:662-674. [PMID: 38384135 PMCID: PMC10925510 DOI: 10.1111/os.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/13/2024] [Accepted: 01/18/2024] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVE The incidence of fragility fractures of the pelvis (FFPs) is increasing in the elderly population, and FFPs that require fixation are a challenge for orthopedic surgeons. The insertion of implants is not risk free due to the complex anatomical and osteoporotic bones and requires a steep learning curve. This study aimed to investigate the clinical efficacy of TiRobot-assisted percutaneous cannulated screw fixation in the treatment of elderly FFP patients. METHOD The clinical data of 46 elderly FFP patients who had been treated with percutaneous cannulated screw fixation from May 2020 to September 2022 were retrospectively analyzed. Twenty-four patients were treated with percutaneous cannulated screw fixation assisted by the TiRobot (TiRobot-assisted group) and 22 patients were treated with conventional freehand surgery (freehand group). Postoperative outcomes, including Matta value, excellent and good rate (EGR) of fracture reduction, and accuracy of screw placement (ASP), were compared. Changes in the Visual analog scale (VAS) pain score and the Majeed score were recorded and compared between groups before and after surgery and during the 24-week follow-up. Repeated-measures analysis of variance (ANOVA) and effect sizes were used as analysis methods. RESULTS A total of 90 screws were implanted, 51 screws in the TiRobot-assisted group and 39 screws in the freehand group. The operation time of the two groups was 34.1 ± 2.67 min versus 64.5 ± 4.19 min (p < 0.001). There were no screw-related complications or revision surgeries in any group. The Matta value of the TiRobot-assisted group was 5.13 ± 3.52, which was significantly lower than that of the freehand group (9.00 ± 3.68, p < 0.001), while the EGR was 91.67% versus 72.73%, with statistical significance (p < 0.001). The ASP was 100% in the TiRobot-assisted group, better than that in the freehand group, where it was 85.7% (p = 0.043). At each timepoint in the early postoperative period, the VAS score of the TiRobot-assisted group was significantly lower than that of the freehand group and was close to consistent by the last follow-up; the Majeed score of the former was significantly higher than that of the latter at each timepoint of follow-up, with statistical significance (p < 0.001). CONCLUSION TiRobot-assisted percutaneous cannulated screw fixation of elderly FFP patients is advantageous over conventional freehand surgery, with less invasion, more accurate screw placement, better fracture reduction, early pain relief, and rapid recovery, suggesting that Freehand method to stabilize FFP in the elderly population.
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Affiliation(s)
- Baorui Xing
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
- Department of Orthopaedic SurgeryHebei Cangzhou Hospital of Integrated Traditional Chinese and Western MedicineCangzhouChina
| | - Xiaoyu Shen
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Lijie Ma
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Xiangbei Qi
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
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Grüneweller N, Leunig J, Zderic I, Gueorguiev B, Wähnert D, Vordemvenne T. Stabilization of Traumatic Iliosacral Instability Using Innovative Implants: A Biomechanical Comparison. J Clin Med 2023; 13:194. [PMID: 38202203 PMCID: PMC10779522 DOI: 10.3390/jcm13010194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 01/12/2024] Open
Abstract
(1) Background: Demographic changes over the past decade have had a significant impact on pelvic ring fractures. They have increased dramatically in the orthogeriatric population. Surgeons are faced with implant fixation issues in the treatment of these fragility fractures. This study compares two innovative implants for stabilizing the iliosacral joint in a biomechanical setting. (2) Methods: An iliosacral screw with a preassembled plate allowing the placement of an additional short, angular stable screw in the ilium and a triangular fixation system consisting of a fenestrated ilium screw and an iliosacral screw quasi-statically inserted through the "fenestra" were instrumented in osteoporotic artificial bone models with a simulated Denis zone 1 fracture. Biomechanical testing was performed on a servo-hydraulic testing machine using increasing, synchronous axial and torsional sinusoidal cyclic loading to failure. (3) Results: The SI-Plate and TriFix showed comparable stiffness values. The values for fracture gap angle and screw tip cutout were significantly lower for the TriFix compared to the SI-Plate. In addition, the number of cycles to failure was significantly higher for the TriFix. (4) Conclusions: Implant anchorage and primary stability can be improved in iliosacral instability using the triangular stabilization system.
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Affiliation(s)
- Niklas Grüneweller
- Bielefeld University, Medical School and University Medical Center OWL, Protestant Hospital of the Bethel Foundation, Department of Trauma and Orthopedic Surgery, Burgsteig 13, 33617 Bielefeld, Germany (D.W.)
| | - Julia Leunig
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland; (J.L.); (I.Z.)
| | - Ivan Zderic
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland; (J.L.); (I.Z.)
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland; (J.L.); (I.Z.)
| | - Dirk Wähnert
- Bielefeld University, Medical School and University Medical Center OWL, Protestant Hospital of the Bethel Foundation, Department of Trauma and Orthopedic Surgery, Burgsteig 13, 33617 Bielefeld, Germany (D.W.)
| | - Thomas Vordemvenne
- Bielefeld University, Medical School and University Medical Center OWL, Protestant Hospital of the Bethel Foundation, Department of Trauma and Orthopedic Surgery, Burgsteig 13, 33617 Bielefeld, Germany (D.W.)
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Cintean R, Fritzsche C, Zderic I, Gueorguiev-Rüegg B, Gebhard F, Schütze K. Sacroiliac versus transiliac-transsacral screw osteosynthesis in osteoporotic pelvic fractures: a biomechanical comparison. Eur J Trauma Emerg Surg 2023; 49:2553-2560. [PMID: 37535095 PMCID: PMC10728224 DOI: 10.1007/s00068-023-02341-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Pelvic fractures were often associated with high-energy trauma in young patients, but data show a significant increase in osteoporotic pelvic fractures in old age due to the progressive demographic change. There is an ongoing discussion about the best fixation techniques, which are ranging from lumbopelvic fixation to sacral bars or long transiliac-transsacral (TITS) screws. This study analyzes TITS screw osteosynthesis and sacroiliac screw osteosynthesis (SI), according to biomechanical criteria of fracture stability in osteoporotic human pelvic cadavers ex vivo. METHODS Ten osteoporotic cadaveric pelvises were randomized into two groups of 5 pelvises each. An FFP-IIc fracture was initially placed unilaterally and subsequently surgically treated with a navigated SI screw or a TITS screw. The fractured side was loaded in a one-leg stance test setup until failure. Interfragmentary movements were assessed by means of optical motion tracking. RESULTS No significant difference in axial stiffness were found between the SI and the TITS screws (21.2 ± 4.9 N and 18.4 ± 4.1 N, p = 0.662). However, there was a significantly higher stability of the fracture treatment in the cohort with TITS-screws for gap angle, flexion, vertical movement and overall stability. The most significant difference in the cycle interval was between 6.000 and 10.000 for the gap angle (1.62 ± 0.25° versus 4.60 ± 0.65°, p = 0.0001), for flexion (4.15 ± 0.39 mm versus 7.60 ± 0.81 mm, p = 0.0016), interval 11.000-15.000 for vertical shear movement (7.34 ± 0.51 mm versus 13.99 ± 0.97 mm, p < 0.0001) and total displacement (8.28 ± 0.66 mm versus 15.53 ± 1.07 mm, p < 0.0001) for the TITS and the SI screws. CONCLUSIONS The results of this biomechanical study suggest a clear trend towards greater fracture stability of the TITS screw with significantly reduced interfragmentary movement. The application of a TITS screw for the treatment of the osteoporotic pelvic ring fracture may be prioritized to ensure the best possible patient care.
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Affiliation(s)
- Raffael Cintean
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - Cornelius Fritzsche
- Department of Handsurgery, Upper Extremities and Foot Surgery, Krankenhaus Waldfriede, Argentinische Allee 40, 14163, Berlin, Germany
| | - Ivan Zderic
- AO Research Institute (ARI), Clavandelerstrasse 8, 7270, Davos Platz, Switzerland
| | | | - Florian Gebhard
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Konrad Schütze
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
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Chiang JB, Yee DKH. A Toolbox of Bone Consolidation for the Interventional Radiologist. Cardiovasc Intervent Radiol 2023; 46:1447-1457. [PMID: 37165213 DOI: 10.1007/s00270-023-03445-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/11/2023] [Indexed: 05/12/2023]
Abstract
Bone consolidation is increasingly used in the treatment of both benign and malignant bone conditions. Percutaneous vertebroplasty, for example, has been shown to be useful in vertebral compression fractures in the VAPOUR trial which showed its superiority to placebo for pain reduction in the treatment of acute vertebral compressive fractures. Further tools have since been developed, such as kyphoplasty, spinal implants, and even developments in bone cements itself in attempt to improve outcome, such as chemotherapy-loaded cement or cement replacements such as radio-opaque silicon polymer. More importantly, bone fixation and its combination with cement have been increasingly performed to improve outcome. Interventional radiologists must first know the tools available, before they can best plan for their patients. This review article will focus on the tool box available for the modern interventional radiologist.
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Affiliation(s)
- Jeanie Betsy Chiang
- Block K Department of Radiology and Imaging, Queen Elizabeth Hospital, 30 Gascoigne Road, Yau Ma Tei, Kowloon, Hong Kong SAR, China.
| | - Dennis King Hang Yee
- Department of Orthopaedics and Traumatology, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
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Aigner R, Föhr J, Lenz J, Knauf T, Bäumlein M, Ruchholtz S, Oberkircher L, Hack J. Cemented Sacroiliac Screw Fixation versus Conservative Therapy in Fragility Fractures of the Posterior Pelvic Ring: A Matched-Pair Analysis of a Prospective Observational Study. J Clin Med 2023; 12:5850. [PMID: 37762790 PMCID: PMC10531520 DOI: 10.3390/jcm12185850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/20/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
The aim of this study was to compare the outcome of cemented sacroiliac screw fixation to that of conservative treatment in nondisplaced fragility fractures of the sacrum during a 12-month follow-up. Therefore, matched-pair analysis including 40 patients from a previously performed prospective observational study was conducted. Pain was assessed using the visual analogue scale (VAS), functional capabilities and mobility were assessed using the Barthel index, and health-related quality of life (HRQL) was assessed using the EQ-5D questionnaire at 6 weeks, 6 months, and 12 months after the fracture, respectively. No significant differences between the two groups were seen regarding pain. In the operative group, a significantly improved Barthel index was observed after 6 months. A significantly higher HRQL was identified after 6 weeks in the operative group. Their mobility was comparable between the two groups before the fracture; after 6 weeks, mobility was significantly improved in the operative group. After 12 months, no significant differences were found regarding the functional outcome, HRQL or mobility. The 1-year mortality rate was 25% in the conservative group versus 5% in the operative group (not statistically significant). The present study revealed favorable short-term outcomes concerning the functional outcome, HRQL and mobility after sacroiliac screw fixation. After 12 months, the outcomes were similar to those of the patients managed conservatively.
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Affiliation(s)
- Rene Aigner
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Jan Föhr
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Julia Lenz
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Tom Knauf
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Martin Bäumlein
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Ludwig Oberkircher
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
- Department for Trauma Surgery, Orthopaedic Surgery and Arthroplasty, Medizin Campus Bodensee, 88048 Friedrichshafen, Germany
| | - Juliana Hack
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
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Marintschev I, Hofmann GO. Minimally invasive bilateral fixed angle locking fixation of the dorsal pelvic ring: clinical proof of concept and preliminary treatment results. Eur J Trauma Emerg Surg 2023; 49:1873-1882. [PMID: 37041259 PMCID: PMC10449978 DOI: 10.1007/s00068-023-02259-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/07/2023] [Indexed: 04/13/2023]
Abstract
PURPOSE Dorsal pelvic ring fractures may result from high energy trauma in younger patients or from osteoporosis as fragility fractures in elderly patients. To date, no strong consensus exists on the best surgical technique to treat posterior pelvic ring injuries. The aim of this study was to evaluate the surgical performance of a new implant for angle-stable fixation of the posterior pelvic ring and patient outcome. METHODS In a prospective pilot study, 27 patients (age: 39-87 years) with posterior pelvic ring fractures classified according to the AO classification (n = 5) or to the fragility fractures of the pelvis (FFP) classification (n = 22) were treated using the new implant. During a follow-up period of 1 year, surgical parameters of the implantation technique, complication rate, morbidity, mortality, preservation of patient mobility, and social independence were evaluated. RESULTS No implant misplacement or failure was observed. Two patients developed symptomatic spinal canal stenosis at L4/L5 following mobilization. MRI diagnosis proved the implant was not responsible for the symptoms. In one case, an additional plate stabilization of a pubic ramus fracture was necessary 6 months later. There was no inpatient mortality. One patient died due to her underlying oncological disease within the first 3 months. The main outcome parameters were pain, mobility, preservation of independent living and employment. CONCLUSION Operative instrumentation of dorsal pelvic ring fractures should be stable enough to allow for immediate weight bearing. The new locking nail implant offers percutaneous reduction and fixation options and may decrease the generally observed rate of complications. TRAIL REGISTRATION German Clinical Trials Register ID: DRKS00023797, date of registration: 07.12.2020.
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Affiliation(s)
- Ivan Marintschev
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany.
| | - Gunther O Hofmann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
- Department of Trauma and Reconstructive Surgery, Workers Compensation Hospital Bergmannstrost, Merseburger Str. 165, 06112, Halle/Saale, Germany
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Briggs P, King SW, Staniland T, Gopal S, Shah R, Chimutengwende-Gordon M. A Systematic Review of Sacral Insufficiency Fractures: Treatment Modalities and Outcomes. Cureus 2023; 15:e41745. [PMID: 37575865 PMCID: PMC10415627 DOI: 10.7759/cureus.41745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/15/2023] Open
Abstract
Sacral insufficiency fractures can be managed conservatively, by surgical fixation or by sacroplasty. This systematic review compared the outcomes of different treatment modalities to ascertain the best. Studies included in this systematic review were those with sacral insufficiency fracture in elderly patients with some measure of outcomes reported. Fractures due to high-energy trauma or malignancy or in non-elderly patients were excluded. The review was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE and Embase databases were searched from inception to January 6, 2022, yielding a total of 4299 papers of which 35 were eligible for inclusion. Pain reduction following sacroplasty (Visual Analogue Scale (VAS) difference 5.83, SD 1.14, n = 901) was superior compared with conservative management (VAS difference 3.7, SD 2.71, n = 65) (p <0.0001) and surgical fixation (with screws/rods +/- cement augmentation; VAS difference 4.1, SD 1.106, n = 154) (p< 0.001). There was no significant difference between pain relief following screw fixation and after conservative management (p = 0.1216). Hospital stay duration was shorter following sacroplasty (4.1 days )SD 3.9)) versus fixation (10.3 days (SD 5.59)) (p= 0.0001). Available evidence points to sacroplasty resulting in better pain relief and shorter hospital stay than other treatment options.
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Affiliation(s)
- Praise Briggs
- Trauma and Orthopaedics, Hull University Teaching Hospitals NHS Trust, Kingston upon Hull, GBR
| | - Samuel W King
- Trauma and Orthopaedics, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, GBR
| | - Tim Staniland
- Knowledge and Library Services, Hull University Teaching Hospitals NHS Trust, Kingston upon Hull, GBR
| | - Shivkumar Gopal
- Pelvic and Hip Orthopaedic Surgery, Hull University Teaching Hospitals NHS Trust, Kingston upon Hull, GBR
| | - Rajesh Shah
- Pelvic and Spinal Orthopaedic Surgery, Hull University Teaching Hospitals NHS Trust, Kingston upon Hull, GBR
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Putzeys G, Dekeyser T, Garré P, Chesser T, Pottel H. Posterior pelvic ring involvement detected with CT taken within a week of admission in acute fragility fractures of the pelvis (FFP) does not predict failure of conservative treatment: a retrospective cohort study. BMC Musculoskelet Disord 2023; 24:320. [PMID: 37087474 PMCID: PMC10122380 DOI: 10.1186/s12891-023-06439-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/18/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Acute low energy pubic rami fractures in the elderly receive primarily conservative treatment. There is debate to what extent posterior ring involvement, which is detected superiorly by CT compared to X-ray, has an impact on outcome and may require modified treatment. We want to demonstrate if posterior ring involvement has an influence on different types of outcome in primarily conservatively treated acute FFP, questioning the usefulness of early CT. Additionally we analysed the early fracture pattern in cases where conservative treatment failed with need for secondary surgery. METHODS A retrospective cohort study of 155 consecutive patients, recruited between 2009 and 2016, aged over 65 years diagnosed with an acute LE-PFr on X-ray at the emergency department of a single, level-one trauma centre and receiving an early CT. A set of outcome parameters was compared between patients with an isolated pubic rami fracture (CTia) and patients who had a combined posterior pelvic ring fracture (CTcp). RESULTS There were 155 patients of whom 85.2% were female with a mean age of 83 years. 76.8% of patients living at home returned home and 15.5% moved to a nursing home. Mortality rate during hospitalisation was 6.4% and 14.8% at one year post-trauma. Secondary fracture displacement occurred in 22.6%. Secondary surgery was performed in 6 cases (3.9%). Median hospitalisation length of stay was 21 days (range 0 to 112 days). There was no significant association between the subgroups and change in residential status (p = 0.65), complications during hospitalisation (p = 0.75), mortality rate during admission (p = 0.75) and at 1 year (p = 0.88), readmission within 30 days (p = 0.46) and need for secondary surgery (p = 0.2). There was a significant increased median length of stay (p = 0.011) and rate of secondary displacement (p = 0.015) in subgroup CTcp. Secondary displacement had no impact on in-hospital complications (p = 0.7) nor mortality rate during admission (p = 0.79) or at 1 year (0.77). Early CT in patients who underwent secondary surgery showed stable B2.1 lesions in 4 of 6 cases. CONCLUSIONS Our data suggest that early CT in patients with conservatively treated acute LE-PFr in order to detect posterior lesions, has limited value in predicting failure of conservative treatment.
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Affiliation(s)
- Guy Putzeys
- Orthopedic and Trauma Department, AZ Groeninge hospital, Kortrijk, Belgium.
| | | | - Patrick Garré
- Department of data management, AZ Groeninge hospital, Kortrijk, Belgium
| | | | - Hans Pottel
- Department of Public Health and Primary Care, KULeuven KULAK, Kortrijk, Belgium
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Schramm S, Kopschina C, Gaßmann KG, Fujak A. Is the conservative treatment of sacral insufficiency fractures still up to date? Retrospective clinical observational study in 46 patients. Orthop Traumatol Surg Res 2023; 109:103495. [PMID: 36455862 DOI: 10.1016/j.otsr.2022.103495] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/01/2022] [Accepted: 06/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND According to current forecasts, our society will grow older and older, so that the proportion of 6% of the German population from 2017 who were 80 years or older will increase further. The frequency of falls in this patient population lead to a further increase of sacral insufficiency fractures. HYPOTHESIS The aim of this study is to evaluate the multimodal interdisciplinary conservative therapy regime for sacral insufficiency fractures in geriatric patients, especially on the basis of mobility and the need for assistance. PATIENTS AND METHODS A cohort of patients, who were treated as inpatients at the Waldkrankenhaus St. Marien in Erlangen with ICD-10 for sacral fractures S32.1 as the main diagnosis, was retrospectively examined. Only newly diagnosed sacral insufficiency fractures were taken into account. Patients were divided into groups based on the factors hospital stay, fracture location on the sacrum, and location of concomitant pelvic ring injury. The Barthel Index, the Tinetti's Mobility Test and the Timed Up&Go Test were recorded. RESULTS 46 patients met the inclusion criteria. Using the conservative therapy, improvements were achieved in all patients in terms of need for care, mobility without aids and risk of falling, also patients with an anterior and posterior pelvic ring fracture. Regard a score improvement in the Barthel Index and Tinetti Mobility Test, patients with bilateral sacral insufficiency fracture (n=17, 37.0%) did not differ significantly from patients with unilateral sacral insufficiency fracture (n=22, 47.8%). CONCLUSION In geriatric patients, decisions about therapy should always be made on an individual and interdisciplinary basis. The conservative therapy regimen continues to play an important role in this. The collected tests-consisting of Barthel Index, Tinetti Mobility Test and Timed Up&Go Test-are well suited for further reproducible, objective studies with a larger patient collective. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Simon Schramm
- Department of Trauma and Orthopaedic Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstr. 12, 91054 Erlangen, Germany.
| | - Carsten Kopschina
- Department of Trauma and Orthopaedic Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstr. 12, 91054 Erlangen, Germany
| | - Karl-Günter Gaßmann
- Department of Internal Medicine III (Medicine of Ageing), Geriatrics Center Erlangen, Malteser Waldkrankenhaus St. Marien, Rathsberger Str. 57, 91054 Erlangen, Germany
| | - Albert Fujak
- Department of Trauma and Orthopaedic Surgery, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstr. 12, 91054 Erlangen, Germany
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10
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Andresen JR, Radmer S, Andresen R, Prokop A, Schröder G, Nissen U, Schober HC. Comparative outcome of different treatment options for fragility fractures of the sacrum. BMC Musculoskelet Disord 2022; 23:1106. [PMID: 36536363 PMCID: PMC9762048 DOI: 10.1186/s12891-022-06039-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Fragility fractures of the sacrum (FFS) have been detected more and more frequently in recent times, and the incidence will continue to increase due to increasing life expectancy. The aim of this study was to compare the clinical outcome of conservative, interventional and surgical treatment of FFS. METHODS Retrospectively, 292 patients (276 women, 16 men) with confirmed FFS were followed up over a period of 2 years. The age of the women was Ø 81.2 (58 - 99) and that of the men Ø 78.1 (76 - 85) years. The pain was quantified using a VAS. Fractures were classified in accordance with the Rommens and Hofmann and with the Denis classification using conventional X-rays, CT and MRI. A QCT of the lumbar spine was performed to quantify bone mineral density. Concomitant diseases of every patient were recorded. An interdisciplinary case conference determined the individual treatment concept considering the age, type of fracture, pain level and comorbidities with classification into conservative, interventional (any type of sacroplasty) or surgical treatment. Over the course pain and independence were measured, complications and patient satisfaction were documented. A vitamin D determination was done, and existing comorbidities were included. RESULTS Patients with a pain level of ≤5 benefited from the conservative therapy measures, with pain levels > 5 significantly delaying the development of mobility. After sacroplasty, the pain reduced significantly, which caused a rapid improvement in mobility without any significant difference being found between vertebro- (VSP), balloon (BSP), radiofrequency (RFS) and cement sacroplasty (CSP). In terms of pain reduction and mobilization, the surgical treated patients benefited from osteosynthesis, although more complex fracture types with lumbopelvic stabilization took longer. Overall, there were no deaths during the hospital stay. Mortality after 12 months was 21.7% for the conservative, 8.4% for the interventional and 13.6% for the surgical therapy group; the differences are significant. For patients in the conservative therapy group who were difficult to mobilize due to pain, the mortality increased to 24.3%. Over 24 months, patients achieved the best independence after sacroplasty. At 12 and 24 months, subjective satisfaction with the therapies was best after sacroplasty, followed by osteosynthesis and conservative measures. All patients had a pronounced vitamin D deficiency and manifest osteoporosis. Cardiovascular pathologies were the main concomitant diseases. CONCLUSIONS Patients with FFS with a low level of pain benefit from conservative therapy measures, whereby complications and mortality increase significantly in the case of persistent immobilizing pain. Patients with an unacceptable level of pain resulting from non-dislocated fractures benefit significantly from sacroplasty. Patients with unstable and displaced fractures (Rommens and Hofmann type III and IV) should be operated on promptly. Different techniques are available for sacroplasty and osteosynthesis, which lead to an improvement of independence and a reduction in mortality.
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Affiliation(s)
- Julian Ramin Andresen
- grid.263618.80000 0004 0367 8888Medical School, Sigmund Freud University, Vienna, Austria
| | | | - Reimer Andresen
- grid.9764.c0000 0001 2153 9986Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg, Heide, Germany
| | - Axel Prokop
- grid.10392.390000 0001 2190 1447Department of Trauma Surgery, Sindelfingen, Academic Teaching Hospital of the University of Tübingen, Tübingen, Germany
| | - Guido Schröder
- Clinic of Orthopaedics and Trauma Surgery, Warnow Klinik, Bützow, Germany
| | - Urs Nissen
- grid.9764.c0000 0001 2153 9986Department of Neurosurgery and Spine Surgery, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg, Heide, Germany
| | - Hans-Christof Schober
- grid.10493.3f0000000121858338Department of Internal Medicine IV, Municipal Hospital Südstadt Rostock, Academic Teaching Hospital of the University of Rostock, Rostock, Germany
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11
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Haveman RA, Bäumlein M, van Veelen N, Oberkircher L, Beeres FJP, Babst R, Ruchholtz S, Link BC. Percutaneous sacroiliac screw fixation in fragility fractures of the pelvis: Comparison of two different augmentation techniques. Injury 2022; 53:4062-4066. [PMID: 36220693 DOI: 10.1016/j.injury.2022.09.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 09/23/2022] [Accepted: 09/25/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Fragility fractures of the pelvis (FFP) are becoming increasingly common. Percutaneous sacroiliac screw fixation is an accepted and safe treatment method for FFP. Augmentation is an option to optimize fixation strength of the screws. This study aims to compare patient mobility and the occurrence of complications after operative treatment of FFP utilizing two different augmentation techniques. METHODS All patients who received augmented sacroiliac screws for the treatment of FFPs between 01.01.2017 and 31.12.2018 at one of the two participating hospitals were included. The operative techniques only differed with regards to the augmentation method used. At the one hospital cannulated screws were used. Definitive screw placement followed augmentation. At the other hospital cannulated and fenestrated screws were used, permitting definitive screw placement prior to augmentation. RESULTS In total, 59 patients were included. The NRS score for pain was significantly lower after surgery. Preoperative mobility levels could be maintained or improved in 2/3 of the patients. There were no fatal complications. Two revision surgeries were performed because of screw misplacement. There were no significant differences between the two augmentation techniques in terms of complications. CONCLUSION Both augmentation techniques have a low complication rate and are safe methods to maintain patients' mobility level. The authors advocate early consideration of surgical treatment for patients with FFP. Augmentation can be considered a safe addition when performing percutaneous sacroiliac screw fixation.
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Affiliation(s)
- R A Haveman
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne.
| | - M Bäumlein
- Center for Orthopedics and Trauma Surgery, Philipps University Marburg
| | - N van Veelen
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne
| | - L Oberkircher
- Center for Orthopedics and Trauma Surgery, Philipps University Marburg
| | - F J P Beeres
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne
| | - R Babst
- Department of Health Science and Medicine, University of Lucerne
| | - S Ruchholtz
- Center for Orthopedics and Trauma Surgery, Philipps University Marburg
| | - B-C Link
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne
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12
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Perioperative outcome of minimally invasive stabilisation of bilateral fragility fractures of the sacrum: a comparative study of bisegmental transsacral stabilisation versus spinopelvic fixation. Eur J Trauma Emerg Surg 2022; 49:1001-1010. [PMID: 36255462 PMCID: PMC10175409 DOI: 10.1007/s00068-022-02123-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 09/27/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Pelvic fragility fractures have steadily risen over the past decades. The primary treatment goal is the fastest possible mobilisation. If conservative therapy fails, surgical fixation is a promising approach. This study compares the outcome of bisegmental transsacral stabilisation (BTS) and spinopelvic fixation (SP) as minimally invasive techniques for bilateral fragility fractures of the sacrum (BFFS). METHODS We performed a prospective, non-randomised, case-controlled study. Patients were included if they remained bedridden due to pain despite conservative treatment. Group assignment depended on sacral anatomy and fracture type. The outcome was estimated by blood loss calculation, cut-seam time, fluoroscopy time, complications, duration of stay at the intensive/intermediate care unit (ICU/IMC), and total inpatient stay. The mobility level at discharge was recorded. RESULTS Seventy-three patients were included (SP: 49, BTS: 24). There was no difference in blood loss (BTS: 461 ± 628 mL, SP: 509 ± 354 mL). BTS showed a significantly lower cut-seam time (72 ± 23 min) than SP (94 ± 27 min). Fluoroscopy time did not differ (BTS: 111 ± 61 s vs. 103 ± 45 s). Thirteen percent of BTS and 16% of SP patients required ICU/IMC stay (BTS: 0.6 ± 1.8 days, SP: 0.5 ± 1.5 days) during inpatient stay (BTS: 9 ± 4 days, SP: 8 ± 3 days). Fourteen patients suffered from urinary tract infections (BTS: 8%; SP: 25%). In-patient mortality was low (BTS: 4.2%, SP: 4.1%). At discharge, the BTS group was almost back to the initial mobility level. In SP patients, mobility was significantly lower than before complaints (p = 0.004). CONCLUSION Both methods allow early mobilization of BFFS patients. Blood loss can be kept low. Hence, transfusion requirement is correspondingly low. The IMC/ICU and the total inpatient stay are lower than reported in the literature. Both BTS and SP can be recommended as safe and low-complication methods for use in BFFS patients. BTS is superior to SP with respect to surgery duration and level of mobility at discharge.
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13
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Cattaneo S, Adriani M, Tonolini S, Oransky M, Galante C, Grava G, Milano G, Casiraghi A. FRAGILITY FRACTURES OF THE SACRUM: A SILENT EPIDEMIC. Orthop Rev (Pavia) 2022; 14:38572. [DOI: 10.52965/001c.38572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Fragility fractures of the sacrum (FFS) are caused by low-energy trauma in the elderly population. Due to the nuanced symptomatology, many FFS remains unrecognized and the prevalence is underestimated. The clinical presentation varies, typically presenting with weightbearing low back pain without even remembering of a previous trauma. Radiographs are usually insufficient for the diagnosis and second level imaging modalities are required. In particular, magnetic resonance demonstrated the highest diagnostic accuracy. Treatment should aim to guarantee early mobilization and weightbearing, efficient pain relief and early discharge from the hospital to a proper facility for rehabilitation. Conservative treatment is reserved to non-displaced fractures with an adequate pain relief within one week allowing early mobilization. Otherwise, surgical treatment must be preferred. Nowadays, minimally invasive techniques, such as ileo-sacral screws or trans-sacral bar osteosynthesis, are safe and effective procedures and have overcome open procedures. In more complex patterns, with complete dissociation between the pelvic ring and the ilio-lumbar spine, spino-pelvic fixation is the procedure of choice.
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Affiliation(s)
| | | | | | | | | | | | - Giuseppe Milano
- Department of Bone and Joint Surgery, ASST Spedali Civili, Brescia, Italy; Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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14
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Rickert MM, Windmueller RA, Ortega CA, Devarasetty VVNM, Volkmar AJ, Waddell WH, Mitchell PM. Sacral Insufficiency Fractures. JBJS Rev 2022; 10:01874474-202207000-00001. [PMID: 35849657 DOI: 10.2106/jbjs.rvw.22.00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Primary osteoporosis is the most common cause of sacral insufficiency fractures (SIFs). Therefore, a multidisciplinary team approach is necessary for treatment of the fracture and the underlying biologic pathology, as well as prevention of future fragility fractures. » The presentation of SIFs typically includes lower back or buttock pain after a ground-level fall or without an identified trauma. Symptoms often have an insidious onset and are nonspecific; consequently, a delay in diagnosis and treatment is common. Clinicians need to have a high index of suspicion, particularly in high-risk patients. » Postmenopausal women who are >55 years of age are the most common demographic affected by SIFs. Other risk factors include osteoporosis, history of a prior fragility fracture, local irradiation, long-term corticosteroid use, rheumatoid arthritis, metabolic bone disorders, vitamin D deficiency, pregnancy, history of prior multilevel spinal fusion, and malignancy. » Typical imaging on computed tomography (CT) shows sclerosis of cancellous bone in the sacral ala, with or without a discrete fracture line or displacement. Magnetic resonance imaging is more sensitive than CT and shows hypointense signal on T1-weighted sequences and hyperintensity on T2-weighted or short tau inversion recovery sequences. » The treatment of SIFs is dependent on the severity of symptoms, fracture displacement, and instability of the pelvis. Accepted treatments include nonoperative rehabilitation, sacroplasty, iliosacral screw fixation, transsacral bar or screw fixation, transiliac internal fixation, and lumbopelvic fixation.
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Affiliation(s)
- Mariel M Rickert
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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15
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Ellmerer AE, Küper MA, Rollmann MF, Herath SC, Histing T. [Cement augmentation in pelvic ring fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:443-451. [PMID: 35925151 DOI: 10.1007/s00113-022-01186-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 06/15/2023]
Abstract
Cement augmentation of sacroiliac (SI) screws in the posterior pelvic ring has been shown to provide greater biomechanical stability in cadaveric studies. Pelvic ring fractures are relatively rare compared to the total number of fractures. Nevertheless, the 1‑year mortality rate of up to 27% is very high, especially for geriatric pelvic ring fractures and is also largely associated with reduced mobility due to the fracture. The primary goal of treatment is therefore the restoration of patient mobility. This requires the achievement of sufficient stability of the pelvic ring. As osteoporosis is often a causative factor for the pelvic ring fracture, a more stable anchoring of the implants in the osteoporotic bone can be achieved by cement augmentation. This article presents the possibilities of cement augmentation of the pelvic ring and describes the technique of cement-augmented SI screws.
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Affiliation(s)
- Andreas E Ellmerer
- Klinik für Unfall- und Wiederherstellungschirurgie an der Eberhard Karls Universität, BG Unfallklinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Markus A Küper
- Klinik für Unfall- und Wiederherstellungschirurgie an der Eberhard Karls Universität, BG Unfallklinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Mika F Rollmann
- Klinik für Unfall- und Wiederherstellungschirurgie an der Eberhard Karls Universität, BG Unfallklinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Steven C Herath
- Klinik für Unfall- und Wiederherstellungschirurgie an der Eberhard Karls Universität, BG Unfallklinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland
| | - Tina Histing
- Klinik für Unfall- und Wiederherstellungschirurgie an der Eberhard Karls Universität, BG Unfallklinik Tübingen, Schnarrenbergstr. 95, 72076, Tübingen, Deutschland.
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16
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Rommens PM, Hopf JC, Arand C, Handrich K, Boudissa M, Wagner D. Prospective assessment of key factors influencing treatment strategy and outcome of fragility fractures of the pelvis (FFP). Eur J Trauma Emerg Surg 2022; 48:3243-3256. [PMID: 35122506 PMCID: PMC9360063 DOI: 10.1007/s00068-022-01887-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/17/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Fragility fractures of the pelvis (FFP) are a clinical entity with an increasing significance in clinical practice. Little is known about the conditions, which influence decision making and outcome. SETTING Level I trauma center. MATERIAL AND METHODS Prospective assessment of selected parameters of patients, who were admitted with a FFP in a 2-year period. Fractures were classified in accordance with the Rommens and Hofmann classification. Living environment, level of autonomy (independent walking), type of treatment (conservative versus operative), type of surgical technique, European Quality of Life-5 Dimensions-5 Levels (EQ-5D-5L), Short Form-8 Physical Component Score (SF-8 PCS) and Short Form-8 Mental Component Score (SF-8 MCS), Barthel Index, Parker Mobility Score (PMS) and Numeric Rating Scale (NRS) were collected at primary presentation (t1), at discharge (t2) and after 3 (t3) and 12 months (t4). Length of hospital stay, in-hospital complications, surgery-related complications, new osteoporotic fractures and mortality rate within the first year were also registered. The key factors influencing the choice of therapy and outcome were looked for. RESULTS 110 patients, 99 women (90%) and 11 men (10%), were included in the study. Their mean age was 79.2 years (SD 10 years). Fourteen patients had FFP type I (12.7%), 59 FFP type II (53.6%), 11 FFP type III (10%) and 26 FFP type IV fractures (23.6%). All patients with FFP type I were treated conservatively. 48 patients with FFP types II-IV were treated conservatively and 48 operatively. Patients, who got a conservative outpatient treatment first and were hospitalized later, had higher FFP fracture types at admission. Operatively treated patients were hospitalized at a median of 33.5 days after the beginning of complaints, whereas the median day of admission of the conservative group was the day of trauma (p < 0.001). The operatively treated patients were hospitalized in a worse clinical condition (SF-8 PCS, EQ-5D-5L, autonomy). Length of stay (LoS) of operatively treated patients was significantly longer than of conservatively treated (p < 0.001). There was a tendency to more in-hospital complications in the operative group (p = 0.059). The rate of surgery-related complications (8.3%) was low with only one revision needed. Selected outcome parameters improved during the observation period nearly reaching the level before FFP after 1 year. SF-8 PCS, Barthel index and rate of patients living home were higher in the operative group at t4. The improvement of autonomy (independent walking) between t1 and t4 was significant in the operated group (p = 0.04) but not in the conservative group (p = 0.96). One-year mortality rate was 11.7% with no difference between the fracture types. One-year mortality rate of conservatively treated patients with FFP type II-IV was 13.5% versus 6.9% in the operative group (p = 0.38). CONCLUSION Conservative treatment is appropriate in patients with FFP type I as well as in patients with FFP type II, provided that the last ones are hospitalized immediately after the traumatic event. Surgical treatment is recommended in patients with higher fracture types, with delayed presentation or after unsuccessful conservative treatment. In the conservative and operative group, all selected parameters considerably improved between t1 and t4 with a steeper increase in the operative group. The rate of postoperative complications is low. The 1-year mortality rate is the lowest in the operative group. Surgical stabilization of FFP is safe and reliable provided it is performed with care and in the appropriate target group.
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Affiliation(s)
- Pol Maria Rommens
- Department of Orthopaedics and Traumatology, University Medical Center, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Johannes Christoph Hopf
- Department of Orthopaedics and Traumatology, University Medical Center, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Charlotte Arand
- Department of Orthopaedics and Traumatology, University Medical Center, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Kristin Handrich
- Department of Orthopaedics and Traumatology, University Medical Center, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Mehdi Boudissa
- Department of Orthopaedics and Traumatology, University Medical Center, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Daniel Wagner
- Department of Orthopaedics and Traumatology, University Medical Center, Langenbeckstrasse 1, 55131 Mainz, Germany
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17
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What is the long-term clinical outcome after fragility fractures of the pelvis? - A CT-based cross-sectional study. Injury 2022; 53:506-513. [PMID: 34656318 DOI: 10.1016/j.injury.2021.09.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 09/17/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Recently, Rommens and Hoffman introduced a CT-based classification system for fragility fractures of the pelvis (FFP). Although fracture characteristics have been described, the relationship with clinical outcome is lacking. The purpose of this study was to get insight into the type of treatment and subsequent clinical outcome after all types of FFP. METHODS A cross-sectional cohort study was performed including all elderly patients (≥ 65 years) with a CT-diagnosed FFP, between 2007-2019 in two level 1 trauma centers. Data regarding treatment, mortality and clinical outcome was gathered from the electronic patient files. Patients were asked to complete patient-reported outcome measures (PROMs) regarding physical functioning (SMFA) and quality of life (EQ-5D). Additionally, a standardized multidisciplinary treatment algorithm was constructed. RESULTS A total of 187 patients were diagnosed with an FFP of whom 117 patients were available for follow-up analysis and 58 patients responded. FFP type I was most common (60%), followed by type II (27%), type III (8%) and type IV (5%). Almost all injuries were treated non-operatively (98%). Mobility at six weeks ranged from 50% (type III) to 80% type II). Mortality at 1 year was respectively 16% (type I and II), 47% (type III) and 13% (type IV). Physical functioning (SMFA function index) ranged from 62 (type III and IV) to 69 (type II) and was significantly decreased (P=<0.001) compared to the age-matched general population. Quality of life was also significantly decreased, ranging from 0.26 (type III) to 0.69 (type IV). CONCLUSIONS FFP type I and II are most common. Treatment is mainly non-operative, resulting in good mobility after six weeks, especially for patients with FFP type I and II. Mortality rates at one year were substantial in all patients. Physical functioning and quality of life was about 20-30% decreased compared to the general population.
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18
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Hack J, Safi M, Bäumlein M, Lenz J, Bliemel C, Ruchholtz S, Oberkircher L. Is cement-augmented sacroiliac screw fixation with partially threaded screws superior to that with fully threaded screws concerning compression and pull-out force in fragility fractures of the sacrum? - a biomechanical analysis. BMC Musculoskelet Disord 2021; 22:1034. [PMID: 34893059 PMCID: PMC8665623 DOI: 10.1186/s12891-021-04933-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/16/2021] [Indexed: 11/29/2022] Open
Abstract
Background Providing a stable osteosynthesis in fragility fractures of the pelvis can be challenging. Cement augmentation increases screw fixation in osteoporotic bone. Generating interfragmentary compression by using a lag screw also improves the stability. However, it is not known if interfragmentary compression can be achieved in osteoporotic sacral bone by cement augmentation of lag screws. The purpose of this study was to compare cement-augmented sacroiliac screw osteosynthesis using partially versus fully threaded screws in osteoporotic hemipelvises concerning compression of fracture gap and pull-out force. Methods Nine fresh-frozen human cadaveric pelvises with osteoporosis were used. In all specimens, one side was treated with an augmented fully threaded screw (group A), and the other side with an augmented partially threaded screw (group B) after generating a vertical osteotomy on both sides of each sacrum. Afterwards, first a compression test with fracture gap measurement after tightening of the screws was performed, followed by an axial pull-out test measuring the maximum pull-out force of the screws. Results The fracture gap was significantly wider in group A (mean: 1.90 mm; SD: 1.64) than in group B (mean: 0.91 mm; SD: 1.03; p = 0.028). Pull-out force was higher in group A (mean: 1696 N; SD: 1452) than in group B (mean: 1616 N; SD: 824), but this difference was not statistically significant (p = 0.767). Conclusions Cement augmentation of partially threaded screws in sacroiliac screw fixation allows narrowing of the fracture gap even in osteoporotic bone, while resistance against pull-out force is not significantly lower in partially threaded screws compared to fully threaded screws.
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Affiliation(s)
- Juliana Hack
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, Baldingerstrasse, 35043, Marburg, Germany.
| | - Maiwand Safi
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, Baldingerstrasse, 35043, Marburg, Germany
| | - Martin Bäumlein
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, Baldingerstrasse, 35043, Marburg, Germany
| | - Julia Lenz
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, Baldingerstrasse, 35043, Marburg, Germany
| | - Christopher Bliemel
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, Baldingerstrasse, 35043, Marburg, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, Baldingerstrasse, 35043, Marburg, Germany
| | - Ludwig Oberkircher
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, Baldingerstrasse, 35043, Marburg, Germany
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19
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Richter PH, Blidon A, Eickhoff A, Gebhard F, Schuetze K. Accuracy of screw stabilization of the dorsal pelvic ring using a hybrid operating room: 5 Year experience in a level 1 trauma center. Injury 2021; 52:2968-2972. [PMID: 34275645 DOI: 10.1016/j.injury.2021.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/26/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Accuracy for screw placement in the dorsal pelvic ring can be enhanced using intraoperative 3D navigation. Advances in intraoperative imaging lead to benefits for pelvic surgery. New c-arms are equipped with flat panel detectors, which have a larger detector and assure higher image quality with accompanying dose reduction. A hybrid OR is defined by a fixed imaging system in an operating room providing the benefit of the surgical environment in combination with advanced intraoperative imaging. Aim of our investigation was to analyze the accuracy of navigated sacroiliac (SI) and transsacral transiliac (TSTI) screws in the dorsal pelvic ring, which were implanted with a hybrid OR in the first five years of use. MATERIAL AND METHODS All percutaneous SI or TSTI screws implanted in the hybrid OR using intraoperative navigation in the first 5 years of utilization (between June 2012 to June 2017) were included. Intraoperative 3D-scans and postoperative computed tomography were examined for screw perforation. RESULTS 210 SI and TSTI screws were implanted in 187 patients using intraoperative navigation in the hybrid-OR. 90.6 % of SI screws showed no cortical perforation. 6,3 % had a grade 1, 2.4 % a grade 2 and 0.8 % a grade 3 perforation. In 80.7 % of TSTI screws no perforation and in 13.3 % a grade 1 perforation was detected. 3.6 % showed a grade 2 and 2.4 % a grade 3 perforation. No significant difference between both screw types regarding the grade of cortical perforation could be seen. No significant relation between perforation rate and year of operation could be detected. CONCLUSION Intraoperative navigation in a hybrid OR ensures a high accuracy for SI screws. Due to the large field of view and high image quality TSTI screws can be safely implanted in S1 and S2. Utilization of a hybrid-OR is accompanied with a steep learning curve.
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Affiliation(s)
- P H Richter
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany.
| | - A Blidon
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
| | - A Eickhoff
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
| | - F Gebhard
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
| | - K Schuetze
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
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20
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Suero EM, Greiner A, Becker CA, Cavalcanti Kußmaul A, Weidert S, Pfeufer D, Woiczinski M, Braun C, Flatz W, Böcker W, Kammerlander C. Biomechanical stability of sacroiliac screw osteosynthesis with and without cement augmentation. Injury 2021; 52:2707-2711. [PMID: 32033807 DOI: 10.1016/j.injury.2020.01.043] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/26/2020] [Accepted: 01/28/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Percutaneous sacroiliac (SI) screw fixation is the standard operative treatment of traumatic disruptions to the posterior pelvic ring. The technique offers good outcomes and early postoperative mobilization, which is vital in elderly patients with fragility fractures of the pelvis. While a double-screw technique has been shown to provide optimal biomechanical stability compared to a single-screw construct, anatomic variations and patient-specific characteristics may prevent the safe insertion of two SI screws. We aimed to determine whether cement augmentation of a single SI screw would provide biomechanical stability comparable to that of the double-screw technique. METHODS Three sacroiliac screw osteosynthesis configurations were tested on 10 human cadaveric pelvis specimens: a single cannulated screw; two cannulated screws; and a single, cement-augmented cannulated screw. Displacement and stiffness of the anterior and posterior pelvic ring after fixation with each technique were measured under axial load. Results where compared using linear regression and paired t-tests. RESULTS A single uncemented screw offered significantly worse stability in the anterior pelvis compared to a double-screw technique (P < 0.05) and to a single cement-augmented screw technique (P < 0.05). There was no significant difference in anterior pelvic ring stability between the single cement-augmented screw technique and the double-screw technique (P > 0.05). There was no significant difference in the stability of the posterior pelvic ring between the three techniques (P > 0.05). CONCLUSIONS A single cement-augmented cannulated sacroiliac screw provides biomechanical stability similar to that of a non-augmented double-screw technique in the treatment of posterior pelvic ring fractures.
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Affiliation(s)
- Eduardo M Suero
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany.
| | - Axel Greiner
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Christopher A Becker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany.
| | - Adrian Cavalcanti Kußmaul
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Simon Weidert
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Daniel Pfeufer
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Matthias Woiczinski
- Department of Orthopedic Surgery, Physical medicine and Rehabilitation, University Hospital, LMU Munich, Munich, Germany
| | - Christian Braun
- Institute of Legal and Forensic Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Wilhelm Flatz
- Institute for Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Böcker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
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21
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Short-term outcome of fragility fractures of the pelvis in the elderly treated with screw osteosynthesis and external fixator. Eur J Trauma Emerg Surg 2021; 48:2413-2420. [PMID: 34545420 PMCID: PMC9192446 DOI: 10.1007/s00068-021-01780-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 09/01/2021] [Indexed: 11/20/2022]
Abstract
Background The treatment of fragility fractures of the pelvis is rising challenge for orthopedic trauma surgeons. Operative treatment should allow immediate full weight bearing and early mobilisation but should also be as minimal invasive as possible. Sacroiliac (SI) or transsacral transiliac screws (TSTI) alone or depending on the fracture in combination with an external fixator meets both of these criteria. Material and methods The outcome of 121 operatively treated patients with fragility fractures of the pelvis were evaluated in this retrospective study. Depending on the type of fracture the patients were treated with navigated SI screw or TSTI screw alone or in combination with an external fixator. All patients were operated in supine position in a hybrid-OR, which consists of a fixed robotic 3D flatpanel detector (Artis zeego, Siemens Healthineers, Germany) and a navigation system (BrainLab Curve, BrainLab, Germany). Results 37 patients were treated with either one or two SI screws and 57 with one TSTI screw. An additional external fixator was combined with SI screws in 17 patients and with TSTI screws in 10 patients. The preoperative pain score was significantly higher compared to the postoperative score (5.1 ± 2.5 vs 2.2 ± 1.9, p < 0.05). Follow-up at 6 month was possible for 106 patients which showed screw loosening in 16.3% of the SI Screws (n = 49) compared to only 5.2% of TSTI screws (n = 57). No screw loosening was seen in the combination of TSTI-screw and external fixator (n = 10). There were two septic and three aseptic pin loosenings of the external fixator. Overall only one patient needed revision surgery due to screw loosening and local irritation. Overall 75.2% (n = 91) of the patients could be released in their home or in a rehabilitation unit and only 14% (n = 17) were released to a nursing home due to immobility despite the operation. Non-surgical complications rate was 21.5%. Conclusion SI or TSTI screws with possible combination with an external fixator show early pain relief and allows most of the patients to keep their former level of independence. With an also low surgical complication rate, it proved to be a safe and reliable treatment for fragility fractures of the pelvis. Due the effective pain relief and the minimal invasive approach, early mobilisation is possible and might prevent typical non-surgical complications which are very common during conservative treatment.
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Wilson DGG, Kelly J, Rickman M. Operative management of fragility fractures of the pelvis - a systematic review. BMC Musculoskelet Disord 2021; 22:717. [PMID: 34419037 PMCID: PMC8380328 DOI: 10.1186/s12891-021-04579-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/02/2021] [Indexed: 02/07/2023] Open
Abstract
Background The incidence of osteoporotic pelvic fractures in elderly patient is rising. This brings an increasing burden on health and social care systems as these injuries often lead to prolonged hospital admissions, loss of independence, morbidity and mortality. Some centres now advocate stabilisation of these injuries to reduce pain, facilitate early mobilisation, decrease hospital stay and restore independence. A systematic review of the literature was planned to establish the evidence for this intervention. Methods A systematic review was performed according to PRISMA guidelines. A clinical librarian performed a search of the following databases: NHS Evidence, TRIP, the Cochrane Database of Systematic Reviews, MEDLINE and EMBASE. Seventeen eligible studies were identified with 766 patients. Results The quality of evidence was poor with no good quality randomised trials. The majority of injuries were minimally displaced. Posterior ring injuries were most often stabilised with percutaneous screws which were sometimes augmented with void filler. A number of techniques were described for stabilisation of the anterior ring although fixation of the anterior ring was frequently not performed. There was consistent evidence from the included studies that operative intervention significantly improved pain. Complications were minimal but there were increased failure rates when a single unaugmented sacroiliac joint screw was used. The limited availability of non-operative comparators made it difficult to draw firm conclusions about the efficacy of surgical over non-surgical management in these patients. Conclusions Operative management of fragility fractures of the pelvis should be considered for patients failing a brief period of non-operative management, however prospective randomised trials need to be performed to provide improved evidence for this intervention. Surgeons should consider which fixation techniques for fragility fractures of the pelvis are robust enough to allow immediate weightbearing, whilst minimising operative morbidity and post-operative complications. PROSPERO Systematic Review ID: CRD42020171237. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04579-w.
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Affiliation(s)
- Daniel G G Wilson
- Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia. .,, Present address: Brighton, UK.
| | - Joshua Kelly
- Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia
| | - Mark Rickman
- Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia.,Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, SA, 5005, Australia
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23
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Oberkircher L, Lenz J, Bücking B, Eschbach D, Aigner R, Bliemel C, Schoeneberg C, Ruchholtz S, Hack J. Which factors influence treatment decision in fragility fractures of the pelvis? - results of a prospective study. BMC Musculoskelet Disord 2021; 22:690. [PMID: 34388997 PMCID: PMC8364046 DOI: 10.1186/s12891-021-04573-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/04/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The aim of the present study was to describe specific characteristics of patients suffering from pelvic fragility fractures and evaluate factors that might influence treatment decisions which may optimize treatment pathways and patient mobility in the future. METHODS A prospective study with patients suffering from fractures of the pelvis and aged 60 years or above was performed between 2012 and 2016. Data acquisition took place at admission, every day during hospitalization and at discharge. RESULTS One hundred thirty-four patients (mean age of 79.93 (± 7.67) years), predominantly female (84%), were included. Eighty-six patients were treated non-operatively. Forty-eight patients underwent a surgical procedure. The main fracture types were B2 fractures (52.24%) and FFP IIb fractures (39.55%). At the time of discharge, pain level (NRS) could be significantly reduced (p < 0.001). Patients who underwent a surgical procedure had a significantly higher pain level on day three and four compared to the non-operative group (p = 0.032 and p = 0.023, respectively). Significant differences were found in the mobility level: patients treated operatively on day four or later were not able to stand or walk on day three as compared to non-operatively treated patients. Regarding B2 fractures, a significantly higher mobility level difference between time of admission and discharge was found in patients treated with a surgical procedure compared to patients treated non-operatively (p = 0.035). CONCLUSIONS Fracture type, mobility level and pain level influence the decision to proceed with surgical treatment. Especially patients suffering from B2 fractures benefitted in terms of mobility level at discharge when treated operatively. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Ludwig Oberkircher
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Marburg, Germany
| | - Julia Lenz
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Marburg, Germany
| | - Benjamin Bücking
- Department of Orthopaedics, Trauma Surgery and Geriatric Trauma, DRK-Hospital Nordhessen, Kassel, Germany
| | - Daphne Eschbach
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Marburg, Germany
| | - René Aigner
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Marburg, Germany
| | - Christopher Bliemel
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Marburg, Germany
| | - Carsten Schoeneberg
- Department of Orthopedic and Emergency Surgery, Alfried Krupp Hospital, Essen, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Marburg, Germany
| | - Juliana Hack
- Center for Orthopaedics and Trauma Surgery, Philipps University of Marburg, University Hospital Giessen and Marburg GmbH, Marburg, Germany
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Spiegl UJA, Schnake KJ, Ullrich B, Scheyerer MJ, Osterhoff G, Siekmann H. Current Minimally Invasive Surgical Concepts for Sacral Insufficiency Fractures. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021; 161:143-153. [PMID: 34318465 DOI: 10.1055/a-1498-2975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
An increasing incidence of sacral insufficiency fractures in geriatric patients has been documented, representing a major challenge to our healthcare system. Determining the accurate diagnosis requires the use of sectional imaging, including computed tomography and magnetic resonance imaging. Initially, non-surgical treatment is indicated for the majority of patients. If non-surgical treatment fails, several minimally invasive therapeutic strategies can be used, which have shown promising results in small case series. These approaches are sacroplasty, percutaneous iliosacral screw fixation (S1 with or without S2), trans-sacral screw fixation or implantation of a trans-sacral bar, transiliac internal fixator stabilisation, and spinopelvic stabilisation. These surgical strategies and their indications are reported in detail. Generally, treatment-related decision making depends on the clinical presentation, fracture morphology, and attending surgeon's experience.
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Affiliation(s)
| | - Klaus J Schnake
- Zentrum für Wirbelsäulen- und Skoliosetherapie, Malteser Waldkrankenhaus St Marien gGmbH, Erlangen, Germany.,Klinik für Orthopädie und Unfallchirurgie, Universitätsklinik der Paracelsus Medizinischen Privatuniversität Klinikum Nürnberg, Nürnberg
| | - Bernhard Ullrich
- Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Germany
| | - Max J Scheyerer
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinik Köln, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University of Leipzig, Germany
| | - Holger Siekmann
- Unfallchirurgie, AMEOS Klinikum Sankt Salvator Halberstadt GmbH, Germany
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25
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Fourman MS, Ramsey DC, Newman ET, Raskin KA, Tobert DG, Lozano-Calderon S. How I do it: Percutaneous stabilization of symptomatic sacral and periacetabular metastatic lesions with photodynamic nails. J Surg Oncol 2021; 124:1192-1199. [PMID: 34291827 DOI: 10.1002/jso.26617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/25/2021] [Accepted: 07/12/2021] [Indexed: 01/23/2023]
Affiliation(s)
- Mitchell S Fourman
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Duncan C Ramsey
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Erik T Newman
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kevin A Raskin
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel G Tobert
- Department of Orthopaedic Surgery, Orthopaedic Spine Service, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Santiago Lozano-Calderon
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts, USA
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26
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Wagner D, Kisilak M, Porcheron G, Krämer S, Mehling I, Hofmann A, Rommens PM. Trans-sacral bar osteosynthesis provides low mortality and high mobility in patients with fragility fractures of the pelvis. Sci Rep 2021; 11:14201. [PMID: 34244526 PMCID: PMC8270908 DOI: 10.1038/s41598-021-93559-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/03/2021] [Indexed: 12/28/2022] Open
Abstract
Operative treatment of osteoporosis-associated fragility fractures of the pelvis (FFP) and the sacrum is advocated with immobilizing or longstanding pain, fracture progression and displacement. We analyzed clinical outcomes regarding mobility, quality of life, and mortality of patients with FFP treated with trans-sacral bar (TB) osteosynthesis through S1. Demographics, clinical data, and operation-related data of patients with an FFP treated with TB were acquired from chart review. We assessed mortality, quality of life (EQ-5D), mobility, and residential status at follow-up. Seventy-nine females and six males with a median age of 78.0 years (IQR 73–84) were included, median follow-up was 3.2 years. Medical complications during hospitalization occurred in 28%. Operative revision was carried out in 15% of patients. One-year survival was 90.4%, this was associated with shorter preoperative and total length of stay in hospital (p 0.006 and 0.025, respectively). At follow-up, 85% lived at home and 82% walked with or without walking aid. Higher EQ-5D was reached with higher mobility status and living at home (p < 0.001 and < 0.001, respectively). TB osteosynthesis is an adequate and reliable method for fixation of FFP in the posterior pelvic ring to ensure timely mobilization. Shorter preoperative and total length of stay had lower mortality rates, advocating a standardized management protocol to limit time delay to operative therapy. Patients treated with TB osteosynthesis had low 1-year mortality of less than 10%.
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Affiliation(s)
- Daniel Wagner
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Miha Kisilak
- Department of Traumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Geoffrey Porcheron
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Sven Krämer
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Isabella Mehling
- Division of Hand Surgery, St. Vincent Hospital Hanau, Hanau, Germany
| | - Alexander Hofmann
- Department of Orthopaedics and Traumatology, Westpfalz-Klinikum Kaiserslautern, Kaiserslautern, Germany
| | - Pol M Rommens
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
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A Bibliometric Analysis of Fragility Fractures: Top 50. ACTA ACUST UNITED AC 2021; 57:medicina57060639. [PMID: 34205638 PMCID: PMC8233744 DOI: 10.3390/medicina57060639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/12/2021] [Accepted: 06/16/2021] [Indexed: 11/24/2022]
Abstract
Background and Objectives: The population is aging and fragility fractures are a research topic of steadily growing importance. Therefore, a systematic bibliometric review was performed to identify the 50 most cited articles in the field of fragility fractures analyzing their qualities and characteristics. Materials and Methods: From the Core Collection database in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to fragility fractures were identified in February 2021 using a multistep approach. Year of publication, total number of citations, average number of citations per year since year of publication, affiliation of first and senior author, geographic origin of study population, keywords, and level of evidence were of interest. Results: Articles were published in 26 different journals between 1997 and 2020. The number of total citations per article ranged from 12 to 129 citations. In the majority of publications, orthopedic surgeons and traumatologists (66%) accounted for the first authorship, articles mostly originated from Europe (58%) and the keyword mostly used was “hip fracture”. In total, 38% of the articles were therapeutic studies level III followed by prognostic studies level I. Only two therapeutic studies with level I could be identified. Conclusions: This bibliometric review shows the growing interest in fragility fractures and raises awareness that more high quality and interdisciplinary studies are needed.
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Lodde MF, Katthagen JC, Riesenbeck O, Raschke MJ, Hartensuer R. [Trends in the surgical treatment of fractures of the pelvic ring : A nationwide analysis of operations and procedures code (OPS) data between 2005 and 2017]. Unfallchirurg 2021; 124:373-381. [PMID: 33030568 DOI: 10.1007/s00113-020-00893-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIM The aim of this study was to analyze the epidemiological trends and incidences in inpatient pelvic surgery in the period from 2005 to 2007. METHOD Approximately 194 million anonymized diagnosis-related groups (DRG) inpatient records were collected by the German Federal Statistical Office between 2005 and 2017. These data were screened for pelvic procedures, gender and age of the patients. Statistical testing was performed using the χ2-test and Mann-Whitney U-test (p < 0.05). RESULTS Between 2005 and 2017 the number of closed reduction and internal fixation of the pelvic ring with screw fixation increased by +1116%. The use of screw fixation for closed reduction and internal fixation of the sacroiliac joint increased by +800%. The number of cases of open reduction and internal fixation of fractures of the pelvic ring and pelvic rim increased by +185% and reposition with external fixator increased by +188%. In 2005 more surgical procedures were undertaken in male inpatients, whereas more surgical procedures were undertaken in female inpatients in 2017. In general, a large increase in the number of pelvic procedures was observed in the group of patients >50 years old. CONCLUSION There was an increase in the number of all analyzed pelvic procedures between 2005 and 2017. Especially the use of screw fixation increased. The introduction of new techniques (e.g. screw fixation of the sacroiliac joint) and progress and innovation in the field of three-dimensional navigation techniques, the demographic trend, greater mobility and higher demands on functionality of older patients might explain this increase in pelvic procedures.
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Affiliation(s)
- Moritz F Lodde
- Klinik für Unfall, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, Waldeyerstraße 1, 48149, Münster, Deutschland.
| | - J Christoph Katthagen
- Klinik für Unfall, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, Waldeyerstraße 1, 48149, Münster, Deutschland
| | - Oliver Riesenbeck
- Klinik für Unfall, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, Waldeyerstraße 1, 48149, Münster, Deutschland
| | - Michael J Raschke
- Klinik für Unfall, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, Waldeyerstraße 1, 48149, Münster, Deutschland
| | - René Hartensuer
- Klinik für Unfall, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, Waldeyerstraße 1, 48149, Münster, Deutschland
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29
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Gericke L, Fritz A, Osterhoff G, Josten C, Pieroh P, Höch A. Percutaneous operative treatment of fragility fractures of the pelvis may not increase the general rate of complications compared to non-operative treatment. Eur J Trauma Emerg Surg 2021; 48:3729-3735. [PMID: 33811488 PMCID: PMC9532300 DOI: 10.1007/s00068-021-01660-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 03/23/2021] [Indexed: 12/16/2022]
Abstract
Purpose Despite an increasing number of fragility fractures of the pelvis (FFP) over the last 2 decades, controversy persists on their therapy with special regard to potential complications. Therefore, the present study compared the complication rates and in-hospital mortality of non-operative therapy, percutaneous treatment and open reduction and internal fixation (ORIF) of pelvic fractures in elderly patients. Methods All consecutive patients treated for FFP between January 2013 and December 2017 aged 65 years or older were retrospectively identified from an institutional database. Demographic data and specific patient data were collected with a special focus on pre-existing comorbidities. General and surgical complications, hospital length of stay (LOS) and mortality rates were compared. Results 379 patients (81.3 ± 7.5 years; 81% female) were identified, 211 (55.7%) were treated non-operatively, 74 (19.5%) percutaneously and 94 (24.8%) with ORIF. The rate of general complications did not differ between treatment groups (non-operative: 21.8%; percutaneous: 28.4%; ORIF: 33.0%; p = 0.103). Surgery-related complications were twofold more frequent in the ORIF group as than in the percutaneously treated group (18.1% vs. 9.5%). The LOS differed significantly (non-operatively: 8.9 ± 7.1 days; percutaneous: 16.6 ± 8.2 days; ORIF: 19.3 ± 12.8 days; p < 0.001). Hospital mortality rate was higher in patients with ORIF (5.3%) than percutaneous treatment (0%) (p = 0.044). Conclusions Complication rates and hospital mortality in elderly patients with FFPs are high and associated with long LOS. For surgical treatment of FFPs, the complication rate and mortality can be significantly reduced using percutaneous procedures compared to ORIF. Therefore, percutaneous surgery should be preferred where possible. Supplementary Information The online version contains supplementary material available at 10.1007/s00068-021-01660-w.
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Affiliation(s)
- Laura Gericke
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Annemarie Fritz
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Georg Osterhoff
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Philipp Pieroh
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Andreas Höch
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
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Minimally invasive posterior locked compression plate osteosynthesis shows excellent results in elderly patients with fragility fractures of the pelvis. Eur J Trauma Emerg Surg 2020; 47:37-45. [PMID: 33104870 PMCID: PMC7851100 DOI: 10.1007/s00068-020-01498-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/08/2020] [Indexed: 02/06/2023]
Abstract
Purpose Fragility fractures of the pelvis (FFP) are common in older patients. We evaluated the clinical outcome of using a minimally invasive posterior locked compression plate (MIPLCP) as therapeutic alternative. Methods 53 Patients with insufficiency fractures of the posterior pelvic ring were treated with MIPLCP when suffering from persistent pain and immobility under conservative treatment. After initial X-ray, CT-scans of the pelvis were performed. In some cases an MRI was also performed to detect occult fractures. Postoperatively patients underwent conventional X-ray controls. Data were retrospectively analyzed for surgical and radiation time, complication rate, clinical outcome and compared to the literature. Results Patients (average age 79.1 years) underwent surgery with operation time of 52.3 min (SD 13.9), intra-operative X-ray time of 9.42 s (SD 9.6), mean dose length product of 70.1 mGycm (SD 57.9) and a mean hospital stay of 21.2 days (SD 7.7). 13% patients (n = 7) showed surgery-related complications, such as wound infection, prolonged wound secretion, irritation of the sacral root or clinically inapparent screw malpositioning. 17% (n = 9) showed postoperative complications (one patient died due to pneumonia 24 days after surgery, eight patients developed urinal tract infections). 42 patients managed to return to previous living situation. 34 were followed-up after a mean period of 31.5 (6–90) months and pain level at post-hospital examination of 2.4 (VAS) with an IOWA Pelvic Score of 85.6 (55–99). Conclusion We showed that MIPLCP osteosynthesis is a safe surgical alternative in patients with FFP 3 and FFP 4. This treatment is another way of maintaining a high level of stability in the osteoporotic pelvic ring with a relatively low complication rate, low radiation and moderate operation time and a good functional outcome.
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Hartensuer R, Lodde MF, Keller J, Eveslage M, Stolberg-Stolberg J, Riesenbeck O, Raschke MJ. Safety, Effect and Feasibility of Percutaneous SI-Screw with and without Augmentation-A 15-Year Retrospective Analysis on over 640 Screws. J Clin Med 2020; 9:jcm9082660. [PMID: 32824548 PMCID: PMC7463525 DOI: 10.3390/jcm9082660] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/11/2020] [Accepted: 08/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Minimally invasive sacroiliac-screw (SI-screw) fixation of the pelvis is used in energy trauma (Arbeitsgemeinschaft für Osteosynthesefragen (AO) classified) and fragility fractures (Fragility Fracture of the Pelvis (FFP) classified). However, available clinical data are based on small case series and biomechanical data seem to be contradictory. METHODS The present single center retrospective cohort study investigated percutaneous SI-screw fixation and augmentation over 15 years. Groups were compared concerning the general epidemiological data, mobilization, complication rates, duration of stay, and safety of SI-screw insertion. Multivariable analyses were performed using logistic regression. RESULTS Between 2005 and March 2020, 448 patients with 642 inserted SI-screws were identified. Iatrogenic neurological impairment was documented in 2.47% and correlated with screw misplacement. There was an increased complication risk in patients with AO type C over patients with AO type B and in FFP II over FFP III/IV patients. Cement-augmented FFP patients showed a 25% reduced stay in hospital and a reduced complication risk. Cement-associated complications were seen in 22% without correlation to neurologic impairment. CONCLUSIONS The present study confirms the safety and usability of percutaneous SI-screw fixation, despite specific risks. Cement augmentation seems to reduce the complication risk in FFP patients and shorten hospital stay for some reasons, without increased specific complications or correlated neurological impairment.
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Affiliation(s)
- René Hartensuer
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
- Correspondence: ; Tel.: +49-251-83-59204
| | - Moritz F. Lodde
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Jonas Keller
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Muenster, 48149 Münster, Germany;
| | - Josef Stolberg-Stolberg
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Oliver Riesenbeck
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Michael J. Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
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Abstract
Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma.This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagnosis, underestimation and inadequate treatment. The diagnosis should be made by assessing specific features during the clinical presentation, while computed tomography (CT) scan continues to be the choice of investigation.Sacral fractures can be treated non-operatively or surgically. Non-operative treatment is based on rest, pain relief therapy and early mobilization as tolerated. Surgical techniques can be split into two main groups: posterior pelvic fixation techniques and lumbopelvic fixation techniques. Anterior pelvic fixation techniques should be considered when sacral fractures are associated with anterior pelvic ring injuries, in order to increase stability and reduce the risk of posterior implant failure. To improve fracture reduction, different solutions could be adopted, including special positioning of the patient, manipulation techniques and use of specific reduction tools. Patients suffering from spinopelvic dissociation with associated neurologic lesions hardly ever recover completely, with residual lower-limb neurologic sequelae, urinary problems and sexual disfunction.Herein, we present issues, challenges and solutions related to the management of sacral fractures. Cite this article: EFORT Open Rev 2020;5:299-311. DOI: 10.1302/2058-5241.5.190064.
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Affiliation(s)
- Emmanuele Santolini
- Academic Unit of Trauma and Orthopaedics, University of Genoa, Italy.,Academic Department of Trauma and Orthopaedics, LGI, University of Leeds, UK
| | | | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, LGI, University of Leeds, UK.,NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK
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Wong JSY, Lau JCK, Chui KH, Tiu KL, Lee KB, Li W. Three-dimensional-guided navigation percutaneous screw fixation of fragility fractures of the pelvis. J Orthop Surg (Hong Kong) 2020; 27:2309499019833897. [PMID: 30862246 DOI: 10.1177/2309499019833897] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Three-dimensional (3D)-guided navigation percutaneous screw fixation of pelvi-acetabular fractures has been reported in patients with high-energy trauma. Its use in fragility fractures of the pelvis is expanding and its results are promising. METHODS We report a series of 17 consecutive patients with fragility fractures of the pelvis treated with 3D-guided navigation percutaneous screw fixation from 2016 to 2017. Percutaneous screw trajectories were planned preoperatively for the majority of patients. Closed reduction was performed prior to fixation in grossly displaced fractures. RESULTS The mean time to surgery was 8.6 ± 2.4 days, and the mean intraoperative blood loss was 94.1 ± 26.6 mL. One early surgical complication occurred involving an infected pelvic external fixator iliac pin track site, and there were no cases of neurological deficits after fixation. In total, 7 of the 14 patients had screw backout, and the mean backout distance was 8.3 ± 4.4 mm. Cortical perforation was seen in one patient involving an anterior column screw by 5.7 mm; 14 patients were followed up for a mean of 18.7 ± 2.8 months; 13 patients achieved complete fracture union, and 1 patient had a fracture non-union. Premorbid ambulatory function was restored in 8 of the 14 patients. The mean visual analogue scale for pain severity at follow-up was 0.36 ± 0.50. There were no cases of 30-day and 1-year mortality. CONCLUSION 3D-guided navigation percutaneous screw fixation is a safe, precise, and effective surgical technique for managing fragility fractures of the pelvis.
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Affiliation(s)
- Justin Shing Yan Wong
- Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Janice Chi Kay Lau
- Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - King Him Chui
- Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Kwok Leung Tiu
- Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Kin Bong Lee
- Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Wilson Li
- Department of Orthopaedics and Traumatology, Queen Elizabeth Hospital, Kowloon, Hong Kong
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Abstract
Despite advances in technology such as locked plating, osteoporotic bone and bone defects remain challenging complications for orthopaedic surgeons. The concept of augmented fixation is useful in these settings. Augmented fixation can be described as improving construct strength and stability by enhancing the surrounding environment. By understanding and using the techniques of alternative fixation strategies, endosteal or medullary support, structural grafting, or the use of bone graft substitutes in combination with standard or integrated fixation, surgeons can improve the chances of success when treating difficult fractures. The purpose of this article is to introduce the reader to the concept of augmented fixation, review strategies for its application, and review applicable published results.
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Osterhoff G, Noser J, Held U, Werner CML, Pape HC, Dietrich M. Early Operative Versus Nonoperative Treatment of Fragility Fractures of the Pelvis: A Propensity-Matched Multicenter Study. J Orthop Trauma 2019; 33:e410-e415. [PMID: 31633644 DOI: 10.1097/bot.0000000000001584] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare early operative treatment with nonoperative treatment of fragility fractures of the pelvis regarding mortality and functional outcome. DESIGN Retrospective. SETTING Two trauma centers. PATIENTS AND METHODS Two hundred thirty consecutive patients 60 years of age or older with an isolated low-energy fracture of the pelvis and with a follow-up of at least 24 months. In center 1, treatment consisted of a nonoperative attempt and early operative fixation if mobilization was not possible. In center 2, all patients were treated nonoperatively. MAIN OUTCOME MEASUREMENTS Primary outcome was mortality. Secondary outcomes were in-hospital complications. Patients who survived were contacted by phone, and a modified Majeed score was obtained to assess functional outcome at the final follow-up. RESULTS At the final follow-up (mean 61 months, SD 24), 105/230 (45.7%) patients had died. One year after the initial hospitalization, 34/148 patients [23%, 95% confidence interval (CI): 17%-31%] of the early operative group and 14/82 patients (17%, 95% CI: 10%-27%) of the nonoperative group had died (P = 0.294). Nonoperative treatment had a protective effect on survival during the first 2 years (hazard ratio of the nonlinear effect: 2.86, 95% CI: 1.38-5.94, P < 0.001). Patients in the early operative treatment group who survived the first 2 years had a better long-term survival. The functional outcome at the end of follow-up as measured by a modified Majeed score was not different between the 2 groups (early operative: 66.1, SD 12.6 vs. nonoperative: 65.7, SD 12.5, P = 0.910). CONCLUSION Early operative fixation of patients who cannot be mobilized within 3-5 days was associated with a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than 2 years. Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Georg Osterhoff
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Department of Orthopaedics, Trauma, and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Jonas Noser
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | | | | | - Michael Dietrich
- Department of Orthopaedics and Traumatology, Department of Surgery, Waid City Hospital, Zurich, Switzerland
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Space available for trans-sacral implants to treat fractures of the pelvis assessed by virtual implant positioning. Arch Orthop Trauma Surg 2019; 139:1385-1391. [PMID: 31111201 DOI: 10.1007/s00402-019-03204-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The use of trans-sacral implants to treat fractures of the sacrum is limited by the variable pelvic anatomy. We were interested in how many trans-sacral implants can be placed per pelvis? If a trans-sacral implant cannot be placed in S1, where is the cortex perforated, and is the use of sacroiliac screws safe in these pelves? MATERIALS AND METHODS 3D pelvic models were created from CT scans of 156 individuals without fractures (92 European and 64 Japanese, 79 male and 77 female, mean age 66.7 ± 13.7 years). Trans-sacral implants with a diameter of 7.3 mm were positioned virtually with and without a surrounding safe zone of 12 mm diameter. RESULTS Fifty-one percent of pelves accommodated trans-sacral implants in S1 with a safe zone. Twenty-two percent did not offer enough space in S1 for an implant even when ignoring the safe zone. Every pelvis had sufficient space for a trans-sacral implant in S2, in 78% including a safe zone as well. In S1, implant perforation was observed in the sacral ala and iliac fossa in 69%, isolated iliac fossa perforation in 23% and perforation of the sacral ala in 8%. Bilateral sacroiliac screw placement was always possible in S1. CONCLUSIONS The use of trans-sacral implants in S1 requires meticulous preoperative planning to avoid injury of neurovascular structures. S2 more consistently offers space for trans-sacral implants.
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Cement augmentation of sacroiliac screws in fragility fractures of the pelvic ring-A synopsis and systematic review of the current literature. Injury 2019; 50:1411-1417. [PMID: 31301810 DOI: 10.1016/j.injury.2019.06.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/29/2019] [Accepted: 06/24/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fragility fractures of the pelvis (FFP) show a notable rise in prevalence. Minimally invasive surgical fixation of FFP is increasingly advocated for its obvious advantages with reference to early mobilization and weight bearing. Concerns regarding the holding power of osteosynthetic materials in osteoporotic bone led to the development of cementing techniques. However, the role of cement augmentation in the surgical treatment of FFP has yet to be defined. Therefore, the aim of this study was to conduct a systematic review of the current literature concerning studies that are comparing the performance of cement augmented versus non-augmented sacroiliac (SI) screws. METHODS We conducted a systematic literature review from 01/01/2000 onwards. Inclusion criteria were randomized controlled studies, case series (n>3), biomechanical studies and reviews, comparing augmented and non-augmented SI screws. Only papers in German or English language were included. RESULTS Out of 1247 initial hits, eleven studies met the inclusion criteria. Out of those, six were biomechanical studies and five were clinical case series. Most biomechanical studies showed cement augmented screws to have a greater mechanical stability, both regarding pull-out force and resistance to cyclic loading. The five case studies reported on a total of 98 patients with 122 screw fixations. Three cases of cement leakage into neuroforamina occurred, however, none of these patients showed clinical symptoms. CONCLUSION In clinical case series, cement augmentation of SI screws appears to be a safe surgical technique without relevant complications and biomechanical studies demonstrate greater pull-out forces of augmented SI screws but no advantage in regard of cyclic loading. Hence, applicability of the mechanical testing results on the clinical situation are debatable. So far, there are neither retrospective nor randomized controlled studies comparing the performance of cemented and non-cemented SI screws in FFP. Therefore, the clinical benefit of SI screw cement augmentation is unclear and their use remains experimental.
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Prolonged pain in patients with fragility fractures of the pelvis may be due to fracture progression. Eur J Trauma Emerg Surg 2019; 47:507-513. [PMID: 31111165 DOI: 10.1007/s00068-019-01150-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/13/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Most fragility fractures of the pelvis (FFPs) are conservatively treated in the early phase. However, the definition of conservative treatment failure and the subsequent treatment protocol is controversial. Fracture progression (FP) sometimes occurs during conservative treatment of FFPs. This study aimed to assess the association between FP and prolonged pain in patients with FFPs receiving conservative treatment. METHODS Retrospective case series in a single institution in Japan. A total of 192 consecutive FFP patients were identified during study period. Seventy-nine patients met the inclusion and exclusion criteria. FFPs were diagnosed using both CT and MRI and FP was diagnosed with CT. Patients met criteria for prolonged pain if they had persisting pain after 2 weeks of conservative treatment and had lack of improvement in mobility. The relationship between FP and prolonged pain was analyzed using Fisher's exact test. RESULTS Of the 79 patients, 18 developed FP. Four of the 18 patients with FP met criteria for prolonged pain. Two of 61 patients without FP had prolonged pain (p = 0.022; odds ratio 8.12). In the entire study cohort, six patients (7.6%) met criteria prolonged pain and underwent elective surgery. CONCLUSION In patients with FFPs, prolonged pain was associated with FP (p = 0.022, OR 8.12). The presence of prolonged pain might help identify FP. If FP is identified, surgical treatment may be required with cautious follow-up particularly in cases, where FFP progresses to type III or IV fracture.
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Kola S, Granville M, Jacobson RE. The Association of Iliac and Sacral Insufficiency Fractures and Implications for Treatment: The Role of Bone Scans in Three Different Cases. Cureus 2019; 11:e3861. [PMID: 30899612 PMCID: PMC6414187 DOI: 10.7759/cureus.3861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Iliac wing fractures are under-diagnosed fractures often associated with sacral insufficiency fractures in osteoporotic patients. They are rarely seen alone. Insufficiency fractures of the iliac bone can often be missed on computerized tomography (CT) and magnetic resonance imaging (MRI) yet identified on radioisotope bone scans. Symptomatic iliac fractures present with more lateralized pain in the hip and groin compared to patients with only sacral insufficiency fractures. Since the acetabulum is the key weight-bearing articulation between the sacrum and pelvis and the femoral head and leg, worsening of iliac stress fractures can have major effects on weight bearing and should be a consideration in patients with persistent pain in this area. The anatomy of the ilium and relationship to other pelvic insufficiency fractures is reviewed as well as treatment options. Typical cases are presented where the iliac fractures were found on bone scan either in addition to the more common sacral fracture or due to the persistence of symptoms of hip and thigh pain.
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Affiliation(s)
- Sandeep Kola
- Physical Medicine and Rehabilitation, Larkin Community Hospital, Miami, USA
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Hack J, Krüger A, Masaeli A, Aigner R, Ruchholtz S, Oberkircher L. Cement-augmented sacroiliac screw fixation with cannulated versus perforated screws - A biomechanical study in an osteoporotic hemipelvis model. Injury 2018; 49:1520-1525. [PMID: 29914671 DOI: 10.1016/j.injury.2018.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/16/2018] [Accepted: 06/08/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Cement-augmentation is a well-established way to improve the stability of sacroiliac screw fixation in osteoporosis-associated fragility fractures of the posterior pelvic ring. However, to date little is known about the influence of different techniques of cement augmentation on construct stability. The aim of this study was to evaluate the primary stability of cement-augmented sacroiliac screw fixation with cannulated versus perforated screws under cyclic loading. MATERIALS AND METHODS A total of eight fresh-frozen human cadaveric hemipelvis specimens with osteoporosis were used. After generating ventral osteotomies on both sides of the sacrum, each specimen was treated using a cement-augmented cannulated screw on one side and a cement-augmented perforated screw on the other side. Afterwards, axial cyclic loading was performed. RESULTS No statistically significant difference was found between cannulated and perforated screws concerning maximum load (356.25 N versus 368.75 N, p = 0.749), plastic deformation (1.95 mm versus 1.43 mm, p = 0.798) and stiffness (27.04 N/mm versus 40.40 N/mm, p = 0.645). CONCLUSIONS Considering the at least equivalent results for perforated screws, cement augmentation via perforated screws might be an interesting option in clinical practice because of potential advantages, e.g. radiological control before cement application, reduced risk of cement displacement and time saving.
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Affiliation(s)
- J Hack
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany.
| | - A Krüger
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany
| | - A Masaeli
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany
| | - R Aigner
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany
| | - S Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany
| | - L Oberkircher
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Germany
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Wagner D, Hofmann A, Kamer L, Sawaguchi T, Richards RG, Noser H, Gruszka D, Rommens PM. Fragility fractures of the sacrum occur in elderly patients with severe loss of sacral bone mass. Arch Orthop Trauma Surg 2018; 138:971-977. [PMID: 29700604 DOI: 10.1007/s00402-018-2938-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Patients suffering from osteoporosis-associated fragility fractures of the sacrum (FFS; also termed sacral insufficiency fractures) are increasingly observed. They have typical fracture patterns with fracture lines located in the sacral ala. When treating these patients operatively, iliosacral screw loosening is not uncommon. We aimed to study the sacral bone mass in patients presenting with a FFS using 3D statistical models. MATERIALS AND METHODS 3D models of averaged Hounsfield units (HU) were generated based on CT scans from 13 patients with a unilateral FFS (mean age 79.6 years; 11 females, 2 males). The control group without fractures consisted of 28 males and 32 females (mean age of 68.3 years). A virtual bone probe along the trans-sacral corridors S1 and S2 was taken. RESULTS The bone mass distribution in the fractured sacra was similar to the control group, however, with overall lower HU. Large zones of negative HU were located in the sacral ala. In the fractured sacra, the HU in the sacral ala was significantly lower on the non-injured side when comparing to the fractured side (p < 0.001) as well as compared to the non-fractured group (p < 0.001). Low bone mass was observed in sacral body S1 (40 HU) and S2 (20 HU). CONCLUSIONS The extensive area of negative HU may explain the fracture location in the sacral ala. The low HU in the sacral bodies advocates the use of trans-sacral implants or augmented iliosacral screws to enhance the strength of fracture fixation. The increased HU in the fractured ala could be explained by fracture-asssociated hemorrhage and can be used as a diagnostic tool.
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Affiliation(s)
- Daniel Wagner
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany. .,AO Research Institute Davos, Davos, Switzerland.
| | - Alexander Hofmann
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Lukas Kamer
- AO Research Institute Davos, Davos, Switzerland
| | - Takeshi Sawaguchi
- Department of Orthopedics and Joint Reconstructive Surgery, Toyama Municipal Hospital, Toyama, Japan
| | | | | | - Dominik Gruszka
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Pol M Rommens
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
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Oberkircher L. In Reply. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:284. [PMID: 29739497 PMCID: PMC5954175 DOI: 10.3238/arztebl.2018.0284b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Ludwig Oberkircher
- * Zentrum für Orthopädie und Unfallchirurgie Universitätsklinikum Gießen und Marburg, Standort Marburg
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