Epidemiology of Pelvic Fractures in Germany: Considerably High Incidence Rates among Older People

The role of sarcopenia in fragility fractures of the pelvis - is sarcopenia an underestimated risk factor?

BACKGROUND

Fragility fractures of the pelvis (FFPs) represent a significant health burden, particularly for the elderly. The role of sarcopenia, an age-related loss of muscle mass and function, in the development and impact of these fractures is not well understood. This study aims to investigate the prevalence and impact of osteoporosis and sarcopenia in patients presenting with FFPs.

METHODS

This retrospective study evaluated 140 elderly patients with FFPs. The diagnosis of sarcopenia was assessed by psoas muscle area (PMA) and the height-adjusted psoas muscle index (PMI) measured on computed tomography (CT) scans. Clinical data, radiological findings and functional outcomes were recorded and compared with the presence or absence of sarcopenia and osteoporosis.

RESULTS

Our study cohort comprised 119 female (85.0%) and 21 (15.0%) male patients. The mean age at the time of injury or onset of symptoms was 82.26 ± 8.50 years. Sarcopenia was diagnosed in 68.6% (n = 96) patients using PMA and 68.8% (n = 88) using PMI. 73.6% (n = 103) of our study population had osteoporosis and 20.0% (n = 28) presented with osteopenia. Patients with sarcopenia and osteoporosis had longer hospital stays (p < 0.04), a higher rate of complications (p < 0.048) and functional recovery was significantly impaired, as evidenced by a greater need for assistance in daily living (p < 0.03). However, they were less likely to undergo surgery (p < 0.03) and the type of FFP differed significantly (p < 0.04). There was no significant difference in mortality rate, pre-hospital health status, age or gender.

CONCLUSION

Our study highlights the important role of sarcopenia in FFPs in terms of the serious impact on health and quality of life in elderly patients especially when osteoporosis and sarcopenia occur together. Identifying and targeting sarcopenia in older patients may be an important strategy to reduce pelvic fractures and improve recovery. Further research is needed to develop effective prevention and treatment approaches that target muscle health in the elderly.

Functional outcome and analysis of factors affecting health-related quality of life of surgically managed pelvic ring fractures: a cross-sectional study

INTRODUCTION

Pelvic ring fractures, particularly those involving the posterior pelvis, pose significant challenges due to their inherent instability. The posterior pelvic ring is critical in providing structural support and stability to the pelvis. This study evaluates the functional outcomes and health-related Quality of life (HRQOL) of patients who underwent internal fixation for unstable pelvic fractures. Various factors influencing the outcomes are also investigated.

MATERIAL AND METHODS

A single-center cross-sectional study was conducted on patients with unstable sacral fractures treated with posterior tension band plate or sacroiliac plating with or without symphyseal plating between 2016 and 2020. Patient demographics, injury mechanisms, associated injuries, surgical details, complications, and return-to-work data were collected. HRQOL was assessed using specific pelvic fracture instruments and general HRQOL questionnaires. Logistic regression analysis was performed to identify factors associated with lower SF-12 and SF-36 scores RESULTS: The study included 54 patients, predominantly males (55.6%), aged 18-70 years, with high-energy trauma mechanisms, such as road traffic accidents and occupational injuries. The majority of patients had lateral compression pelvic fractures. Overall, the functional outcomes were favorable, with excellent or good outcomes observed in 86.1% of cases. Patients with associated injuries, such as abdominal, chest, or head injuries, were likelier to have lower SF-12 physical component scores. Sexual satisfaction scores remained stable for most patients post-surgery.

DISCUSSION

This study highlights the favorable functional outcomes and HRQOL for patients undergoing fixation for unstable pelvic ring fractures. Younger, working-age males were the most commonly affected demographic. Associated injuries significantly affected physical HRQOL scores. Despite high-energy trauma, patients generally reported satisfactory sexual function post-surgery.

What interventions add value in lateral compression type 1 fragility pelvis fractures? A retrospective cohort study

Introduction

Fragility fractures are a large source of morbidity and mortality in the elderly. Orthopaedic surgeons are regularly the main point of contact in patients with lateral compression type 1 pelvis fractures, despite many of these being treated non-operatively. This study aims to identify risk factors for mortality and elucidate which follow-up visits have the potential to improve care for these patients.

Methods and materials

In all, 211 patients have been identified with fragility lateral compression type 1 fractures at a level 1 trauma centre over a 5-year period. For all patients, we recorded patient demographics, imaging data, hospital readmissions, medical complications and death dates if applicable.

Results

Of the 211 patients identified, 56.4% had at least one orthopaedic follow-up, of which no patient had a clinically meaningful medical intervention initiated. 30-day readmission rate was 19%, and 1-year mortality was 24%. Male sex, need for an assist device, higher Charlson Comorbidity Index and increased age were found to be statistically associated with increased risk of mortality. Patients who followed up with their primary care physician were found to have a statistically lower risk of mortality. Computed tomography scans were obtained in 70% of patients and never limited patient weight-bearing status or found any additional injury not already identified on the radiograph.

Discussion/Conclusions

For patients with lateral compression type 1 type fragility fractures, orthopaedic surgeons did not offer additional clinically meaningful intervention after the time of initial diagnosis in this patient cohort. The rate of clinical follow-up with a primary care physician is relatively low despite high rates of medical comorbidity. Computed tomography scans were utilised frequently but did not change recommendations. The high rate of medical complications and lack of orthopaedic intervention suggest that we should re-evaluate the role of the orthopaedic surgeon versus the primary care physician as the primary point of medical contact for patients with these injuries.

Surgical versus non-surgical management of lateral compression type-1 pelvic fracture in adults 60 years and older: the L1FE RCT

Background

Lateral compression type-1 pelvic fractures are a common fragility fracture in older adults. Patients who do not mobilise due to ongoing pain are at greater risk of immobility-related complications. Standard treatment in the United Kingdom is provision of pain relief and early mobilisation, unlike fragility hip fractures, which are usually treated surgically based on evidence that early surgery is associated with better outcomes. Currently there is no evidence on whether patients with lateral compression type-1 fragility fractures would have a better recovery with surgery than non-surgical management.

Objectives

To assess the clinical and cost effectiveness of surgical fixation with internal fixation device compared to non-surgical management of lateral compression type-1 fragility fractures in older adults.

Design

Pragmatic, randomised controlled superiority trial, with 12-month internal pilot; target sample size was 600 participants. Participants were randomised between surgical and non-surgical management (1 : 1 allocation ratio). An economic evaluation was planned.

Setting

UK Major Trauma Centres.

Participants

Patients aged 60 years or older with a lateral compression type-1 pelvic fracture, arising from a low-energy fall and unable to mobilise independently to a distance of 3 m and back due to pelvic pain 72 hours after injury.

Interventions

Internal fixation device surgical fixation and non-surgical management. Participants, surgeons and outcome assessors were not blinded to treatment allocation.

Main outcome measures

Primary outcome - average patient health-related quality of life, over 6 months, assessed by the EuroQol-5 Dimensions, five-level version utility score. Secondary outcomes (over the 6 months following injury) - self-rated health, physical function, mental health, pain, delirium, displacement of pelvis, mortality, complications and adverse events, and resource use data for the economic evaluation.

Results

The trial closed early, at the end of the internal pilot, due to low recruitment. The internal pilot was undertaken in two separate phases because of a pause in recruitment due to the coronavirus disease 2019 pandemic. The planned statistical and health economic analyses were not conducted. Outcome data were summarised descriptively. Eleven sites opened for recruitment for a combined total of 92 months. Three-hundred and sixteen patients were assessed for eligibility, of whom 43 were eligible (13.6%). The main reason for ineligibility was that the patient was able to mobilise independently to 3 m and back (n = 161). Of the 43 eligible participants, 36 (83.7%) were approached for consent, of whom 11 (30.6%) provided consent. The most common reason for eligible patients not consenting to take part was that they were unwilling to be randomised to a treatment (n = 10). There were 11 participants, 5 randomised to surgical management with internal fixation device and 6 to non-surgical management. The average age of participants was 83.0 years (interquartile range 76.0, 89.0) and the EuroQol-5 Dimensions, five-level version utility score at 6 months post randomisation (n = 8) was 0.32 (standard deviation 0.37). A limitation of the trial was that study objectives were not addressed due to poor recruitment.

Conclusions

It was not feasible to recruit to this trial in the current context. Further research to understand the treatment and recovery pathways of this group of patients, along with their outcomes, would be needed prior to undertaking a future trial.

Future work

Exploration of equipoise across different healthcare professional groups. Investigate longer-term patient outcomes.

Trial registration

This trial is registered as ISRCTN16478561.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/167/57) and is published in full in Health Technology Assessment; Vol. 28, No. 15. See the NIHR Funding and Awards website for further award information.

[Possibilities and limits of intraoperative 2D imaging in trauma surgery]

BACKGROUND

The two-dimensional (2D) imaging represents an essential and cost-effective component of intraoperative position control in fracture stabilization, even in the era of new three-dimensional (3D) imaging capabilities.

OBJECTIVE

The aim of the present study, in addition to a current literature review, was to examine whether the intraoperative use of 2D images leads to a quality of fracture reduction comparable to postoperative computed tomographic (CT) analysis including 3D reconstructions.

MATERIAL AND METHODS

A comparative retrospective analysis of intraoperative 2D and postoperative 3D image data was performed on 21 acetabular fractures stabilized via a pararectus approach according to an established protocol using the Matta criteria.

RESULTS

The assessment of fracture reduction in intraoperative fluoroscopy compared with postoperative CT revealed a difference only in one case with respect to the categorization of the joint step reduction in the main loading zone.

CONCLUSION

In the intraoperative use of 2D imaging for fracture treatment it is important to select the correct adjustment planes taking the anatomical conditions into account in order to achieve optimum assessability. In this way, the reduction result can be adequately displayed in fluoroscopy and is also comparable to the postoperative CT control. In addition, depending on the findings, optional intraoperative dynamic fluoroscopic assessment can have a direct influence on the further surgical procedure.

Gluteal Muscle Fatty Atrophy: An Independent Risk Factor for Surgical Treatment in Elderly Patients Diagnosed with Type-III Fragility Fractures of the Pelvis

BACKGROUND

Gluteal muscle fatty atrophy (gMFA) might impair pelvic stability and negatively influence remobilization in patients with fragility fractures of the pelvis (FFP). This study aimed to investigate the association between gMFA and surgical indication in patients with FFP.

METHODS AND MATERIALS

A retrospective analysis of 429 patients (age ≥80) diagnosed with FFP was performed. gMFA of the gluteus maximus, medius, and minimus was evaluated using a standard scoring system based on computer tomography images.

RESULTS

No significant difference was found in gMFA between genders or among FFP types. The severity of gMFA did not correlate with age. The severity of gMFA in the gluteus medius was significantly greater than in the gluteus maximus, whereas the most profound gMFA was found in the gluteus minimus. gMFA was significantly more severe in patients who underwent an operation than in conservatively treated patients with type-III FFP, and an independent correlation to surgical indication was found using logistic regression.

CONCLUSION

Our findings imply that gMFA is an independent factor for surgical treatment in patients with type-III FFP. Besides focusing on the fracture pattern, the further evaluation of gMFA could be a feasible parameter for decision making toward either conservative or surgical treatment of type-III FFP.

Epidemiology of fragility fracture of the pelvic ring: a regional population-based study in Northern Japan

Using a regional population-based dataset in Japan, we identified the epidemiological characteristics of patients with fragility fractures of the pelvic ring. The incidence rate was 35.5-121.2 per 100,000 population/year. Age-specific incidence increased after 75 years. This fracture is associated with worse prognosis in terms of walking function and life expectancy.

PURPOSE

Fragility fracture of the pelvic ring (FFP) is common among older patients; however, little information is available on the epidemiology of FFP worldwide. We aimed to identify the epidemiological characteristics of patients with FFP using a regional population-based dataset in Japan.

METHODS

This descriptive epidemiologic study analyzed data obtained from clinical information of patients diagnosed with FFP from January 1, 2011 through December 31, 2020 at a regional dominant hospital in Japan. We calculated the crude and age-adjusted annual incidences and the age-specific incidence and described epidemiological date, injury characteristics, walking ability before and after FFP, and mortality. Additionally, we investigated factors associated with walking ability.

RESULTS

We identified 66 FFP patients, of whom 55 (83.3%) were female, with a mean age of 82.2 years. The crude annual incidence of FFP ranged from 35.5-121.2 per 100,000 population/year during the study period. The age-specific incidence of FFP increased after 75 and 80 years in females and males, respectively. In total, 44.4% of patients had declines in walking ability 1 year after their FFP injuries. Patients with declining walking ability were significantly older (p < 0.01), and age ≥ 80 years was significantly associated with the decline in walking ability (p < 0.01). The 1- and 5-year mortality rates were 15.4% and 39.9%, respectively.

CONCLUSION

The incidence rate of FFP was 35.5-121.2 per 100,000 population/year. Age-specific incidence of FFP increased after 75 years. Our results indicate that FFP is associated with worse prognosis of walking function and life expectancy.

Cemented Sacroiliac Screw Fixation versus Conservative Therapy in Fragility Fractures of the Posterior Pelvic Ring: A Matched-Pair Analysis of a Prospective Observational Study

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.

Evaluation of a New Treatment Strategy for Geriatric Fragility Fractures of the Posterior Pelvic Ring Using Sensor-Supported Insoles: A Proof-of-Concept Study

The incidence of fragility fractures of the pelvis (FFPs) is currently rising. Surgical treatment, which is performed using sacroiliac screws, is complicated by compromised bone quality, oftentimes resulting in implant failure. The iFuse implant system aims to improve attachment and durability with promising results for sacroiliac dysfunction, though data for its feasibility on FFPs are rare. Consequently, this study aims to evaluate the feasibility of the iFuse for FFPs. A total of 10 patients with FFPs were treated with the iFuse in this study. Pre- and postoperatively, both mobility using an established insole force sensor for an inpatient gait analysis and general well-being and pain using questionnaires were evaluated. When comparing pre- and postoperative findings, this study demonstrated a significant increase in the average (8.14%) and maximum (9.4%) loading (p < 0.001), a reduction in pain, as measured by the visual analog scale (VAS), from 4.60 to 2.80 at rest (p = 0.011) and from 7.00 to 4.40 during movement (p = 0.008), an increase in the Barthel Index by 20 points (p < 0.001) and an increase in the Parker Mobility Score by 2.00 points (p = 0.011). All this contributes to the possibility of early postoperative mobilization and improved general well-being, ultimately preventing the late consequences of postoperative immobilization and maintaining patients autonomy and contentment.

Minimally invasive bilateral fixed angle locking fixation of the dorsal pelvic ring: clinical proof of concept and preliminary treatment results

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.

Trends and treatments of pelvic and acetabular fractures in Taiwan: facing an aging society

Pelvic-acetabular fractures lead to high mortality in elders and their association between different groups is not known. Our results indicate that older age with pelvic-acetabular fracture was significantly associated with mortality. This finding may help planning and allocating healthcare resources, risk stratification, and optimizing the treatment of pelvic fractures.

PURPOSE

Pelvic or acetabular fractures are among main outcomes of low-energy trauma such as falls, especially in older adults. They represent approximately 3-8% of all fractures and are associated with a high mortality rate ranging from 4 to 28%. This study is aimed at comparing the incidence and trends of hip fractures and pelvic-acetabular fractures in the Taiwanese general population, gender differences in adults aged over 65 years, and mortality risk between pelvic or acetabular fractures and hip fractures and surgery trends in patients with these fractures.

METHODS

A retrospective study was conducted extracting data from the National Health Insurance Research Database of patients diagnosed with hip fracture and pelvic acetabular fracture between 2000 and 2018.

RESULTS

Older age with pelvic-acetabular fracture was significantly associated with increased mortality. No significant differences were found in comorbidities between the two fracture groups. Results provide clear epidemiological evidence for trends in pelvic-acetabular fractures in Taiwan and demonstrate the need for better strategies to manage these fractures and comorbidities, particularly in older adults.

CONCLUSION

Findings of this study may aid in planning and allocating healthcare resources, risk stratification, and optimizing the treatment of pelvic fractures among older adults in Taiwan.

Epidemiology of pelvic and acetabular fractures in the USA from 2007 to 2014

Incidence of pelvic and acetabular fracture is increasing in Europe. From 2007 to 2014 in the USA, this study found an age-adjusted incidence of 198 and 40 fractures/100,000/year, respectively, much higher than what has been described before. Incidence remained steady over that period and only a small increase in incidence of pelvic fracture in men was identified.

PURPOSE

To determine the incidence of pelvic ring and acetabular fractures in the USA over the period 2007-2014 and to examine trends over time.

METHODS

Retrospective population-based observational study using data from the Nationwide Emergency Department Sample (NEDS), a 20% stratified all-payer sample of US hospital-based emergency departments (EDs). All patients seen in the ED and diagnosed with pelvic/acetabular fracture from 2007 to 2014 were included. The primary outcome was age-adjusted incidence of pelvic and acetabular fractures per 100,000 persons/years. Secondary outcomes included incidence stratified by age and sex, patient- and hospital-related characteristics, and ED procedures. Tests for linear trends were used to determine if there were statistically significant differences by sex and age groups over time.

RESULTS

The age-adjusted incidence of pelvic fracture was 198 fractures/100,000/year, 323 in women and 114 in men. The age-adjusted incidence of acetabular fracture was 40 fractures/100,000/year, 36 in women and 51 in men. A small increase in the age-adjusted incidence of pelvic fracture in men was the only significant trend observed during the study time (p = 0.03). Over that period, the mean age of patients at presentation increased, as well as their number of comorbidities and associated fragility fractures, and they were more often sent home or to nursing facilities.

CONCLUSIONS

When considering all patients coming to the ED, not only those admitted to the hospital, adjusted incidence of pelvic and acetabular fracture is much higher than what has been described before. Contrarily to the global increase seen in other countries, incidence of pelvic and acetabular fractures dropped in the USA from 2007 to 2014 and only a small increase in age-adjusted incidence of pelvic fracture in men was identified.

Lateral compression type 1 fracture fixation in the elderly (L1FE): study protocol for a randomised controlled trial (with internal pilot) comparing the effects of INFIX surgery and non-surgical management for treating patients with lateral compression type 1 (LC-1) fragility fractures

BACKGROUND

Lateral compression type1 (LC-1) fragility fractures are a common, painful injury in older adults resulting in reduced mobility. The incidence of these fractures is increasing with the growing older adult population. The current standard of care is non-surgical management; however, patients with this injury are at risk of long-term immobility and related complications. INFIX is a pelvic fixation device used in younger patients with high-energy fractures. The device is fitted via a percutaneous technique with no external pin sites and has good purchase even in osteoporotic bone. It therefore has the potential to be well tolerated in patients with LC-1 fragility fractures. INFIX could improve patients' ability to mobilise and reduce the risk of immobility-related complications. However, there is a risk of complications related to surgery, and robust evidence is required on patient outcomes. This study will investigate the clinical and cost-effectiveness of surgical fixation with INFIX compared to non-surgical management of LC-1 fragility fractures in older adults.

METHODS

A multi-centre randomised controlled trial of 600 patients allocated 1:1 to non-surgical management or INFIX surgery. The study will have a 12-month internal pilot to assess recruitment and trial feasibility. The primary outcome will be the patient quality of life over 6 months, measured by the patient-reported EQ-5D-5L. The secondary outcomes will include physical function, mental health, pain, delirium, imaging assessment, resource use, and complications.

DISCUSSION

The L1FE study aims to compare the clinical and cost-effectiveness of surgical and non-surgical management of people aged 60 years and older with LC-1 fragility fractures. The trial is sufficiently powered and rigorously designed to inform future clinical and patient decision-making and allocation of NHS resources.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number Registry ISRCTN16478561. Registered on 8 April 2019.

Deep Learning in the Detection of Rare Fractures - Development of a "Deep Learning Convolutional Network" Model for Detecting Acetabular Fractures

BACKGROUND

Fracture detection by artificial intelligence and especially Deep Convolutional Neural Networks (DCNN) is a topic of growing interest in current orthopaedic and radiological research. As learning a DCNN usually needs a large amount of training data, mostly frequent fractures as well as conventional X-ray are used. Therefore, less common fractures like acetabular fractures (AF) are underrepresented in the literature. The aim of this pilot study was to establish a DCNN for detection of AF using computer tomography (CT) scans.

METHODS

Patients with an acetabular fracture were identified from the monocentric consecutive pelvic injury registry at the BG Trauma Center XXX from 01/2003 - 12/2019. All patients with unilateral AF and CT scans available in DICOM-format were included for further processing. All datasets were automatically anonymised and digitally post-processed. Extraction of the relevant region of interests was performed and the technique of data augmentation (DA) was implemented to artificially increase the number of training samples. A DCNN based on Med3D was used for autonomous fracture detection, using global average pooling (GAP) to reduce overfitting.

RESULTS

From a total of 2,340 patients with a pelvic fracture, 654 patients suffered from an AF. After screening and post-processing of the datasets, a total of 159 datasets were enrolled for training of the algorithm. A random assignment into training datasets (80%) and test datasets (20%) was performed. The technique of bone area extraction, DA and GAP increased the accuracy of fracture detection from 58.8% (native DCNN) up to an accuracy of 82.8% despite the low number of datasets.

CONCLUSION

The accuracy of fracture detection of our trained DCNN is comparable to published values despite the low number of training datasets. The techniques of bone extraction, DA and GAP are useful for increasing the detection rates of rare fractures by a DCNN. Based on the used DCNN in combination with the described techniques from this pilot study, the possibility of an automatic fracture classification of AF is under investigation in a multicentre study.

Internal fixation of radiation-induced fragility fractures of the pelvis: a case series

BACKGROUND

The optimal treatment for radiation-induced fragility fractures of the pelvis (RI-FFP) is not well evaluated due to the rarity of the condition.

PURPOSE

The aim of this retrospective study was to assess the prevalence of RI-FFP, the radiological and clinical outcomes as well as the complications of patients treated with internal fixation.

METHODS

A retrospective review of our database was performed to identify all surgically treated patients with RI-FFP. Surgical stabilization was recommended for patients with FFP type III and FFP type IV. Surgical stabilization was also recommended after 5-7 days for patients with FFP type II in case of unsuccessful conservative treatment. Demographic data, fracture patterns according to the FFP classification of Rommens and Hofmann, type of treatment and surgery-related complications including nonunion, hardware failure, fracture progression (secondary fracture) or infection were documented.

RESULTS

Among 500 patients with FFP, the prevalence of patients with RI-FFP was 1% (5/500): 5 patients with a median age of 79 years (76-79). The median time interval from radiation to fracture was 18 months (18-24). All of them underwent internal fixation. Two patients experienced surgery-related complications, one due to hardware failure and one due to fracture progression. At median follow-up of 27 months, all fractures had healed. Patients reached a good level of mobility with a median Parker Mobility Score of 7 and suffered moderate pain with a median value of 2.5 on the numeric rating scale.

CONCLUSION

RI-FFP remains a rare injury (1%). In our experience, patients, who underwent surgical treatment, obtained a high level of mobility and a moderate pain score after 2 years of follow-up. Internal fixation can be recommended in RI-FFP. Because bone healing may be impaired due to previous irradiation, highly stable constructs are required to avoid fracture progression or revision surgery.

LEVEL OF EVIDENCE

III, retrospective study.

Comparative outcome of different treatment options for fragility fractures of the sacrum

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.

[Techniques and results of primary hip arthroplasty in geriatric acetabular fractures]

As a result of demographic changes, there is an increase in geriatric acetabular fractures [1, 2]. Geriatric patients often have comorbidities, such as pre-existing coxarthritis, reduced bone quality or limited compliance, which makes injury-adapted follow-up treatment difficult [3]. As a result joint-preserving interventions often fail at an early stage, so that hip arthroplasty is necessary in the short term. The 1‑year mortality after surgically stabilized acetabular fractures is 8.1%, a significant increase by a factor of 4 compared to the age group [4]. This illustrates that differentiated criteria for the indication of joint-preserving surgery versus arthroplasty are necessary to avoid reoperations and complications. Criteria for the indications for primary arthroplasty are fracture type, pre-existing coxarthritis, poor bone quality, limited compliance and patient age (> 75 years) [5, 6].In the following article, three treatment strategies for geriatric acetabular fractures and periprosthetic acetabular fractures are presented; the 1‑stage prosthesis implantation without osteosynthesis, the 1‑stage prosthesis implantation with osteosynthesis and the 2‑stage approach with limited osteosynthesis and early total arthroplasty. The advantages and disadvantages of these options are presented based on cases and the various aspects of the treatment. The treatment of geriatric acetabular fractures is an operative challenge for the surgeon and requires a high level of expertise in both special trauma surgery and revision arthroplasty and thus represents a special interface in the fields of orthopedics and trauma surgery.

[Sacral fragility fractures: risk factors and outcomes after cement sacroplasty]

BACKGROUND

The objective of the present study on patients with fragility fractures of the sacrum (FFS) was to assess existing risk factors and clinical outcomes after cement sacroplasty (CSP).

PATIENTS AND METHODS

68 patients (64 women, 4 men) with previous FFS were followed up retrospectively. CT and MRI images were used to classify fractures according to Denis et al. and Rommens and Hofmann. Bone mineral content was determined by QCT in all patients. Concomitant diseases as well as central and peripheral fractures were recorded, considering the patient's medical history and X‑ray images. Vitamin D levels were also determined. If conservative therapy was unsuccessful, CSP was performed. The results were documented on the basis of pain development, physical independence, patient satisfaction, complication rate and mortality.

RESULTS

The age of the women in the study was Ø 83.2 (72-99) and that of the men Ø 77.8 (76-85) years. 42.4% had a Denis type 1, 4.2% a Denis type 2, 0% a Denis type 3, 43.3% a Denis type 1-2 and 10.1% a Denis type 1-2-3 fracture zone. FFP type II a to II c fractures were found in 88.2%, FFP type III c in 7.4% and FFP type IV b in 4.4%. Bilateral FFS were found in 68.8%. The average bone mineral content (BMC) was 35.4 (2-74) mg/ml, and the average vitamin D value was 8.8 (0-28) nmol/l. Other osteoporosis-associated fractures were found in around 50% of the patients. After CSP, patients showed a rapid and significant (p < 0.001) reduction in pain and sustained clinical improvement.

CONCLUSION

FFS fracture risk factors were found to be female gender, advanced age, existing osteoporosis and severe vitamin‑D deficiency. Patients with non-displaced FFS who could not be mobilised due to pain experienced sustained benefit from CSP.

The incidence of musculoskeletal injuries: a systematic review and meta-analysis

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

Methods

PubMed (National Library of Medicine) and Scopus (Elsevier) databases were searched. Articles were eligible for inclusion if they reported incidence rate (or count with population at risk), contained data on adult population, and were written in English language. The number of cases and population at risk were collected, and the pooled incidence rates (per 100,000 person-years) with 95% confidence intervals (CIs) were calculated by using either a fixed or random effects model.

Results

The screening of titles yielded 206 articles eligible for inclusion in the study. Of these, 173 (84%) articles provided sufficient information to be included in the pooled incidence rates. Incidences of fractures were investigated in 154 studies, and the most common fractures in the whole adult population based on the pooled incidence rates were distal radius fractures (212.0, 95% CI 178.1 to 252.4 per 100,000 person-years), finger fractures (117.1, 95% CI 105.3 to 130.2 per 100,000 person-years), and hip fractures (112.9, 95% CI 82.2 to 154.9 per 100,000 person-years). The most common sprains and dislocations were ankle sprains (429.4, 95% CI 243.0 to 759.0 per 100,000 person-years) and first-time patellar dislocations (32.8, 95% CI 21.6 to 49.7 per 100,000 person-years). The most common injuries were anterior cruciate ligament (17.5, 95% CI 6.0 to 50.2 per 100,000 person-years) and Achilles (13.7, 95% CI 9.6 to 19.5 per 100,000 person-years) ruptures.

Conclusion

The presented pooled incidence estimates serve as important references in assessing the global economic and social burden of musculoskeletal injuries. Cite this article: Bone Joint Res 2022;11(11):814–825.

A Case of Fragility Fracture of the Pelvis Initially Diagnosed as Osteoarthritis of the Hip

We present the case of a 58-year-old woman who presented with anterior groin pain, initially diagnosed with hip osteoarthritis (OA), scheduled for total hip arthroplasty, and subsequently diagnosed with an occult fragility fracture of the pelvis (FFP) by preoperative computed tomography (CT) examination. We diagnosed the patient with pre-existing hip OA and a bilateral sacrum and left pubic tubercle fracture that exacerbated the groin pain. We operated on the FFP followed by simultaneous bilateral total hip arthroplasty. Given the high prevalence of hip OA and the increasing incidence of FFP, comorbidity of these 2 entities should be ruled out. Even if hip OA is apparent, plain radiographs are insufficient to rule out FFP, necessitating a thorough clinical examination, followed by a CT examination if an FFP is suspected.

Multi-center Retrospective Study of Factors Affecting Perioperative Transfusion of Packed Red Blood Cells for Pelvic Fracture Patients

Objective

To analyze the use of packed red blood cells (PRBCs) for patients with pelvic fracture and evaluate factors associated with PRBC transfusion for patients with pelvic fracture.

Methods

This retrospective cohort study collected 551 patients with pelvic fractures from six hospitals between September 1, 2012, and June 31, 2019. The age span of patients varied from 10 to 95 years old, and they were classified into two groups based on high‐energy pelvic fractures (HE‐PFs) or low‐energy pelvic fractures (LE‐PFs). The study's outcome was the use of PRBCs, fresh frozen plasma (FFP), and albumin. Demographic data, characteristics, laboratory tests, clinical treatment details, and clinical outcomes were compared between the two groups. Factors that were statistically associated with perioperative PRBCs in univariate analyses were included to conduct an optimal scale regression to determine the independent factors for perioperative PRBCs.

Results

A total of 551 patients were screened from six hospitals, and after inclusion and exclusion, 319 were finally included and finished the follow‐up from admission to discharge, while four patients died during hospitalization. Three hundred and nineteen patients were classified into two groups by their injury mechanisms. A total of 230/319 (72.1%) patients were classified into the HE‐PF group, and 89/319 (27.8%) patients were classified into the LE‐PF group. Patients in the HE‐PF group were transfused with 4.5 (3–8) units of PRBCs, 300 (0–600) ml of FFP, and 0 (0–30) g of albumin, while patients in the LE‐PF group were transfused with 3.5 (2–4.5) units of PRBCs, 0 (0–295) ml of FFP, and 0 (0–0) g of albumin (all P < 0.001). There were higher proportions of male patients and patients under 65 in the HE‐PF group (all P < 0.001). HE‐PF group patients were more severely injured and likely to take external fixation. The optimal scale regression revealed four significant factors associated with perioperative transfused PRBCs, which were patients on admission with hemorrhagic shock (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.283, P = 0.004), followed by fracture types identified by Tile classification (importance = 0.156, P < 0.001), hemoglobin levels below 70 g/L on admission (importance = 0.148, P = 0.039), and methods of pelvic fixation (importance = 0.008, P = 0.026), ranked by the importance.

Conclusion

Patients with HE‐PFs had increased transfusions of PRBCs, FFP, and albumin, and hemorrhagic shock on admission, Tile classification, Hb levels, and stabilization methods were found to be associated with perioperative PRBCs.

The Association of Pelvic Bone Mineral Density and With Proximal Femoral and Spine Bone Mineral Density in Post-menopausal Women

Pelvic fragility fractures result in significant morbidity and their incidence has increased over the past 30 years. One of the main risk factors in skeletal fragility is bone mineral density (BMD). Most of the current literature has focused on understanding spine and hip BMD. We aimed to measure the BMD of pelvis in a cohort of post-menopausal women and compare it to BMD at other skeletal sites. A questionnaire regarding risk factors for osteoporosis was completed by each participant. DXA scan of the pelvis was performed using research software. Three areas of the pelvis corresponding to common fractures were defined on pelvic DXA: R1 = symphysis public, R2 = inferior public rami, R3 = superior public rami. Pelvic BMD was calculated as the average BMD of R1-3. BMD at each location was reported as mean and standard deviation (SD). ANOVA was used to compare BMD between R1-R3 and pelvis, femoral neck, total hip, and spine. Pearson correlation was used to correlate pelvic BMD to BMD of proximal femur and spine. BMD was compared in four participant groups: 1- osteoporosis in spine and hip, 2- osteoporosis in spine only, 3-osteoporosis in hip only, and 4- no osteoporosis in spine and hip. The effect of diabetes and obesity on BMD at various skeletal sites was analyzed. Among the one hundred postmenopausal women enrolled in the study, age was: 64 ± 8, 31% were obese (BMI ≥ 30), and 8% had a diagnosis of type 2 diabetes. Pelvic area R3 had significantly higher BMD than R1 or R2 (p < 0.001). Pelvic BMD (0.50 ± 0.16) was significantly lower than total hip (0.70 ± 0.20) and spine BMD (0.97 ± 0.19) (p < 0.001). Pelvic BMD correlated with BMD at other skeletal locations, with the highest correlation with total hip (total hip: R2: 0.70, femoral neck R2: 0.50, spine R2: 0.65). Pelvic BMD was significantly lower in patients with osteoporosis of both hip and spine compared to the group without osteoporosis at both locations (p = 0.02). Obesity and type 2 diabetes were both associated with significantly higher BMD at pelvis, spine, and total hip. Pelvic BMD is lower than at other skeletal sites and is highly correlated with total hip area bone density. Obesity and type 2 diabetes are associated with higher pelvic BMD. To establish guidelines for the treatment pelvic BMD, studies defining the association of pelvic BMD with pelvic fracture risk are needed.

Sacroiliac Screw Placement with Ease: CT-Guided Pelvic Fracture Osteosynthesis in the Elderly

Background and Objectives: The number of geriatric patients presenting with fragility fractures of the pelvis is increasing due to ageing Western societies. There are nonoperative and several operative treatment approaches. Many of which cause prolonged hospitalisation, so patients become bedridden and lose mobility and independence. This retrospective study evaluates the postoperative outcome of a computed tomography-guided (CT-guided) minimally invasive approach of sacroiliac screw osteosynthesis. The particular focus is to demonstrate its ease of use, feasibility with the equipment of virtually every hospital and beneficial outcomes to the patients. Materials and Methods: 28 patients (3 men, 25 women, age 80.5 ± 6.54 years) with fragility fractures of the pelvis types II-IV presenting between August 2015 and September 2021 were retrospectively reviewed. The operation was performed using the CT of the radiology department for intraoperative visualization of screw placement. Patients only received screw osteosynthesis of the posterior pelvic ring and cannulated screws underwent cement augmentation. Outcomes measured included demographic data, fracture type, postoperative parameters and complications encountered. The quality of life (QoL) was assessed using the German version of the EQ-5D-3L. Results: The average operation time was 32.4 ± 9.6 min for the unilateral and 50.7 ± 17.4 for the bilateral procedure. There was no significant difference between surgeons operating (p = 0.12). The postoperative CT scans were used to evaluate the outcome and showed only one case of penetration (by 1 mm) of the ventral cortex, which did not require operative revision. No case of major complication was reported. Following surgery, patients were discharged after a median of 4 days (Interquartile range 3-7.5). 53.4% of the patients were discharged home or to rehabilitation. The average score on the visual analogue scale of the EQ-5D-3L evaluating the overall wellbeing was 55.6 (Interquartile range (IQR) 0-60). Conclusions: This study shows that the operative method is safe to use in daily practice, is readily available and causes few complications. It permits immediate postoperative mobilization and adequate pain control. Independence and good quality of life are preserved.

Pararectus approach vs. Stoppa approach for the treatment of acetabular fractures - a comparison of approach-related complications and operative outcome parameters from the German Pelvic Registry

PURPOSE

The Pararectus approach has been introduced as an alternative anterior approach to the Stoppa approach in acetabular surgery. There is no evidence which approach should be preferred, especially regarding approach-related complications. Therefore, aim of this registry study was to compare the Pararectus approach to the Stoppa approach regarding complications and quality of reduction.

METHODS

Patients from the German Pelvic Registry with a surgically treated acetabular fracture, either through the Pararectus approach or the Stoppa approach, were analyzed or compared regarding demographic, clinical and operative parameters.

RESULTS

In total, 384 patients with an acetabular fracture received a surgical procedure with either the Pararectus approach (n=120) or the Stoppa approach (n=264). There were no differences between the two groups regarding demographic parameters and fracture pattern. The overall complication rate (35.0% vs. 31.4%), the mortality rate (5.0% vs. 3.0%) and the osteosynthesis-associated complication rate (5.8% vs. 4.2%) tended to be higher in the Pararectus group with no statistical significance. There were significantly more anatomical reductions in the Pararectus group (56% vs. 43%; p=0.01). However, operation time was significantly longer in the Pararectus group (255±125 vs. 205±103 minutes; p<0.001).

CONCLUSION

Despite a longer operation time, the Pararectus approach and the Stoppa approach are equivalently applicable for the treatment of acetabular fractures regarding complication rates and quality of reduction.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Pelvic Fractures-An Underestimated Problem? Incidence and Mortality Risk after Pelvic Fracture in Austria, 2010-2018

(1) Background: Pelvic fractures (PFs) are related to osteoporosis, and represent a serious individual and socioeconomic burden. (2) Methods: We examined age- and sex-standardised incidence rates (SIRs) of PF, along with rates of all-cause overall and one-year mortality among patients with PF. We compared the mortality rates between PF patients and a matched fracture-free cohort. Patients ≥50 years old in Austria hospitalised with PF in 2010−2018, along with their dates of death, were recorded. (3) Results: We identified 54,975 patients with PF, of whom 70.9% were women. Between 2010 and 2018 the SIR of PF increased in men by 10.0%—from 125.3 (95% Confidence Interval 118.9−132.0) to 137.8 (95% CI 131.8−144.0) per 100,000—and in women by 2.7%—from 218.7 (95% CI 212.0−225.6) to 224.7 (95% CI 218.3−231.3) per 100,000. The one-year post-PF mortality rate was higher in men than in women (13.0% and 11.1%, respectively; p < 0.001). Pelvic fracture patients aged ≥65 had an elevated mortality risk (Hazard Ratio 1.75, 95% CI 1.71−1.79, p < 0.001) compared to controls. (4) Conclusions: There is a clear increase in the incidence of PF in the elderly population, with a greater increase in men over time. Pelvic fracture itself contributes to increased mortality in individuals aged 65 and above.

[Minimally invasive stabilization of fragility fractures of the pelvis with transsacral bar and retrograde transpubic screw]

OBJECTIVE

Stabilization of fragility fractures of the pelvis (FFP) using a minimally invasive technique. Insertion of a transsacral rod into the transsacral corridor of S1. Insertion of a retrograde transpubic screw through the superior branch of the pubic bone.

INDICATIONS

Uni- or bilateral displaced fragility fractures of the sacrum or sacroiliac joint. Nondisplaced fractures of the sacrum or sacroiliac joint in case of nonsuccessful conservative treatment. Uni- or bilateral fractures of the superior branch of the pubic bone, which are present in combination with a posterior pelvic instability.

CONTRAINDICATIONS

Fragility fractures of the pelvis, which can be successfully treated conservatively. Absence of transsacral corridor in sacral body S1. Major displacement, nonreducible fractures of the superior branch of the pubic bone. Soft tissue infection at insertion site of implants.

SURGICAL TECHNIQUE

The transsacral bar is inserted under fluoroscopic control from ilium to ilium through the transsacral corridor of the sacral body S1. The retrograde transpubic screw is inserted from the pubic tubercle through the superior branch of the pubic bone past the acetabulum into the body of the ilium.

POSTOPERATIVE MANAGEMENT

An early mobilization with weight bearing of both lower extremities as tolerated by the patient is allowed. Conventional radiographs for control of the position of the implants and fractures are taken after mobilization RESULTS: In all, 64 patients with FFP type II, FFP type III or FFP type IV were stabilized with a transacral bar osteosynthesis in the posterior pelvis. In 32 patients (50%), additional sacroiliac screws were inserted. In 29 patients (45.3%) the transsacral bar osteosynthesis was combined with a transpubic retrograde screw. Median length of hospital stay was 17.5 days. In all, 20 patients (31.3%) suffered general, 10 patients (15.6%) suffered surgery-related complications, and 41 patients (64.1%) were mobile in the room or on the ward at discharge. One-year mortality was 10.9%. The values of the SF‑8 Physical and Mental Component Scores, Parker Mobility Score and Numeric Rating Scale were moderate, yet comparable with the values of patients of the same age.

Patients with combined pelvic and spinal injuries have worse clinical and operative outcomes than patients with isolated pelvic injuries analysis of the German Pelvic Registry

Background

Pelvic fractures are often associated with spine injury in polytrauma patients. This study aimed to determine whether concomitant spine injury influence the surgical outcome of pelvic fracture.

Methods

We performed a retrospective analysis of data of patients registered in the German Pelvic Registry between January 2003 and December 2017. Clinical characteristics, surgical parameters, and outcomes were compared between patients with isolated pelvic fracture (group A) and patients with pelvic fracture plus spine injury (group B). We also compared apart patients with isolated acetabular fracture (group C) versus patients with acetabular fracture plus spine injury (group D).

Results

Surgery for pelvic fracture was significantly more common in group B than in group A (38.3% vs. 36.6%; p = 0.0002), as also emergency pelvic stabilizations (9.5% vs. 6.7%; p < 0.0001). The mean time to emergency stabilization was longer in group B (137 ± 106 min vs. 113 ± 97 min; p < 0.0001), as well as the mean time until definitive stabilization of the pelvic fracture (7.3 ± 4 days vs. 5.4 ± 8.0 days; p = 0.147). The mean duration of treatment and the morbidity and mortality rates were all significantly higher in group B (p < 0.0001). Operation time was significantly shorter in group C than in group D (176 ± 81 min vs. 203 ± 119 min, p < 0.0001). Intraoperative blood loss was not significantly different between the two groups with acetabular injuries. Although preoperative acetabular fracture dislocation was slightly less common in group D, postoperative fracture dislocation was slightly more common. The distribution of Matta grades was significantly different between the two groups. Patients with isolated acetabular injuries were significantly less likely to have neurological deficit at discharge (94.5%; p < 0.0001). In-hospital complications were more common in patients with combined spine plus pelvic injuries (groups B and D) than in patients with isolated pelvic and acetabular injury (groups A and C).

Conclusions

Delaying definitive surgical treatment of pelvic fractures due to spinal cord injury appears to have a negative impact on the outcome of pelvic fractures, especially on the quality of reduction of acetabular fractures.

The grade of instability in fragility fractures of the pelvis correlates with impaired early mobilization

PURPOSE

This study aimed to investigate whether gait patterns of patients with fragility fractures of the pelvis (FFP) comply with the grade of fracture instability, defined by radiological patterns.

PATIENTS AND METHODS

This prospective, single-center, observational study included 39 patients with an FFP. Gait analysis was performed with a wearable insole force sensor (Loadsol® by Novel, Munich, Germany) 4-7 days after admission. Patients were divided in two groups: Group A included FFP type 1 fractures, which affect the anterior pelvic ring only, Group B contained FFP type 2-4 fractures with an involvement of the posterior pelvic ring. Primary outcome parameter was the FTI ratio (force-time integral (N*s)).

RESULTS

The mean age was 85.08 years (SD ± 6.45), 94.9% (37/39) of the patients were female. The most common fracture type was an FFP 2b (64.1%, 25/39). Group A showed a significantly higher FTI ratio (45.12%, SD ± 4.19%) than Group B (38.45%, SD ± 5.97%, p = 0.002). Further, a significant correlation of the FTI ratio and the average (r = 0.570, p < 0.001) and maximum (r = 0.394, p = 0.013) peak force was observed.

CONCLUSION

The gait pattern of patients with an FFP type 2-4 was more imbalanced than of patients with an FFP type 1 fracture. These findings match with the radiological classification of FFP, which indicates higher instability, when the posterior pelvis is affected. Gait analysis might offer earlier functional diagnostics and may accelerate the treatment decision with shorter periods of immobility in future. Especially in cross-border cases, early gait analysis could be beneficial to clarify the indication for or against surgery.

Epidemiology of major osteoporotic fractures: a population-based analysis in Catalonia, Spain

PURPOSE

The aim of this study was to estimate the incidence of major osteoporotic fractures in Catalonia, Spain, in 2018 and 2019 and their association with age, sex, income, climate and a set of comorbidities.

METHODS

Data on age, sex, smoking, alcohol abuse, comorbidities (obesity, Parkinson's disease, arthritis, chronic kidney disease, hepatic cirrhosis, diabetes, chronic obstructive pulmonary disease, dementia, cerebrovascular disease, hyperthyroidism, multiple myeloma and epilepsy) and income levels in people aged ≥ 50 years with a new diagnosis of major osteoporotic fractures in 2018 and 2019 were collected from the Catalan Health Surveillance System (CHSS). Climatological variables were obtained from the Catalan Meteorological Service. Incidence rates were estimated for five major osteoporotic fractures (MOF). Associations between osteoporotic fractures and age, sex, income, comorbidities and climate variables were ascertained through multilevel generalized linear model analysis (Poisson's regression).

RESULTS

There were 60,671 MOF. The annual incidence rate per 1000 persons/years at risk (PYAR) was 10.6 (3.1 for hip, 2.3 for distal forearm, 2.2 for vertebrae, 1.7 for pelvis and 1.5 for proximal humerus). Female sex, older age, lower income, smoking, alcohol abuse and some common comorbidities were associated with a higher incidence of MOF while obesity was a protective factor.

CONCLUSIONS

MOF are frequent in the adult Catalan population, especially in older women and people on low incomes. Hip fracture is the most frequent, followed by forearm and vertebral fractures. Smoking, alcohol abuse and some comorbidities were associated with an increased incidence of fracture.

Inverse association between sarcopenia and displacement in the early phase of fragility fractures of the pelvis

Objectives

Fragility fractures of the pelvis (FFP) commonly occur in the frail elderly. Displacement in the posterior pelvic ring is recognized as the key sign of instability. This study aims to elucidate the relationship between computer tomography (CT)-based frailty markers and displacement of the posterior pelvic ring within 7 days after injury.

Methods

This retrospective study included 49 patients (42 females, 7 males) with FFP (type I 10, type II 24, type III 12, type IV 3). On a CT slice at the level of the third lumbar vertebra, skeletal muscle area, skeletal muscle radiation attenuation, and skeletal muscle index (SMI) were calculated as sarcopenia markers. Osteopenia was measured with trabecular region of interest attenuation technique on the same CT slice.

Results

There was no difference in the demographics between non-displaced and displaced FFP. CT-based data showed that patients with FFP had osteopenia. However, no difference was found between non-displaced and displaced FFP. SMI was higher in FFP types III/IV than non-displaced FFP when CT-based data on sarcopenia were compared among all patients. Female patients with FFP demonstrated similar results. Logistic regression analysis using the demographics and CT-based markers on sarcopenia and osteopenia revealed that SMI was a potential determinant of displacement of the posterior pelvic ring fractures.

Conclusions

There was inverse association between sarcopenia and displacement of the posterior pelvic ring in the early phase of FFP. Relatively preserved muscle may develop displacement in the elderly with osteopenia.

A computed tomography based survey study investigating the agreement of the therapeutic strategy for fragility fractures of the pelvis

Treatment recommendations for fragility fractures of the pelvis (FFP) have been provided along with the good reliable FFP classification but they are not proven in large studies and recent reports challenge these recommendations. Thus, we aimed to determine the usefulness of the FFP classification determining the treatment strategy and favored procedures in six level 1 trauma centers. Sixty cases of FFP were evaluated by six experienced pelvic surgeons, six inexperienced surgeons in training, and one surgeon trained by the originator of the FFP classification during three repeating sessions using computed tomography scans with multiplanar reconstruction. The intra-rater reliability and inter-rater reliability for therapeutic decisions (non-operative treatment vs. operative treatment) were moderate, with Fleiss kappa coefficients of 0.54 (95% confidence interval [CI] 0.44–0.62) and 0.42 (95% CI 0.34–0.49). We found a therapeutic disagreement predominantly for FFP II related to a preferred operative therapy for FFP II. Operative treated cases were generally treated with an anterior–posterior fixation. Despite the consensus on an anterior–posterior fixation, the chosen procedures are highly variable and most plausible based on the surgeon’s preference.

Prospective assessment of key factors influencing treatment strategy and outcome of fragility fractures of the pelvis (FFP)

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.

Midterm follow-up of elderly patients with fragility fractures of the pelvis: A prospective cohort-study comparing operative and non-operative treatment according to a therapeutic algorithm

INTRODUCTION

The treatment of fragility fractures of the pelvis (FFP) is a challenge. The variations of non-operative- and of operative treatment are manifold and a structured treatment algorithm is lacking. The purpose of this study was to evaluate the outcome of elderly patients with a FFP who were treated with a therapeutic algorithm based on the FFP-classification.

PATIENTS AND METHODS

In a prospective cohort study 154 patients (mean age: 81.8 ±.61 (65-96); female: (86.8%; 131/154). BMI: 23.7 ±.34 (15-43)) with a FFP after inadequate mono trauma were treated according to a strict therapeutic algorithm between 04/2016 and 12/2018. According to a classification based on CT-scans either a standardized operative treatment or conservative therapy was induced and the outcome regarding objective measurements of mobility, pain, need for analgesics and mortality during hospital stay and after one year was analyzed.

RESULTS

82/154 participants (53.2%) were assigned to the conservative treatment group and 72 participants (46.8%) to the operative treatment group. The overall one-year survival rate was 78.1% (118/151). The survival of the operative treatment group was 90.7% (49/54) and significantly higher than the survival of the conservative treatment group (74.7%; 56/75; p=.023). The one-year follow up showed a high dispersion of the pain level in the operatively treated patients and a significantly higher mean in comparison to conservatively treated patients. Both treatment groups showed increasing numbers of patients with unlimited mobilization but also immobile patients. Overall in 31.0% (18/58) of the operative participants and in 14.9% (14/93) of the non-operatively treated participants complications occurred (p=.04).

CONCLUSION

The strict compliance to the presented treatment algorithm of FFP with an operative strategy starting from FFP IIc leads to a significantly lower mortality within one year in comparison to the conservatively treated patients. The worst outcome and the highest mortality was seen in patients who refused the recommendation of operative stabilization. The results of this study justify to proceed with the strict classification dependent treatment algorithm and also support the early switch-over to operative treatment of patients with failed conservative therapy in FFP I to FFP IIb.

Fragility Fractures of the Pelvis and Sacrum: Current Trends in Literature

Fragility fractures of the pelvis (FFP) and fragility fractures of the sacrum (FFS), which are emerging in the geriatric population, exhibit characteristics that differ from those of pelvic ring disruptions occurring in the younger population. Treatment of FFP/FFS by a multidisciplinary team can be helpful in reducing morbidity and mortality with the goal of reducing pain, regaining early mobility, and restoring independence for activities of daily living. Conservative treatment, including bed rest, pain therapy, and mobilization as tolerated, is indicated for treatment of FFP type I and type II as loss of stability is limited with these fractures. Operative treatment is indicated for FFP type II when conservative treatment has failed and for FFP type III and type IV, which are displaced fractures associated with intense pain and increased instability. Minimally invasive stabilization techniques, such as percutaneous fixation, are favored over open reduction internal fixation. There is little evidence regarding outcomes of patients with FFP/FFS and more literature is needed for determination of optimal management. The aim of this article is to provide a concise review of the current literature and a discussion of the latest recommendations for orthopedic treatment and management of FFP/FFS.

Instability of the posterior pelvic ring: introduction of innovative implants

BACKGROUND

Increasing numbers of posterior pelvic ring fractures, especially in elderly patients, demonstrate the need for soft tissue protecting surgical techniques. Standard of care is iliosacral screw osteosynthesis. This type of osteosynthesis has its limitations especially in patients with reduced bone properties. Therefore, the development of new and straightforward surgical techniques and implant designs is favorable.

METHODS

Introducing this modular system for the posterior pelvic ring, known complications of iliosacral screw osteosynthesis, such as implant loosening and malpositioning may be reduced, due to innovative mechanical characteristics.

RESULTS

The shown cases demonstrate the potential benefits of the system with a wide range of treatment options due to its modularity.

CONCLUSION

The modular implant system presented here can significantly facilitate and improve the stabilization of posterior pelvic ring instabilities.

Epidemiology Of Pelvic Ring Fractures and Injuries: A Retrospective Study

BACKGROUND: Despite relatively rare occurrence in trauma victims, pelvic fractures have a high risk of mortality and morbidity. AIM: This study was conducted to study epidemiology of patients with pelvic ring injuries in a level 1 trauma center in Kazakhstan. METHODS: This is a descriptive cross-sectional study within a single institution. In the period of 2014–2017, we encountered 212 patients with pelvic fractures. About 92% of them had concomitant injures due to a high-energy trauma. Measures were compared using the SPSS 20.0 program. RESULTS: The mean age was 34.5. Pelvic fractures are more often verified in males. The most common mechanism of injury was road traffic injuries and falls from heights. The highest recovery rates were observed for type B fractures, but mortality was highest for type C fractures. The average length of hospital stay was 18.71 days. Non-surgical treatment was used in 62.3% of patients, external fixation device was imposed as an emergency intervention in 64.2% (n = 136) of patients. CONCLUSIONS: Overall most patients with pelvic fractures had multiple injuries and the mortality rate was 7.1%. Non-surgical treatment was most commonly used. Type C fractures had significantly fatal outcome.

Operative treatment of fragility fractures of the pelvis: a critical analysis of 140 patients

Background

Fragility fractures of the pelvis (FFP) are a clinical entity with an increasing frequency. Indications for and type of surgical treatment are still a matter of debate.

Purpose

This retrospective study presents and critically analyses the results of operative treatment of 140 patients with FFP.

Setting

Level-I trauma center.

Materials and methods

Demographic data, comorbidities, FFP-classification, type of surgical stabilization (percutaneous (P-group) versus open procedure (O-group)), length of hospital stay (LoS), general in-hospital complications, surgery-related complications, living environment before admission, mobility and destination at discharge were retracted from the medical and radiographic records. Patients were asked participating in a survey by telephone call about their quality of life. SF-8 Physical Component Score (PCS) and SF-8 Mental Component Score (MCS) were calculated as well as the Parker Mobility Score (PMS) and the Numeric Rating Scale (NRS).

Results

Mean age was 77.4 years and 89.3% of patients were female. 92.1% presented with one comorbidity, 49.3% with two or more comorbidities. Median length of hospital stay was 18 days, postoperative length of hospital stay was 12 days. 99 patients (70.7%) received a percutaneous operative procedure, 41 (29.3%) an open. Patients of the O-group had a significantly longer LoS than patients of the P-group (p = 0.009). There was no in-hospital mortality. There were significantly more surgery-related complications in the O-group (43.9%) than in the P-group (19.2%) (p = 0.006). Patients of the O-group needed more often surgical revisions (29.3%) than patients of the P-group (13.1%) (p = 0.02). Whereas 85.4% of all patients lived at home before admission, only 28.6% returned home at discharge (p < 0.001). The loss of mobility at discharge was not influenced by the FFP-classes (p = 0.47) or type of treatment (p = 0.13). One-year mortality was 9.7%. Mortality was not influenced by the FFP-classes (p = 0.428) or type of treatment (p = 0.831). Median follow-up was 40 months. SF-8 PCS and SF-8 MCS were moderate (32.43 resp. 54.42). PMS was 5 and NRS 4. Follow-up scores were not influenced by FFP-classes or type of treatment.

Conclusion

Patients with FFP, who were treated operatively, suffered from a high rate of non-lethal general, in-hospital complications. Open surgical procedures induced more surgery-related complications and surgical revisions. Mental and physical follow-up scores are low to moderate. Condition at follow-up is not influenced by FFP-classes or type of treatment. Indications for operative treatment of FFP must be critically examined. Surgical fixation should obtain adequate stability, yet be as less invasive as possible. The advantages and limitations of different surgical techniques have to be critically evaluated in prospective studies.

The Incidence of Fractures Among the Adult Population of Germany – and Analysis From 2009 through 2019

BACKGROUND

Detailed analyses of epidemiological data on fractures are an important resource for persons and institutions providing health care services, as they yield information on the effects of current treatment strategies and on the need for preventive measures. The epidemiology of fractures in Germany, however, is unknown. The goal of this study is to determine the nationwide fracture burden from 2009 through 2019, as a function of anatomical site, age, and sex.

METHODS

Annual compilations of ICD-10 diagnosis codes for the years 2009-2019 were made available to us by the German Federal Statistical Office. The prevalence and incidence of fractures at 30 different sites were quantified, and standardized sex and age distributions were calculated.

RESULTS

A total of 688 403 fractures was registered in 2019. From 2009 to 2019, the incidence of fractures rose by 14%, to 1014 fractures per 100 000 persons per year. The most common fracture types were femoral neck fractures (120 per 100 000 persons per year), pertrochanteric femural fractures (109 per 100 000 persons per year), and distal radius fractures (106 per 100 000 persons per year). All types were more common in women, with incidences that rose with age. The highest incidence was of pertrochanteric femoral fractures in women over age 90, with an incidence of 2550 per 100 000 persons per year. The largest rises in incidence were seen with regard to acetabular fractures (+ 58.16%) and clavicular fractures (+ 44.02%).

CONCLUSION

The increasing frequency of fractures, particularly among the elderly, presents a challenge to the health care system. Given the high frequency of geriatric fractures, prophylactic measures against fractures ought to be intensified.

Health care utilization and excess costs after pelvic fractures among older people in Germany

Our study demonstrates a strong increase in utilization of inpatient health care and clear excess costs in older people in the first year after pelvic fracture, the latter even after adjustment for several confounders. Excess costs were particularly high in the first few months and mainly attributable to inpatient treatment.

INTRODUCTION

We aimed to estimate health care utilization and excess costs in patients aged minimum 60 years up to 1 year after pelvic fracture compared to a population without pelvic fracture.

METHODS

In this retrospective population-based observational study, we used routine data from a large statutory health insurance (SHI) in Germany. Patients with a first pelvic fracture between 2008 and 2010 (n=5685, 82% female, mean age 80±9 years) were frequency matched with controls (n=193,159) by sex, age at index date, and index month. We estimated health care utilization and mean total direct costs (SHI perspective) with 95% confidence intervals (CIs) using BCA bootstrap procedures for 52 weeks before and after the index date. We calculated cost ratios (CRs) in 4-week intervals after the index date by fitting mixed two-part models including adjustment for possible confounders and repeated measurement. All analyses were further stratified for men/women, in-/outpatient-treated, and major/minor pelvic fractures.

RESULTS

Health care utilization and mean costs in the year after the index date were higher for cases than for controls, with inpatient treatment being particularly pronounced. CRs (95% CIs) decreased from 10.7 (10.2-11.1) within the first 4 weeks to 1.3 (1.2-1.4) within week 49-52. Excess costs were higher for inpatient than for outpatient-treated persons (CRs of 13.4 (12.9-13.9) and 2.3 (2.0-2.6) in week 1-4). In the first few months, high excess costs were detected for both persons with major and minor pelvic fracture.

CONCLUSION

Pelvic fractures come along with high excess costs and should be considered when planning and allocating health care resources.

The FFP-classification: From eminence to evidence

Fragility fractures of the pelvis (FFP) are a clinical entity with a rapidly growing incidence among elderly women. The characteristics of these fractures are different from those appearing after high-energy trauma. In 2013, the comprehensive FFP-classification provided a new framework for analysis of these fractures. It is based on the estimation of loss of stability in the pelvic ring. It is connected with recommendations for surgical treatment, justified by the fact that higher instabilities will need surgical stabilization. Since ist appearance, we can observe an increasing clinical-scientific interest in FFP. Multiple publications use the FFP-classification studying the characteristics of fractures, choice of treatment and outcome. Other studies focus on minimal-invasive techniques for stabilization. The actual knowledge describes higher mortality rates as the reference population, lower mortality rates after operative treatment but for the price of surgery-related complications. Mobility, independency and quality of life are worse than before the fracture, independent of the FFP-classification and the type of treatment. The classification triggered a rapid increase of expertise. This publication gives a detailed overview on the evolution from eminence to evidence.

Pelvic fractures in severely injured elderly: a double-adjustment propensity score matched analysis from a level I trauma center

Purpose

Pelvic trauma has increased risk of mortality in the elderly. Our study aimed to analyze the impact of the additional burden of pelvic fractures in severely injured elderly.

Methods

This is a retrospective analysis of a prospectively maintained trauma registry from 2012 to 2018 at an American College of Surgeons (ACS) verified Level I Trauma Center. Trauma patients aged ≥ 65 years with ISS ≥ 16 and AIS severity score ≥ 3 in at least two body regions were divided in two groups: group I, consisted of elderly polytrauma patients without pelvic fractures, and group II elderly who had concomitant pelvic fractures. We used a double-adjustment method using propensity score matching (PSM) with subsequent covariate adjustment to minimize the effect of confounding factors, and give unbiased estimation of the impact of pelvic fractures. Balance assessment was conducted by computing absolute standardized mean differences (ASMDs) and ASMD < 0.10 reflects good balance between groups.

Results

Of 12,774 patients admitted during this time, 411 (3.2%) elderly with a mean age of 77.75 ± 8.32 years met the inclusion criteria. Of this cohort, only 92 patients (22.4%) had pelvic fractures. Females outnumbered males (55 vs. 45%). Comparing characteristics of group I and group II using ASMDs, pelvic trauma patients were more likely to have higher systolic blood pressure (SBP), head injuries, lower extremity injuries, anticoagulant therapy, and cirrhosis. Fewer variables differed significantly after matching. We observed few instances of worse outcomes associated with pelvic trauma using PSM with and without covariate adjustment. Crude PSM without covariate adjustment, showed a significantly higher rate of deep vein thrombosis (DVT) for pelvic trauma (p < 0.001). Crude PSM also showed a significantly higher rate of ventilator-associated pneumonia (VAP) in group II (p = 0.006). PSM with covariate adjustment did not confirm differences on these outcomes. PSM both without and with covariate adjustment found lower ventilator days and ICU length of stay among patients with pelvic trauma. No significant differences were seen on 12 outcomes: death, acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), cardiac arrest with cardiopulmonary resuscitation (CPR), myocardial infarction (MI), pulmonary embolism (PE), unplanned intubation, unplanned admission to intensive care unit (ICU), catheter-associated urinary tract infection (CAUTI), and hospital length of stay.

Conclusions

At a Level I Trauma Center the additional burden of pelvic fractures in seriously injured elderly did not translate into higher mortality. PSM without covariate adjustment suggests worse rates among pelvic trauma patients for DVT and VAP but covariate adjustment removed statistical significance for both outcomes. Pelvic trauma patients had shorter time on ventilator and in the ICU. Whether similar analytic methods applied to patients from larger data sources would produce similar findings remains to be seen.

Anatomical evaluation of the transpubic screw corridor based on a 3D statistical model of the pelvic ring

Retrograde transpubic screw fixation is a common procedure for the treatment of anterior pelvic ring fractures. With its sparing surgical approach and significant pain relief after screw fixations allowing early mobilisation, it has gained importance especially in the treatment of insufficiency fractures in elderly patients. However, positioning of transpubic screw osteosynthesis is not always possible due to narrowness and curvature of the screw corridor. The aim of the present study was to evaluate availability and length of the screw corridor using a 3D statistical model of the pelvic ring consisting out of 150 uninjured pelves. Virtual bore probes with a diameter of 7.5 mm were analysed as to accessibility, length and grey value distribution in Hounsfield Unit (HU). A transpubic corridor with a diameter of ≥ 7.5 mm was available in 185 of 300 investigated superior pubic rami with mean screw length of 131.7 mm. Accessibility of the screw corridor was higher in males than in females. However, screw length showed no systematic differences between the sexes or ethnicities. Analysis of the grey value distribution demonstrated the strongest bone to be located at the lateral ilium and the supraacetabular region.

Which factors influence treatment decision in fragility fractures of the pelvis? - results of a prospective study

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.

Operative treatment of fragility fractures of the pelvis is connected with lower mortality. A single institution experience

Background

Fragility fractures of the pelvis (FFP) represent an increasing clinical entity. Until today, there are no guidelines for treatment of FFP. In our center, recommendation for operative treatment was given to all patients, who suffered an FFP type III and IV and to patients with an FFP type IIwith unsuccessful non-operative treatment. We performed a retrospective observational study and investigated differences between fracture classes and management alternatives. We hypothetized that operative treatment may reduce mortality.

Materials and methods

The medical charts and radiographs of 362 patients were analysed. Patient demographics, FFP-classification, length of hospital stay (LoS), type of treatment, general and surgery-related complications, mortality, Short Form-8 physical component score (SF-8 PCS) and mental component score (SF-8 MCS), Parker Mobility Score (PMS) and Numeric Rating Scale (NRS) were documented.

Results

238 patients had FFP type II and 124 FFP type III and IV. 52 patients with FFP type II (21.8%) and 86 patients with FFP type III and IV (69.4%) were treated operatively (p<0.001). Overall mortality did not differ between the fracture classes (p = 0.127) but was significantly lower in the operative group (p<0.001). Median LoS was significantly higher in FFP type III and IV (p<0.001) and in operated patients (p<0.001). There were more in-hospital complications in patients with FFP type III and IV (p = 0.001) and in the operative group (p = 0.006). More patients of the non-operative group were mobile (p<0.001) and independent (p<0.001) at discharge. Half of the patients could not return in their living environment.203 of the 235 surviving patients (86%) answered the questionnaires after a mean follow-up time of 38 months. SF-8 PCS, SF-8 MCS and PMS did not differ between the fracture classes and treatment groups. Pain perception was higher in the operated group (p = 0.013).

Conclusion

In our study, we observed that operative treatment of FFP provides low mortality rates, although LoS and in-hospital complications were higher in the operative group. At discharge, the non-operative group was more mobile and independent. At follow up, quality of life and mobility were comparable between the groups. Further prospective studies are needed to clarify the impact of operative treatment of FFP on mortality and functional outcome.

[Angle stable plate for treatment for insufficiency fractures of the pelvis (minimally invasive posterior locked compression plate) : Video article]

Operationsziel

Belastungsstabile Versorgung des Beckenringes mit hoher Primärstabilität.

Indikation

Instabilität und ausbleibende Mobilisierbarkeit bei osteoporotischen Beckenbrüchen.

Kontraindikationen

Dekubitalgeschwüre, Infekte.

Operationstechnik

Minimal-invasive winkelstabile Versorgung durch 4,5 LCP (locked compression plate, DePuy Synthes, Zuchwil, Schweiz) von dorsal.

Weiterbehandlung

Sofortige Mobilisation mit Vollbelastung, Röntgenverlaufskontrolle.

Evidenz

Die Nachuntersuchung eines Kollektivs von 34 Patienten zeigte keine Implantatlockerungen sowie eine vergleichsweise niedrige Strahlenexposition.

Video online

Die Online-Version dieses Beitrags (10.1007/s00113-021-01039-x) enthält das Video zur hier beschriebenen Operationstechnik „Winkelstabile Platte zur Behandlung der Insuffizienzfrakturen des Beckens“.

Does surgical treatment for unstable fragility fracture of the pelvis promote early mobilization and improve survival rate and postoperative clinical function?

PURPOSE

This retrospective multicenter study aimed to compare rates of early mobilization and survival and functional outcome of surgical treatment (S) with that of conservative treatment (C) according to each unstable fragility fracture of the pelvis (FFP) classification type with displacement of the posterior component ≥ 5 mm.

METHODS

We analyzed 64 patients with unstable type III and IV FFP who could move and transfer themselves before injury and had ≥ 5 mm displacement of the posterior component. We compared survival rate, early mobilization, walking ability at final follow-up, and complications at admission for each type of surgical and conservative treatment.

RESULTS

Most of the unstable FFP were type IIIa and IVb in the study population. Type III comprised 40 cases (group S:13/group C:27) and type IV comprised 24 cases (group S:7/group C:17). There were no significant differences in 3 month and 1 year survival rates, although group C (III) had the tendency of higher mortality rate (p = 0.08). Mobilization (transferring to a wheelchair) was enabled significantly earlier in group S (III) than in group C (III) (p = 0.02), but in type IV, most patients enabled early mobilization even without surgical intervention. There were no significant differences in hospital complications and walking ability at final follow-up.

CONCLUSION

In this study, the superiority of surgical treatment for unstable FFP was not proven. However, the results suggest that type IVb may be a relatively stable type compared to type III and that type IVb should be considered separately from bilaterally complete unstable sacral fractures due to high-energy trauma.

Detecting pelvic fracture on 3D-CT using deep convolutional neural networks with multi-orientated slab images

Pelvic fracture is one of the leading causes of death in the elderly, carrying a high risk of death within 1 year of fracture. This study proposes an automated method to detect pelvic fractures on 3-dimensional computed tomography (3D-CT). Deep convolutional neural networks (DCNNs) have been used for lesion detection on 2D and 3D medical images. However, training a DCNN directly using 3D images is complicated, computationally costly, and requires large amounts of training data. We propose a method that evaluates multiple, 2D, real-time object detection systems (YOLOv3 models) in parallel, in which each YOLOv3 model is trained using differently orientated 2D slab images reconstructed from 3D-CT. We assume that an appropriate reconstruction orientation would exist to optimally characterize image features of bone fractures on 3D-CT. Multiple YOLOv3 models in parallel detect 2D fracture candidates in different orientations simultaneously. The 3D fracture region is then obtained by integrating the 2D fracture candidates. The proposed method was validated in 93 subjects with bone fractures. Area under the curve (AUC) was 0.824, with 0.805 recall and 0.907 precision. The AUC with a single orientation was 0.652. This method was then applied to 112 subjects without bone fractures to evaluate over-detection. The proposed method successfully detected no bone fractures in all except 4 non-fracture subjects (96.4%).

[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]

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.

Percutaneous operative treatment of fragility fractures of the pelvis may not increase the general rate of complications compared to non-operative treatment

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.

[Reliability of the FFP classification in pelvic fractures]

BACKGROUND

Pelvic fractures are typical for frail geriatric patients. They are characterized by increasing pain and loss of mobility. As geriatric pelvic fractures differ from the typical high velocity injuries, Rommens and Hofmann recommended a new classification for fragility fractures of the pelvis (FFP) in 2013. In addition to the location of the fracture they also assessed the degree of dislocation.

OBJECTIVE

Compared to known fracture classifications of the pelvis, the FFP classification appears complex. Therefore, this study was designed to investigate the interobserver reliability of the FFP classification.

MATERIAL AND METHODS

The members of the Section of Geriatric Traumatology (DGOU) were presented with 10 DICOM data sets with fractures of the pelvis for classification. As a reference the classification of P.M. Rommens, the author of the FFP, was established.

RESULTS

In this study 24 consultants (47%) and 27 (53%) residents took part. Also, six radiologists were invited to participate. A total of 493 assessments were made. In 184 (37%) cases there was agreement with the reference, in 183 (37%) computed tomography images the fractures were classified lower, in 26 (26%) higher than the reference. This initially resulted in a Cohens κ coefficient of 0.36. This corresponds to a sufficient agreement (fair) according to Garbuz. With the reduction of the classification to four main groups, the Cohens κ coefficient increased to a satisfactory value.

CONCLUSION

The reasons for the partly low agreement could be the participants' lack of experience and an inaccurate description of the classification levels. In the end, however, the FFP classification is the only one that meaningfully represents pelvic fractures of geriatric and frail patients. By simplifying to the four main groups, a better interobserver reliability is achieved. For a successful treatment, however, attention to the individual patient and the "fracture personality" is essential.