Feasibility of anterior pelvic ring fixation alone for treating lateral compression type 1 pelvic fractures with nondisplaced complete sacral fractures: a retrospective study

Comparison of the MIPPO technique and the modified Stoppa approach in the treatment of unstable anterior pelvic ring injuries: a retrospective cohort study

BACKGROUND

Anterior pelvic ring injuries have gradually become common. Using a minimally invasive technique to treat this injury may be feasible if the reduction and stability can be effectively achieved. We describe a percutaneous technique, minimally invasive percutaneous plate osteosynthesis (MIPPO), to fixate the anterior pelvis via establishing a subperiosteal tunnel between two limited incisions over the iliac crest(s) and pubic ramus in this research.

METHODS

A retrospective cohort study comparing the MIPPO technique (n = 60) versus the modified Stoppa approach (n = 53) for anterior pelvic ring injuries with posterior ring instability was performed from September 2016 to January 2023. The relative surgery variables, follow-up function evaluation, and complications were compared in two groups. The reduction quality of fracture was assessed according to the Matta criterion, and the functional score was evaluated using the Majeed score.

RESULTS

All patients completed follow-up, with an average interval of 39.90 ± 17.53 months (range 12-78). In the MIPPO technique group, the surgery interval and blood losses were lower compared to the modified Stoppa approach group (P<0.05). The mean procedure times and intraoperative blood losses were 69.56 ± 14.04 min/side (range 50-110) and 156.23 ± 49.75 mL/side (range 90-250) for unilateral anterior ring MIPPO fixation separately. All patients got a satisfactory reduction of the fracture. In the follow-up, earlier ambulation, shorter postoperative hospital stays, and lower complication rates were observed for patients using the MIPPO technique compared to the modified Stoppa approach (P<0.05). However, there is no statistical difference in these indicators including fracture union interval, full load time, the Majeed score, patient satisfaction level, and return to pre-injured work rate between the two groups.

CONCLUSION

This clinical experience gives support for the use of the MIPPO technique to stabilize the anterior pelvis. This minimally invasive technique was an effective and safe surgery method and could obtain satisfactory function results, particularly fitting to part of patients with resistance using the modified Stoppa approach.

Combined Anterior-Posterior versus Posterior-Only Fixation of Stress-Positive Minimally Displaced Lateral Compression Type 1 (LC1) Pelvic Ring Injuries

OBJECTIVES

To compare hospital outcomes and late displacement between stress-positive minimally displaced lateral compression type 1 (LC1) pelvic ring injuries treated with combined anterior-posterior versus posterior-only fixation.

DESIGN

Retrospective comparative cohort.

SETTING

Urban level-one trauma center.

PATIENTS/PARTICIPANTS

LC1 injuries managed operatively.

INTERVENTION

Anterior-posterior versus posterior-only fixation.

MAIN OUTCOME MEASUREMENTS

Physical therapy (PT) clearance, discharge location, hospital length of stay (LOS), inpatient morphine equivalent doses (MED), and fracture displacement at follow-up.

RESULTS

Groups were similar in demographic and injury characteristics (age, high energy mechanism, ASA score, stress displacement, and rami/sacral fracture classifications). Anterior-posterior fixation resulted in longer operative times (median difference (MD): 27.0 minutes, 95% confidence interval (CI): 17.0 to 40.0, P < 0.0001) and had a trend of increased estimated blood loss (MD: 10 mL, CI: 0 to 30, P = 0.07). Patients with anterior-posterior fixation required less inpatient MEDs (MD: -180.0, CI: -341.2 to -15.0, P = 0.02), were more likely to clear PT by discharge (100% vs. 70%, proportional difference (PD): 30%, CI: 2.0%-57.2%, P = 0.02), were less likely to discharge to rehabilitation facilities (0% vs. 30%, PD: 30%, CI: 2.0%-57.2%, P = 0.02), and had a trend of less days to clear PT after surgery (MD: -1, CI: -2 to 0, P = 0.09) and decreased LOS (MD: -1, CI: -4 to 1, P = 0.17). Late fracture displacement did not differ between groups.

CONCLUSION

Anterior-posterior fixation of LC1 injuries was associated with an improved early hospital course-specifically, reduced inpatient opioid use and an increased number of patients who could clear PT and discharge home.

LEVEL OF EVIDENCE

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

The morphological mapping of lateral compression type 1 pelvic fracture and pelvic ring stability classification: a finite element analysis

Purpose

This finite element analysis assessed lateral compression (LC-1) fracture stability using machine learning for morphological mapping and classification of pelvic ring stability.

Methods

Computed tomography (CT) files of LC-1 pelvic fractures were collected. After morphological mapping and producing matrix data, we used K-means clustering in unsupervised machine learning to classify the fractures. Based on these subtypes, we manually added fracture lines in ANSYS software. Finally, we performed a finite element analysis of a normal pelvis and eight fracture subtypes based on von Mises stress and total deformation changes.

Results

A total of 218 consecutive cases were analyzed. According to the three main factors—zone of sacral injury and completion, pubic ramus injury side, and the sagittal rotation of the injured hemipelvis—the LC-1 injuries were classified into eight subtypes (I–VIII). No significant differences in stress or deformation were observed between unilateral and bilateral public ramus fractures. Subtypes VI and VIII showed the maximum stress while subtypes V–VIII showed the maximum deformation in the total pelvis and sacrum. The subtypes did not differ in superior public ramus deformation.

Conclusions

Complete fracture of sacrum zones 2/3 may be a feature of unstable LC-1 fractures. Surgeons should give surgical strategies for subtypes V–VIII.

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

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