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Godolias P, Plümer J, Cibura C, Dudda M, Schildhauer TA, Chapman JR. Posterior pelvic ring injuries, lumbosacral junction instabilities and stabilization techniques for spinopelvic dissociation: a narrative review. Arch Orthop Trauma Surg 2024; 144:1627-1635. [PMID: 38353686 DOI: 10.1007/s00402-024-05211-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/23/2024] [Indexed: 03/27/2024]
Abstract
INTRODUCTION From transiliac Harrington rods to minimally invasive (MIS) percutaneous 3D-navigated transsacral-transiliac screw (TTS) fixation, concepts of fixation methods in pelvic injuries with spinopelvic dissociation (SPD) are steadily redefined. This narrative review examines the literature of recent years regarding surgical treatment options and trends in SPD, outlining risks and benefits of each treatment option and addressing biomechanical aspects of sacral injuries and common classification systems. MATERIALS AND METHODS A literature search on the search across relevant online databases was conducted. As a scale for quality assessment, the SANRA-scoring system was taken into account. RESULTS Sacral Isler type 1 injuries of the LPJ in U- and H-type fractures are frequently treated with stand-alone TTS. Fractures with higher instability (Isler types 2 and 3) require unilateral or bilateral LPF, subject to side involvement, as a buttressing construct, or triangular fixation as additional compression and neutralization, determined by fracture radiation. A more comprehensive classification from which to derive stabilization options is provided by the 2023 301SPD classification. MIS techniques are on the rise and offer shorter OR time, less blood loss, fewer infections, and fewer wound complications. It is advisable to implement MIS techniques as much as possible, as long as decompression is not required and closed fracture reduction succeeds satisfactorily. CONCLUSION SPD is characteristic of severe injuries, mostly in polytraumatized patients. The complication rates are decreasing due to the increasing adaptation of MIS techniques.
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Affiliation(s)
- Periklis Godolias
- Department of Orthopedics and Trauma Surgery, St. Josef Hospital Essen-Werden, Propsteistrasse 2, 45239, Essen, Germany.
| | - Jonathan Plümer
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Charlotte Cibura
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Marcel Dudda
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany
- Department of Orthopaedics and Trauma Surgery, BG-Klinikum Duisburg, Großenbaumer Allee 250, 47249, Duisburg, Germany
| | - Thomas A Schildhauer
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Jens R Chapman
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
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Dalos D, Guttowski D, Thiesen DM, Berger-Groch J, Fensky F, Frosch KH, Hartel MJ. Operative versus conservative treatment in pelvic ring fractures with sacral involvement. Orthop Traumatol Surg Res 2024; 110:103691. [PMID: 37741442 DOI: 10.1016/j.otsr.2023.103691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 07/04/2023] [Accepted: 08/24/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND To evaluate the performance in activities of daily living (ADL), level of pain, mortality and rate of complications in patients with a pelvic ring fracture with sacral involvement who were treated conservatively compared to a surgically treated patient collective using percutaneous iliosacral screw fixation. HYPOTHESIS Conservative treatment does not result in inferior clinical outcome compared to operative treatment. PATIENTS AND METHODS A retrospective study of 112 conservatively (n=46) or operatively (n=66) treated patients with an isolated posterior or a combined posterior and anterior pelvic ring fracture was performed. The analysis included: age, sex, mechanism of injury, fracture type according to AO/OTA classification, energy of trauma sustained (no-, low-, high-energy trauma), type of treatment (operative or conservative), complications as well as duration of in-hospital stay. To assess clinical and activity outcome, the visual analog scale for pain (VAS), Barthel Scale, American Society of Anaesthesiologists (ASA) scores as well as mortality were assessed. The mean follow-up was 29.3±14.6 months. Furthermore, a geriatric subgroup (n=68, age≥60, low-energy trauma only) was analyzed. RESULTS The majority of the patients were female (79%) and suffered from low-energy trauma (n=64, 58%). There were no significant differences in the operative and the conservative groups and subgroups concerning VAS, Barthel scores and ASA scores. The survival analyses showed a significantly lower survival rate in the conservative group (41.8±3.6 months) compared to the operative group (55.9±2 months, p=0.002). Similar findings were encountered in the geriatric subgroup analysis. CONCLUSION This study demonstrates equivalent clinical outcome in conservatively and surgically treated patients using a percutaneous iliosacral screw fixation at a mid-term follow-up. However, operatively treated patients showed decreased mortality. This needs to be carefully considered in clinical decision-making but must be further explored using a prospective randomized study approach. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Dimitris Dalos
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; UKE Athleticum, Center for Athletic Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Institute of Interdisciplinary Exercise Science and Sports Medicine, Faculty of Medicine, MSH, Medical School Hamburg, Am Kaiserkai 1, 20457 Hamburg, Germany.
| | - Dario Guttowski
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Department of Orthopaedic Surgery, ENDO-Klinik, Holstenstraße 2, 22767 Hamburg, Germany
| | - Darius M Thiesen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Josephine Berger-Groch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Florian Fensky
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorferstraße 10, 21033 Hamburg, Germany
| | - Maximilian J Hartel
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Hospital Hamburg, Bergedorferstraße 10, 21033 Hamburg, Germany
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Andresen JR, Radmer S, Andresen R, Prokop A, Schröder G, Nissen U, Schober HC. Comparative outcome of different treatment options for fragility fractures of the sacrum. BMC Musculoskelet Disord 2022; 23:1106. [PMID: 36536363 PMCID: PMC9762048 DOI: 10.1186/s12891-022-06039-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Fragility fractures of the sacrum (FFS) have been detected more and more frequently in recent times, and the incidence will continue to increase due to increasing life expectancy. The aim of this study was to compare the clinical outcome of conservative, interventional and surgical treatment of FFS. METHODS Retrospectively, 292 patients (276 women, 16 men) with confirmed FFS were followed up over a period of 2 years. The age of the women was Ø 81.2 (58 - 99) and that of the men Ø 78.1 (76 - 85) years. The pain was quantified using a VAS. Fractures were classified in accordance with the Rommens and Hofmann and with the Denis classification using conventional X-rays, CT and MRI. A QCT of the lumbar spine was performed to quantify bone mineral density. Concomitant diseases of every patient were recorded. An interdisciplinary case conference determined the individual treatment concept considering the age, type of fracture, pain level and comorbidities with classification into conservative, interventional (any type of sacroplasty) or surgical treatment. Over the course pain and independence were measured, complications and patient satisfaction were documented. A vitamin D determination was done, and existing comorbidities were included. RESULTS Patients with a pain level of ≤5 benefited from the conservative therapy measures, with pain levels > 5 significantly delaying the development of mobility. After sacroplasty, the pain reduced significantly, which caused a rapid improvement in mobility without any significant difference being found between vertebro- (VSP), balloon (BSP), radiofrequency (RFS) and cement sacroplasty (CSP). In terms of pain reduction and mobilization, the surgical treated patients benefited from osteosynthesis, although more complex fracture types with lumbopelvic stabilization took longer. Overall, there were no deaths during the hospital stay. Mortality after 12 months was 21.7% for the conservative, 8.4% for the interventional and 13.6% for the surgical therapy group; the differences are significant. For patients in the conservative therapy group who were difficult to mobilize due to pain, the mortality increased to 24.3%. Over 24 months, patients achieved the best independence after sacroplasty. At 12 and 24 months, subjective satisfaction with the therapies was best after sacroplasty, followed by osteosynthesis and conservative measures. All patients had a pronounced vitamin D deficiency and manifest osteoporosis. Cardiovascular pathologies were the main concomitant diseases. CONCLUSIONS Patients with FFS with a low level of pain benefit from conservative therapy measures, whereby complications and mortality increase significantly in the case of persistent immobilizing pain. Patients with an unacceptable level of pain resulting from non-dislocated fractures benefit significantly from sacroplasty. Patients with unstable and displaced fractures (Rommens and Hofmann type III and IV) should be operated on promptly. Different techniques are available for sacroplasty and osteosynthesis, which lead to an improvement of independence and a reduction in mortality.
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Affiliation(s)
- Julian Ramin Andresen
- grid.263618.80000 0004 0367 8888Medical School, Sigmund Freud University, Vienna, Austria
| | | | - Reimer Andresen
- grid.9764.c0000 0001 2153 9986Institute of Diagnostic and Interventional Radiology/Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg, Heide, Germany
| | - Axel Prokop
- grid.10392.390000 0001 2190 1447Department of Trauma Surgery, Sindelfingen, Academic Teaching Hospital of the University of Tübingen, Tübingen, Germany
| | - Guido Schröder
- Clinic of Orthopaedics and Trauma Surgery, Warnow Klinik, Bützow, Germany
| | - Urs Nissen
- grid.9764.c0000 0001 2153 9986Department of Neurosurgery and Spine Surgery, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg, Heide, Germany
| | - Hans-Christof Schober
- grid.10493.3f0000000121858338Department of Internal Medicine IV, Municipal Hospital Südstadt Rostock, Academic Teaching Hospital of the University of Rostock, Rostock, Germany
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Kons C, Wicklein S, Biber R. [Sacral fractures in geriatric patients]. Z Gerontol Geriatr 2022; 55:331-341. [PMID: 35641795 DOI: 10.1007/s00391-022-02061-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/18/2022] [Indexed: 10/18/2022]
Abstract
Sacral fractures in geriatric patients are increasing and form a distinct entity. Clinical findings can be unspecific, which is why they are easily overlooked. It is mandatory to analyze the whole pelvic ring for evaluation of pelvic stability and for making treatment decisions. The primary diagnostics are made using plain X‑radiography; however, for assessment of the posterior pelvic ring an examination using sectional imaging is regularly necessary. The fragility fractures of the pelvis (FFP) classification is suitable as a guideline for the surgical treatment to be used. Stable fractures without relevant displacement after initial mobilization should be treated conservatively. Instability, failure of mobilization and persistent pain are, however, common reasons for surgical treatment. Fracture displacement determines if minimally invasive procedures for posterior and anterior pelvic ring stabilization are possible. Otherwise, complex open procedures such as spinopelvic fixation may be necessary.
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Affiliation(s)
- Christine Kons
- Klinik für Unfallchirurgie, Akademisches Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Kliniken Dr. Erler gGmbH, Kontumazgarten 4-19, 90429, Nürnberg, Deutschland
| | - Susanne Wicklein
- Klinikum Nürnberg, Universitätsklinik für Geriatrie, Paracelsus Medizinische Privatuniversität, Prof.-Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland
| | - Roland Biber
- Klinik für Unfallchirurgie, Akademisches Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Kliniken Dr. Erler gGmbH, Kontumazgarten 4-19, 90429, Nürnberg, Deutschland.
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Andresen JR, Prokop A, Wollny M, Radmer S, Schober HC, Andresen R. [Clinical outcome and revenue situation after conservative, interventional and surgical/osteosynthetic treatment of sacral insufficiency fractures]. Unfallchirurg 2020; 124:588-597. [PMID: 33301083 DOI: 10.1007/s00113-020-00932-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Insufficiency fractures of the sacrum are being detected increasingly more frequently, whereby their incidence will no doubt increase further as a result of the rise in life expectancy. OBJECTIVE The clinical appearance of sacral insufficiency fractures, the treatment approach taking into account the clinical outcomes and the DRG proceeds are discussed on the basis of clinical examples. PATIENTS AND METHODS Three female patients (average age 78.3 years) with sacral insufficiency fractures were admitted for inpatient treatment due to increasing disabling pain. Taking into account the clinical symptoms and the recommendation of an interdisciplinary case conference, one patient was treated conservatively with short-term bed rest, accompanying analgesic medication and pain-adapted exercise measures. The second patient underwent computed tomography (CT)-guided balloon sacroplasty. Transsacroiliac screw fixation was performed on the third patient. Pain was documented over the course on a visual analogue scale (VAS) and the degree of independence on the Barthel scale. The fractures were classified according to Denis et al. and the classification of the FFP according to Rommens and Hofmann. The DRG revenue for the 2020 accounting period was then presented for each case. RESULTS Patient No. 1: conservative therapy, unilateral Denis 1 fracture zone, corresponding to an FFP type IIa, baseline pain 7 score points, at discharge 4 score points, the Barthel scale increased from 55 to 75 points. After 6 days hospitalization, transferred to rehab. The DRG proceeds were € 3817.95. Patient No. 2: balloon sacroplasty, bilateral Denis 1-2 fracture zone, corresponding to an FFP type IIa, baseline pain 9 score points, at discharge 2 score points, the Barthel scale increased from 35 to 95 points. After 4 days hospitalization, discharged to outpatient follow-up treatment. The DRG proceeds were € 7409.44. Patient No. 3: osteosynthesis, bilateral Denis 1 fracture zone, corresponding to an FFP type IIa, baseline pain 7 score points, at discharge 2 score points, the Barthel scale increased from 40 to 90 points. After 5 days hospitalization, transferred to rehab. The DRG proceeds were € 6714.30. CONCLUSION The sacral insufficiency fracture is a strong indicator for the presence of manifest osteoporosis. Fracture risk factors are the female sex, advanced age, the presence of osteoporosis and vitamin D deficiency. Conservative therapy is the first step of the treatment cascade; however, in patients with persistent, disabling pain and no potential for mobilization, sacroplasty or osteosynthesis should be performed at an early stage. In patients treated with coordinated therapy processes and without clinical complications, all three treatment options are economically sufficient.
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Affiliation(s)
- Julian Ramin Andresen
- Fakultät für Medizin, Sigmund-Freud-Privatuniversität, Freudplatz 3, 1020, Wien, Österreich.
| | - Axel Prokop
- Klinik für Unfallchirurgie, Klinikum Sindelfingen-Böblingen, Akademisches Lehrkrankenhaus der Universität Tübingen, Sindelfingen, Deutschland
| | | | - Sebastian Radmer
- Zentrum für Bewegungsheilkunde, Facharztpraxis für Orthopädie, Berlin, Deutschland
| | - Hans-Christof Schober
- Klinik für Innere Medizin IV, Klinikum Südstadt Rostock, Akademisches Lehrkrankenhaus der Universität Rostock, Rostock, Deutschland
| | - Reimer Andresen
- Institut für Diagnostische und Interventionelle Radiologie/Neuroradiologie, Westküstenklinikum Heide, Akademisches Lehrkrankenhaus der Universitäten Kiel, Lübeck und Hamburg, Heide, Deutschland
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