Transiliac Osteotomy in Surgical Management of Pelvic Post-Traumatic Malunions: A Retrospective Study

Gradual Traction Reduction With the Ilizarov Method for Tile C1.2 Old Pelvic Fracture: A Case Report

CASE

A 20-year-old man with a Tile C1.2 pelvic fracture was treated with skeletal traction. After 3 months, the patient was unable to stand and walk, and the right lower limb was shortened by 7 cm. Radiographs showed that the sacroiliac joint dislocation was not reduced. Gradual traction reduction with the Ilizarov method was used to correct sacroiliac joint dislocation, and open internal fixation was performed. Postoperatively, the old pelvic fracture was successfully reduced without sacral plexus injury.

CONCLUSION

Gradual traction reduction with the Ilizarov method can reduce the risk of sacral plexus injury and achieve satisfactory reduction of Tile C1.2 old pelvic fractures.

Pelvic Malunion: A Systematic Review, Dichotomy of Definitions and Treatment

Background and Objectives: Pelvic nonunion and malunion have been documented as rare complications in pelvic fractures and literature describing these topics is severely limited. Articles dedicated solely to pelvic malunion are nearly nonexistent. We conducted a literature search with the goal of providing a summary of the definition, causes, treatment strategies, and outcomes of pelvic malunion correction. Materials and Methods: An initial review of the literature was performed using the PubMed, ScienceDirect, and Cochrane Database of Systematic Reviews databases. Search terms used were “malunion” AND “pelvic” OR “pelvis”. Duplicate articles, non-English language articles without translations available and non-human subject studies were excluded. Results: Eleven original publications were found describing experiences with pelvic malunion. Seven of the articles were exclusively dedicated to the topic of pelvic fracture malunion, and only two reported on a series of patients treated for malunion with variably staged procedures. Most reports define pelvic pain as the main indication for surgical correction, along with gait disturbance, standing or sitting imbalance, and urinary or sexual dysfunction. Radiographically, vertical displacement of one to two centimeters and rotation of the hemipelvis of fifteen degrees or more have been described in defining malunion. No treatment algorithms exist, and each patient is treated with a unique work-up and operative plan due to the complexity of the problem. Only one series reported a patient satisfaction rate of 75% following malunion treatment. Conclusions: Pelvic malunion is a rare complication of pelvic ring injury and is seldom discussed in the literature. We found two small case series reporting exclusively on malunion treatment and complications. While some of the combination studies made the distinction in the diagnosis of malunion and nonunion, they rarely differentiated the treatment outcomes between the two categories. This paper describes pelvic malunion and highlights the need for more research into surgical outcomes of treatment specifically regarding functionality, patient satisfaction, and recurrence of preoperative symptoms.

Pelvic post-traumatic asymmetry: Assessment and sequenced treatment

The most common cause of post-traumatic pelvic asymmetry is, by far, initial nonoperative treatment.

Open reduction and internal fixation of unstable pelvic fractures are recommended to avoid pelvic nonunion or subsequent structural deformities.

The most common symptom is pelvic pain. Pelvic instability is another symptom, as well as persistent urogenital problems and neurological sequelae.

Preoperative evaluation of these patients requires careful clinical and functional assessment, in addition to a complete radiological study.

Surgical treatment of pelvic fracture nonunions is technically demanding and has potentially serious complications.

We have developed a new classification that modifies and completes Mears and Velyvis’s classification in which we highlight two types of post-traumatic sequelae with different clinical conditions and whose basic differentiating element is whether pelvic deformity is present or not. Based on this classification, we have established our strategy of surgical treatment.

Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170069.

Three-dimensional reduction and finite element analysis improves the treatment of pelvic malunion reconstructive surgery: A case report

RATIONALE

Pelvic malunion is a rare complication and is technically challenging to correct owing to the complex three-dimensional (3D) geometry of the pelvic girdle. Hence, precise preoperative planning is required to ensure appropriate correction. Reconstructive surgery is generally a 2- or 3-stage procedure, with transiliac osteotomy serving as an alternative to address limb length discrepancy.

PATIENT CONCERNS

A 38-year-old female patient with a Mears type IV pelvic malunion with previous failed reconstructive surgery was admitted to our department due to progressive immobilization, increasing pain especially at the posterior pelvic arch and a leg length discrepancy. The leg discrepancy was approximately 4 cm and rotation of the right hip joint was associated with pain.

DIAGNOSIS

Radiography and computer tomography (CT) revealed a hypertrophic malunion at the site of the previous posterior osteotomy (Mears type IV) involving the anterior and middle column, according to the 3-column concept, as well as malunion of the left anterior arch (Mears type IV).

INTERVENTIONS

The surgery was planned virtually via 3D reconstruction, using the patient's CT, and subsequently performed via transiliac osteotomy and symphysiotomy. Finite element method (FEM) was used to plan the osteotomy and osteosynthesis as to include an estimation of the risk of implant failure.

OUTCOMES

There was not incidence of neurological injury or infection, and the remaining leg length discrepancy was ≤ 2 cm. The patient recovered independent, pain free, mobility. Virtual 3D planning provided a more precise measurement of correction parameters than radiographic-based measurements. FEM analysis identified the highest risk for implant failure at the symphyseal plate osteosynthesis and the parasymphyseal screws. No implant failure was observed.

LESSONS

Transiliac osteotomy, with additional osteotomy or symphysiotomy, was a suitable surgical procedure for the correction of pelvic malunion and provided adequate correction of leg length discrepancy. Virtual 3D planning enabled precise determination of correction parameters, with FEM analysis providing an appropriate method to predict areas of implant failure.