Pelvic Ring Fractures: A Biomechanical Comparison of Sacral and Lumbopelvic Fixation Techniques

BACKGROUND CONTEXT

Pelvic ring fractures are becoming more common in the aging population and can prove to be fatal, having mortality rates between 10% and 16%. Stabilization of these fractures is challenging and often require immediate internal fixation. Therefore, it is necessary to have a biomechanical understanding of the different fixation techniques for pelvic ring fractures.

METHODS

A previously validated three-dimensional finite element model of the lumbar spine, pelvis, and femur was used for this study. A unilateral pelvic ring fracture was simulated by resecting the left side of the sacrum and pelvis. Five different fixation techniques were used to stabilize the fracture. A compressive follower load and pure moment was applied to compare different biomechanical parameters including range of motion (contralateral sacroiliac joint, L1-S1 segment, L5-S1 segment), and stresses (L5-S1 nucleus stresses, instrument stresses) between different fixation techniques.

RESULTS

Trans-iliac-trans-sacral screw fixation at S1 and S2 showed the highest stabilization for horizontal and vertical displacement at the sacral fracture site and reduction of contralateral sacroiliac joint for bending and flexion range of motion by 165% and 121%, respectively. DTSF (Double transiliac rod and screw fixation) model showed highest stabilization in horizontal displacement at the pubic rami fracture site, while the L5_PF_W_CC (L5-Ilium posterior screw fixation with cross connectors) and L5_PF_WO_CC (L5-Ilium posterior screw fixation without cross connectors) showed higher rod stresses, reduced L1-S1 (approximately 28%), and L5-S1 (approximately 90%) range of motion.

CONCLUSIONS

Longer sacral screw fixations were superior in stabilizing sacral and contralateral sacroiliac joint range of motion. Lumbopelvic fixations displayed a higher degree of stabilization in the horizontal displacement compared to vertical displacement of pubic rami fracture, while also indicating the highest rod stresses. When determining the surgical approach for pelvic ring fractures, patient-specific factors should be accounted for to weigh the advantages and disadvantages for each technique.

Quality of Life from Return to Work and Sport Activities to Sexual Dysfunction after Surgical Treatment of Pelvic Ring Fractures

BACKGROUND

Pelvic ring fractures are life-threatening injuries that have a severe impact on patients' lives. The aim of this clinical study was to evaluate the outcome of surgical treatment in terms of Quality of Life (QoL), return to work, functional results and sport activities, and post-operative sexual dysfunction.

METHODS

A retrospective study with patients retrieved from a Level 1 Trauma Center was performed. Minimum patient follow-up was 12 months: QoL was evaluated with the SF-12 (Short Form Survey) questionnaire, return to work with the Workplace Activity Limitation Survey (WALS), functional outcomes and sport activities with the Harris Hip Score and Tegner activity score, respectively, and sexual function damage with a 0-10 NRS.

RESULTS

Seventy-six patients (41 males and 35 females) were enrolled, with a mean age at surgery of 56.4 years (18-89 years). Overall, their quality of life remained significantly affected, with male patients reporting worse WALS outcomes (p = 0.036), sexual damage (p = 0.001), and SF-12 Bodily Pain (p = 0.046) than females. In particular, 70.7% of men and 45.7% of women reported sexual limitations, and only 53.7% returned to their job, with 35.2% losing their job as a consequence of the pelvic ring disruption.

CONCLUSIONS

An important deterioration in general health state, return to work, and sexual function was documented in patients treated surgically for pelvic trauma, especially in male patients. There are disabling secondary sequels at all levels beyond the mere functional scores, and both patients and clinicians should be aware and have the correct expectations.

Outcomes at 2 years follow-up of sacral fractures associated with unstable vertical pelvic ring injuries in obese patients: a multicentric retrospective study

BACKGROUND AND AIM

Sacral fractures with concomitant unstable pelvic ring injuries are severe conditions which occur in patients involved in high-energy trauma. When operative treatment is required, high surgical experience on the field is mandatory, especially in a sub-polpulation of obese patients which have increased risk of complications. The aim of this multicentric retroscpective study was to describe and analyze clinical and radiological outcomes of sacral vertical fractures in obese patients with a minimum of 2 years follow-up.   Methods: A total of 121 pelvic fractures admitted to Emergency Departments of three II level trauma centres from April 2015 to April 2021 were retrospectively reviewed. Demographics, injury mechanism, surgical data and complications were collected. The quality of life and the pelvic function were respectively measured by SF-12 questionnaires, Denis Work Scale and Majeed Score. The inter-rater agreement between the clinical scores and the Denis Work Scale was assessed.   Results: A total of 19 patients were included in the study. The average follow up was 41.16 months. The average BMI was 38.63 and the mean abdominal circumference was 128.10 cm. The average Majeed and SF-12 scores were respectively 66.47 and 74.32. Five patients were able to return to their previous employment. The post traumatic life's quality and related dysfunctions are influenced by the high BMI.   Conclusions: Faster recovery and early weight-bearing should be persued in order to minimize complications, expecially in obese patients. In these sample of patients, "triangular osteosynthesis" was the best treatment choice for sacral vertical fractures.

Transiliac Cerclage in Unstable Pelvic Ring Fractures

BACKGROUND

To evaluate the outcomes of transiliac cerclage with Dall-Miles cable in the internal fixation of the posterior complex in unstable pelvic ring fractures between January 1995 and December 2014.

MATERIAL AND METHODS

A study of 42 men injured at work with an average age of 35.2 years (range, 23 to 61) was conducted. The mechanisms of injury were traffic accidents in 25 cases (59.5%), crushing accidents in 12 cases (28.6%), and fall from height in 5 cases (11.9%). Thirty-six cases were polytraumatized patients (85.7%). The patients were evaluated using Majeeds functional score and Mattas radiological criteria.

RESULTS

The average follow-up time was 135.8 45.6 months. The clinical outcomes were excellent in 17 cases (40.5%), good in 19 cases (45.2%), fair in 5 cases (11.9%), and poor in 1 case (2.4%). The radiological outcomes were satisfactory in 32 cases (76.2%) and unsatisfactory in 10 cases (23.8%). All fractures were healed. The sequelae were 3 cases (7.2%) of lower limb dysmetria and 3 cases (7.2%) of chronic neuropathic pain.

CONCLUSION

The internal fixation of the sacroiliac complex by Dall-Miles cable cerclage reinforced with small fragment plates should be considered as an alternative method for minimally invasive osteosynthesis in selected cases of unstable pelvic ring fractures.

Pelvic Ring Injury Mortality: Are We Getting Better?

OBJECTIVES

To determine if changes in pelvic trauma care and treatment protocols have affected overall mortality rates after pelvic ring injury.

DESIGN

Retrospective cohort study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

A total of 3314 patients with pelvic ring injuries who presented to a single referral center from 1999 to 2018 were included in the study.

INTERVENTION

Pelvic ring management, years 1999-2006 versus years 2007-2018.

MAIN OUTCOME MEASUREMENTS

In hospital mortality. Other examined variables included change in patient demographics, fracture characteristics, date of injury, associated injuries, length of hospital stay, Abbreviated Injury Severity Score.

RESULTS

The composite mortality rate was 6.5% (214/3314). The earliest cohort presented a mortality rate of 9.1% [111/1224; 95% confidence interval (CI), 7.6%-10.8%] compared with the more recent cohort mortality rate of 4.9% (103/2090; 95% CI, 4.1%-5.9%). Overall mortality was significantly lower in the more recent period, a risk difference of 4.1% (95% CI, 2.3%-6.1%; P < 0.01). After adjusting for age and Abbreviated Injury Severity Score of the brain, chest, and abdomen, the mortality reduction was more pronounced with an adjusted risk difference of 6.4% (95% CI, 4.7%-8.1%; P < 0.01).

CONCLUSION

Significant improvement in the mortality rate of pelvic ring injuries has been demonstrated in recent years (4.9% vs. 9.1%) and the difference is even large when accounting for known confounders. Improvement appears to coincide chronologically with changes in trauma resuscitation and implementation of adjuvant treatments for managing patients with severe hemorrhagic shock. Although the exact benefit of each treatment awaits further research, these data might indicate improved care over time for these difficult patients.

LEVEL OF EVIDENCE

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

Navigated percutaneous screw fixation of the pelvis with O-arm 2: two years' experience

Aim To evaluate the case series of the patients operated with percutaneous fixation by the navigation system based on 3D fluoroscopic images, to assess the precision of a surgical implant and functional outcome of patients. Methods A retrospective study of pelvic ring fractures in a 2-year period included those treated with the use of the O-Arm 2 in combination with the Stealth Station 8. Pelvic fractures were classified according to the Tile and the Young-Burgess classification. All patients were examined before surgery, with X-rays and CT scans, and three days after surgery with additional CT scan. The positioning of the screws was evaluated according to the Smith score, the outcome with the SF-36. Results Among 24 patients 18 were with B and six with C type fracture according to Tile, while eight were with APC, 10 LC, and six with VS type according to Young-Burgess classification. All patients were treated in the supine position, except two. A total of 41 iliosacral or transsacral screws and five anterior pelvic ring screws were implanted. The medium surgical time per screw was 41 minutes. There was a perfect correspondence of screw scores value from post-operative CT and intraoperative fluoroscopy. The mean screw score value was 0.92. There were no cases of poor positioning. The median follow-up was 17.5 months. The patients were satisfied with their health condition on SF-36. Conclusion The use of the O-arm guarantees great precision in the positioning of the screws and reduced surgical times with excellent clinical results in patients.

Minimally Invasive Surgery for Unstable Pelvic Ring Fractures: Transiliac Rod and Screw Fixation

Pelvic fractures occur with high-energy trauma, and the patient's clinical status is unstable. Although a number of surgical methods for unstable pelvic fractures are available, none can achieve strong fixation with minimal invasiveness. We describe a surgical transiliac rod and screw fixation (TIF) procedure that provides minimally invasive fixation using a spinal implant for unstable pelvic ring fractures, and we retrospectively analyzed the procedure's outcomes in 27 patients with type B or C1 fractures (based on the AO/ATO classification system). Small skin incisions are made above the posterior superior iliac spines on both sides. The ilium is partially resected, and two iliac screws are inserted on each side. The spinous process of the sacral spine is then shaved, and the iliac screws are connected to 2 rods, one placed caudal to the other. Corrective manipulation is performed at the fracture site, and the rods are connected with connectors. Favorable fracture reduction, defined as a rating of 'excellent' or 'good,' was achieved in 77.8% of the patients. Transiliac rod and screw fixation (TIF) will be a useful therapeutic option for unstable pelvic ring fractures.

Pelvic ring fractures in the elderly

Pelvic ring fractures are rare injuries in the elderly though the incidence is increasing due to the increasing age of the population.

Main goal of treatment is the quickest possible re-mobilization to prevent side-effects of immobilization such as osteopenia, pulmonary infections or thromboembolic events.

Isolated anterior pelvic ring fractures are stable injuries and therefore they usually can be treated conservatively, while pelvic ring injuries with involvement of the posterior ring are considered unstable and should undergo surgical stabilization if the patient’s condition allows for it.

Conservative treatment includes adequate analgesia, guided mobilization with partial weight bearing if possible and osteoanabolic medication.

The appropriate surgical procedure should be discussed in an interdisciplinary round considering patient’s pre-injury condition, anaesthetic and surgical risks.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180062

In-hospital mortality of pelvic ring fractures in older adults now and then: A pelvic registry study

AIM

With the predicted demographic change, the treatment of geriatric patients will become a major issue for health systems worldwide. The majority of pelvic ring fractures occur in older adults, and their treatment might be associated with a distinct mortality. Herein, we analyzed the data of 5665 patients with pelvic ring fractures aged ≥60 years included in the German Pelvic Trauma Registry from 1991 to 2013.

METHODS

The data were collected prospectively, multicentrically in hospitals participating in the German Pelvic Trauma Registry. Demographic data were retrospectively analyzed, stratified for age, sex, type of injury, mode of therapy, injury severity score (ISS) and mortality.

RESULTS

The overall mortality decreased over the 22-year study period from 9.3% to 3.8% (P < 0.05), whereas the median ISS significantly increased. During the observation period, mortality was higher in patients with type B and, particularly, type C fractures when compared with patients with type A fractures. Mortality rates of patients aged >80 years did not significantly differ from those aged >60 or >70 years. Male patients showed a significantly higher mortality compared with female patients, as well as a significantly higher median ISS. The mortality rate of patients with surgically-treated type C fractures decreased over the study period from 35.7% to 6.9% (P < 0.05).

CONCLUSIONS

Over the past two decades, the mortality of older patients after pelvic ring fractures has significantly decreased. The higher overall mortality rate of male patients might mainly be accounted for by the relatively higher fraction of type C fractures and a higher ISS. Geriatr Gerontol Int 2019; 19: 24-29.