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Oberkircher L, Masaeli A, Bliemel C, Debus F, Ruchholtz S, Krüger A. Primary stability of three different iliosacral screw fixation techniques in osteoporotic cadaver specimens-a biomechanical investigation. Spine J 2016; 16:226-32. [PMID: 26282106 DOI: 10.1016/j.spinee.2015.08.016] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 07/09/2015] [Accepted: 08/11/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND The incidence of osteoporotic and insufficiency fractures of the pelvic ring is increasing. Closed reduction and percutaneous fixation with cannulated sacroiliac screws is well-established in the operative treatment of osteoporotic posterior pelvic ring fractures. However, osteoporotic bone quality might lead to the risk of screw loosening. For this reason, cement augmentation of the iliosacral screws is more frequently performed and recommended. PURPOSE The aim of the present biomechanical study was to evaluate the primary stability of three methods of iliosacral screw fixation in human osteoporotic sacrum specimens. STUDY DESIGN/SETTING This study used methodical cadaver study. METHODS A total of 15 fresh frozen human cadaveric specimens with osteoporosis were used (os sacrum). After matched pair randomization regarding bone quality (T-score), three operation technique groups were generated: screw fixation (cannulated screws) without cement augmentation (Group A); screw fixation with cement augmentation before screw placement (cannulated screws) (Group B); and screw fixation with perforated screws and cement augmentation after screw placement (Group C). In all specimens both sides of the os sacrum were used for operative treatment, resulting in a group size of 10 specimens per group. One operation technique was used on each side of the sacral bone to compare biomechanical properties in the same bone quality. Pull-out tests were performed with a rate of 6 mm/min. A load versus displacement curve was generated. RESULTS Subgroup 1 (Group A vs. Group B): Screw fixation without cement augmentation: 594.4 N±463.7 and screw fixation with cement augmentation before screw placement: 1,020.8 N±333.3; values were significantly different (p=.025). Subgroup 2 (Group A vs. Group C): Screw fixation without cement augmentation: 641.8 N±242.0 and perforated screw fixation with cement augmentation after screw placement: 1,029.6 N±326.5; values were significantly different (p=.048). Subgroup 3 (Group B vs. Group C): Screw fixation with cement augmentation before screw placement: 804.0 N±515.3 and perforated screw fixation with cement augmentation after screw placement: 889.8 N±503.3; values were not significantly different (p=.472). CONCLUSIONS Regarding iliosacral screw fixation in osteoporotic bone, the primary stability of techniques involving cement augmentation is significantly higher compared with screw fixation without cement augmentation. Perforated screws with the same primary stability as that of conventional screw fixation in combination with cement augmentation might be a promising alternative in reducing complications of cement leakage. These biomechanical results have to be transferred into clinical practice and prove their clinical value.
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Affiliation(s)
- Ludwig Oberkircher
- Philipps University Marburg, Marburg, Germany; Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg, Marburg, Germany.
| | - Adrian Masaeli
- Philipps University Marburg, Marburg, Germany; Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - Christopher Bliemel
- Philipps University Marburg, Marburg, Germany; Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - Florian Debus
- Philipps University Marburg, Marburg, Germany; Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - Steffen Ruchholtz
- Philipps University Marburg, Marburg, Germany; Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg, Marburg, Germany
| | - Antonio Krüger
- Philipps University Marburg, Marburg, Germany; Department of Trauma, Hand and Reconstructive Surgery, University Hospital Giessen and Marburg, Marburg, Germany
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Yoo JH, Moon SH, Ha YC, Lee DY, Gong HS, Park SY, Yang KH. Osteoporotic Fracture: 2015 Position Statement of the Korean Society for Bone and Mineral Research. J Bone Metab 2015; 22:175-81. [PMID: 26713308 PMCID: PMC4691591 DOI: 10.11005/jbm.2015.22.4.175] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 11/11/2022] Open
Abstract
Osteoporotic fractures are one of the most common causes of disability and a major contributor to medical care costs worldwide. Prior osteoporotic fracture at any site is one of the strongest risk factors for a new fracture, which occurs very soon after the first fracture. Bone mineral density (BMD) scan, a conventional diagnostic tool for osteoporosis, has clear limitations in diagnosing osteoporotic fractures and identifying the risk of subsequent fractures. Therefore, early and accurate diagnosis of osteoporotic fractures using the clinical definition which is applicable practically and independent of BMD, is essential for preventing subsequent fractures and reducing the socioeconomic burden of these fractures. Fractures caused by low-level trauma equivalent to a fall from a standing height or less at major (hip, spine, distal radius, and proximal humerus) or minor (pelvis, sacrum, ribs, distal femur and humerus, and ankle) sites in adults over age 50, should be first regarded as osteoporotic. In addition, if osteoporotic fractures are strongly suspected on history and physical examination even though there are no positive findings on conventional X-rays, more advanced imaging techniques such as computed tomography, bone scan, and magnetic resonance imaging are necessary as soon as possible.
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Affiliation(s)
- Je-Hyun Yoo
- Department of Orthopedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Seong-Hwan Moon
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul, Korea
| | - Dong Yeon Lee
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Sik Gong
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Si Young Park
- Department of Orthopaedic Surgery, Korea University College of Medicine, Seoul, Korea
| | - Kyu Hyun Yang
- Department of Orthopedic Surgery, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
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Lustenberger T, Wutzler S, Störmann P, Laurer H, Marzi I. The role of angio-embolization in the acute treatment concept of severe pelvic ring injuries. Injury 2015; 46 Suppl 4:S33-8. [PMID: 26542864 DOI: 10.1016/s0020-1383(15)30016-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND In recent years a wide variety of strategies to treat the haemodynamically unstable patient with pelvic ring fractures have been proposed. This study evaluates our institutional management of patients with severe pelvic fractures and analyses their outcomes. METHODS Retrospective review of all severely injured trauma patients with pelvic ring injuries admitted to a level I trauma centre from 2007 to 2012. Patient records were documented prospectively in a trauma database and evaluation was performed by SPSS. RESULTS During the study period, a total of 173 patients with pelvic ring fractures were admitted and formed the basis of this study. Overall, 46% of the patients had suffered a type A fracture, 25% a type B fracture and the remaining 29% a type C pelvic ring fracture. Surgical treatment was required in 21% of the patients (pelvic C-clamp, n = 6; supra-acetabular external fixator, n = 32; pelvic packing, n = 12; definitive plate osteosynthesis of the pubis symphysis, n = 6). Angio-embolization was performed in 16 patients (9%); in 8 patients it was the only specific treatment for the pelvic injury on day 0 and in 8 patients it was performed immediately post-operatively. The overall mortality rate was 12.7% (n = 22), with the type C pelvic fractures having the highest mortality (30.0%). Four patients died immediately after admission in the shock room. CONCLUSIONS Angiographic embolization as a first-line treatment was only performed in haemodynamically stable patients or in patients responding to fluid resuscitation with the finding of an arterial blush in the CT scan. In haemodynamically unstable patients, pre-peritoneal pelvic packing in combination with mechanical pelvic stabilization was immediately carried out, followed by angio-embolization post-operatively if signs of persistent bleeding remained present.
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Affiliation(s)
- Thomas Lustenberger
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Frankfurt, Germany.
| | - Sebastian Wutzler
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Philip Störmann
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Helmut Laurer
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt am Main, Frankfurt, Germany
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Grüneweller N, Wähnert D, Raschke MJ, Fuchs T. [Implant augmentation in pelvic surgery. Options and technique]. Unfallchirurg 2015; 118:831-7. [PMID: 26341619 DOI: 10.1007/s00113-015-0058-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Osteoporotic fractures of the pelvis are an increasing problem in trauma surgery. Sufficient implant anchorage is reduced due to the poor bone stock; however, early mobilization is especially necessary for geriatric patients in order to prevent additional complications. MATERIAL AND METHODS Implant augmentation may be one technique to increase implant anchorage and stability in osteoporotic bone. This procedure is currently used in the treatment of osteoporotic fractures of the dorsal pelvic ring. Beside the augmentation of iliosacral screws in the treatment of sacral insufficiency fractures, cement augmentation with lumbar or sacral pedicle screws is used for increased stability. INDICATIONS AND RISKS Implant augmentation in pelvic surgery should be indicated crucially due to the specific risks of the procedure. Cement leakage and heat generation during cement curing (when PMMA--polymethylmetacrylate--cement is used) can compromise neurovascular structures. Potential complications like cement embolism are possible. CONCLUSION The use of special implants (cannulated and perforated screws) as well as intraoperative navigation and 3D imaging increase patient safety and help to make implant augmentation a low risk procedure.
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Affiliation(s)
- N Grüneweller
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - D Wähnert
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - M J Raschke
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland.
| | - T Fuchs
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
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Bastian JD, Bergmann M, Schwyn R, Keel MJB, Benneker LM. Assessment of the Breakaway Torque at the Posterior Pelvic Ring in Human Cadavers. J INVEST SURG 2015; 28:328-33. [PMID: 26270866 PMCID: PMC4732422 DOI: 10.3109/08941939.2015.1016249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Purpose: To enhance the diminished screw purchase in cancellous, osteoporotic bone following the fixation of posterior pelvic ring injuries by iliosacral screws an increased bone-implant contact area using modificated screws, techniques or bone cement may become necessary. The aim of the study was to identify sites within the pathway of iliosacral screws requiring modifications of the local bone or the design of instrumentations placed at this site. Materials and Methods: The breakaway torque was measured mechanically at the iliosacral joint (“ISJ”), the sacral lateral mass (“SLM”) and the center of the S1 (“CS1”), at a superior and an inferior site under fluoroscopic control on five human cadaveric specimens (3 female; mean age 87 years, range: 76–99) using the DensiProbe™Spine device. Results: The measured median (range) breakaway torque was 0.63 Nm (0.31–2.52) at the “iliosacral joint”, 0.14 Nm (0.05–1.22) at the “sacral lateral mass”, 0.57 Nm (0.05–1.42) at the “S1 center.” The “sacral lateral mass” breakaway torque was lower than compared to that at the “iliosacral joint” (p < .001) or “S1 center” (p < .001). The median (range) breakaway torque measured at all superior measurement points was 0.52 Nm (0.10–2.52), and 0.48 Nm (0.05–1.18) at all inferior sites. The observed difference was statistically significant (p < .05). Conclusions: The lateral mass of the sacrum provides the lowest bone quality for implant anchorage. Iliosacral screws should be placed as superior as safely possible, should bridge the iliosacral joint and may allow for cement application at the lateral mass of the sacrum through perforations.
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Affiliation(s)
| | | | | | | | - Lorin Michael Benneker
- a Department of Orthopaedic and Trauma Surgery, Inselspital , University of Bern , Switzerland
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Arduini M, Saturnino L, Piperno A, Iundusi R, Tarantino U. Fragility fractures of the pelvis: treatment and preliminary results. Aging Clin Exp Res 2015; 27 Suppl 1:S61-7. [PMID: 26264247 DOI: 10.1007/s40520-015-0430-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 07/14/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND With increasing life expectancy, fragility fractures of the pelvic ring (FFP) are becoming frequent. In elderly, osteoporosis leads to a decrease of bone strength and resistance to the ligament's traction; this represents the most important difference between FFP and fractures in young patients. Usually, these fractures are underestimated and treatment is often conservative. AIMS To evaluate clinical and surgical outcomes of surgically treated patients with FFP. METHODS We retrospectively enrolled 14 patients, in our Trauma Center, underwent surgery procedures for FFP between 2012 and 2014. All patients attended clinical and radiological investigation at 1, 3, and 6 months postoperatively and every year after surgery with a mean follow-up of 22 months. RESULTS At 6-month follow-up, 11 patients resulted asymptomatic: able to maintain standing position and walk without crunches. Two patients were able to walk with one crunch. The patient with history of previous acetabular fracture walks with two crunches and is still waiting for total hip arthroplasty. DISCUSSION The compromised health status and the diminished bone-healing capacity, in elderly, decrease chances for a good clinical outcome. In literature, many authors suggest that mortality rate in patients with FFP is similar to those with hip fracture. Diagnosis of FFP is very important: these fractures are highly disabling in elderly and can lead to displacement and instability. For these reasons, correct diagnosis and well-conduct preoperative plan are necessary to improve stability of fractures and support bone healing. After diagnosis, an anti-osteoporotic treatment is indicated to improve bone quality and bone healing. CONCLUSIONS Our study shows encouraging results and demonstrates that minimally or less invasive osteosynthesis technique could lead to good outcome in these patients.
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Affiliation(s)
- M Arduini
- Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, "Policlinico Tor Vergata" Foundation, Rome, Italy.
| | - L Saturnino
- Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - A Piperno
- Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - R Iundusi
- Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, "Policlinico Tor Vergata" Foundation, Rome, Italy
| | - U Tarantino
- Department of Orthopaedics and Traumatology, University of Rome Tor Vergata, "Policlinico Tor Vergata" Foundation, Rome, Italy
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Vigdorchik JM, Jin X, Sethi A, Herzog DT, Oliphant BW, Yang KH, Vaidya R. A biomechanical study of standard posterior pelvic ring fixation versus a posterior pedicle screw construct. Injury 2015; 46:1491-6. [PMID: 25986670 DOI: 10.1016/j.injury.2015.04.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 01/29/2015] [Accepted: 04/25/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to biomechanically test a percutaneous pedicle screw construct for posterior pelvic stabilisation and compare it to standard fixation modalities. METHODS Utilizing a sacral fracture and sacroiliac (SI) joint disruption model, we tested 4 constructs in single-leg stance: an S1 sacroiliac screw, S1 and S2 screws, the pedicle screw construct, and the pedicle screw construct+S1 screw. We recorded displacement at the pubic symphysis and SI joint using high-speed video. Axial stiffness was also calculated. Values were compared using a 2-way ANOVA with Bonferroni adjustment (p<0.05). RESULTS In the sacral fracture model, the stiffness was greatest for the pedicle screw+S1 construct (p<0.001). There was no significant difference between the pedicle screw construct and S1 sacroiliac screw (p=1). For the SI joint model, the S1+S2 SI screws had the largest overall load and stiffness (p<0.001). The S1 screw was significantly stronger than pedicle screw construct (p=0.001). CONCLUSIONS The pedicle screw construct biomechanically compares to currently accepted methods of fixation for sacral fractures when the fracture is uncompressible. It should not be used for SI joint disruptions as one SI or an S1+S2 are significantly stiffer and cheaper.
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Affiliation(s)
- Jonathan M Vigdorchik
- Department of Orthopedic Surgery, Detroit Receiving Hospital, Detroit Medical Center, 4201 St. Antoine Blvd., Suite 4G, Detroit, MI 48201, United States
| | - Xin Jin
- Department of Biomedical Engineering, Wayne State University, 818 West Hancock, Detroit, MI 48201, United States
| | - Anil Sethi
- Department of Orthopedic Surgery, Detroit Receiving Hospital, Detroit Medical Center, 4201 St. Antoine Blvd., Suite 4G, Detroit, MI 48201, United States.
| | - Darren T Herzog
- Department of Orthopedic Surgery, Detroit Receiving Hospital, Detroit Medical Center, 4201 St. Antoine Blvd., Suite 4G, Detroit, MI 48201, United States
| | - Bryant W Oliphant
- Department of Orthopedic Surgery, Detroit Receiving Hospital, Detroit Medical Center, 4201 St. Antoine Blvd., Suite 4G, Detroit, MI 48201, United States
| | - King H Yang
- Department of Biomedical Engineering, Wayne State University, 818 West Hancock, Detroit, MI 48201, United States
| | - Rahul Vaidya
- Department of Orthopedic Surgery, Detroit Receiving Hospital, Detroit Medical Center, 4201 St. Antoine Blvd., Suite 4G, Detroit, MI 48201, United States
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Percutaneous iliosacral screw fixation after osteoporotic posterior ring fractures of the pelvis reduces pain significantly in elderly patients. Injury 2015; 46:1631-6. [PMID: 26052052 DOI: 10.1016/j.injury.2015.04.036] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 02/03/2015] [Accepted: 04/25/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Osteoporotic posterior ring fractures of the pelvis are common injuries in the elderly, but the treatment of these fractures still remains controversial. Percutaneous iliosacral screw fixation is one surgical option if conservative treatment cannot provide sufficient pain reduction. The aim of this study is to provide short-term results of elderly patients with percutaneous screw fixation. METHODS 30 patients with posterior ring fractures were treated between 12/2009 and 01/2014 with percutaneous iliosacral screw fixation. Patients' mean age was 78.4 years. Concerning short-term outcome, we focused on initial pain level and postoperative pain reduction together with intra- and postoperative complications. RESULTS The average hospital stay was 23.7 days, with surgical treatment performed after an average of 9.2 days. 90% of our patients were female. All 30 patients had a lower level of pain at discharge compared with admission or immediately prior to surgery. The difference in pain level at admission compared with the pain level upon discharge showed a mean reduction from 6.8 to 1.8 with a statistically significant change (P≤0.001). 24 of 30 patients had no registered complications, one screw malpositioning with postoperative nerve irritation occurred. DISCUSSION Conventional percutaneous iliosacral screw fixation is a successful operative treatment for elderly patients with persistent lower back pain after unstable posterior ring fractures of the pelvis. Intra- and postoperative complications are rare, so this treatment can be regarded as a safe procedure. LEVEL OF EVIDENCE IV (retrospective study).
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Wagner D, Ossendorf C, Gruszka D, Hofmann A, Rommens PM. Fragility fractures of the sacrum: how to identify and when to treat surgically? Eur J Trauma Emerg Surg 2015; 41:349-62. [PMID: 26038048 PMCID: PMC4523697 DOI: 10.1007/s00068-015-0530-z] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/07/2015] [Indexed: 12/29/2022]
Abstract
The increasing prevalence of fragility fractures of the sacrum (FFS) occurring predominantly in osteoporotic individuals poses a diagnostic and therapeutic challenge. The clinical presentation varies from longstanding low back pain without the patient remembering a traumatic event to immobilized patients after suffering a low-energy trauma. FFS are often combined with a fracture of the anterior pelvic ring; hence they are classified as a part of fragility fractures of the pelvis (FFP). If not displaced, the patients are treated with weight bearing as tolerated and analgesics; however, we advocate to treat displaced fractures surgically according to the fracture personality and the patient’s comorbidities. Surgical options include minimal invasive sacro-iliac screws, trans-sacral bar osteosynthesis, open reduction and internal fixation, or spinopelvic stabilization. In the light of the high complication rate associated with immobilized patients, an operative approach often is indicated to accelerate the patient’s mobility.
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Affiliation(s)
- D Wagner
- Department of Orthopaedics and Traumatology, University Medical Centre, Johannes Gutenberg-University Mainz, Langenbeckstr. 1, 55131, Mainz, Germany,
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Kanezaki S, Rommens PM. Bilateral nonunion of the sacrum in a long-term paraplegic patient treated with trans-sacral bar and spinopelvic fixation. Arch Orthop Trauma Surg 2015; 135:345-9. [PMID: 25559304 DOI: 10.1007/s00402-014-2143-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Indexed: 12/27/2022]
Abstract
The incidence of fragility fractures of the pelvis is sharply increasing in accordance with growing life expectancy in developed countries. Numerous conditions may compromise bone density and quality, and paraplegia due to spinal cord injury is one of them. As screw anchorage is often problematic in poor bone stock, spinopelvic dissociation demands a type of osteosynthesis, which is less dependent on the density of trabecular bone. We present a case of a paraplegic 45-year-old man, with non-displaced bilateral nonunion of the sacrum. The patient was treated with trans-sacral bar and spinopelvic fixation. Rapid relief from pain and functional recovery was achieved with complete bone healing 1 year after the operation.
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Affiliation(s)
- Shozo Kanezaki
- Department of Orthopaedics and Traumatology, University Medical Center, Johannes Gutenberg-University, Langenbeckstrasse 1, 55131, Mainz, Germany,
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Nüchtern JV, Hartel MJ, Henes FO, Groth M, Jauch SY, Haegele J, Briem D, Hoffmann M, Lehmann W, Rueger JM, Großterlinden LG. Significance of clinical examination, CT and MRI scan in the diagnosis of posterior pelvic ring fractures. Injury 2015; 46:315-9. [PMID: 25527459 DOI: 10.1016/j.injury.2014.10.050] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2014] [Revised: 05/29/2014] [Accepted: 10/14/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Patients with a fracture in the anterior pelvic ring often simultaneously demonstrate pain in the posterior pelvic ring. The aim of the present prospective study was to assess the sensitivity of CT, MRI and clinical examination in the detection of fractures in the posterior pelvic ring in patients with fractures of the anterior pelvic ring diagnosed in conventional radiographs. METHODS Sixty patients with radiographic signs of an anterior pelvic ring injury were included in this prospective analysis. Following a focused clinical examination of the posterior pelvis, all patients underwent both a CT and then a MRI scan of their pelvis. Two board certified radiologists evaluated the CT and MRI scans independently. To estimate the presence of osteoporosis the Hounsfield units of the vertebral body of L5 were measured in each case. RESULTS Fifty-three women and seven men, with a mean age of 74.7+/-15.6 years were included into the study. A fracture of the posterior pelvic ring was found in fourty-eight patients (80%) patients using MRI. Fractures of the posterior pelvic ring would have been missed in eight cases (17%), if only CT had been used. Eighty-five percent of the patients with a posterior fracture had an osteoporosis. The majority of the cases suffered from a low energy trauma. Thirty-eight patients (83%) with positive clinical signs at the posterior pelvic ring actually had a fracture of the posterior pelvic ring in the MRI. The clinical examination proved to be equally effective to CT in detecting posterior pelvic ring fractures. CONCLUSION The significance of both, clinical examination and CT was confirmed in the detection of fractures in the posterior pelvic ring. MRI examination of the pelvis however, was found to be superior in detecting undislocated fractures in a cohort of patients with a high incidence of osteoporosis. Using MRI may be beneficial in select cases, especially when reduced bone density is suspected.
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Affiliation(s)
- J V Nüchtern
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
| | - M J Hartel
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - F O Henes
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - M Groth
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - S Y Jauch
- Institute of Biomechanics, TUHH Hamburg University of Technology, Denickestrasse 15, 21079 Hamburg, Germany
| | - J Haegele
- Clinic for Radiology and Nuclear Medicine, University Hospital Schleswig Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - D Briem
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - M Hoffmann
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - W Lehmann
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - J M Rueger
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - L G Großterlinden
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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Zheng Z, Wu W, Yu X, Pan J, Latif M, Hou Z, Zhang Y. Axial view of acetabular anterior column: a new X-ray projection of percutaneous screw placement. Arch Orthop Trauma Surg 2015; 135:187-192. [PMID: 25450306 DOI: 10.1007/s00402-014-2127-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION To search for a new radiographic view/projection of the acetabular anterior column to provide a safe guide for percutaneous screw placement for acetabular fractures. MATERIALS AND METHODS Eight pelvic specimens taken from normal adult cadavers were positioned in a supine position on the operating table. First, the ipsilateral ilium-oblique view of the observed side was obtained on C-arm fluoroscopy by tilting the C-arm approximately 35° toward the contralateral hip joint. Then, the tilting angle of the C-arm was changed gradually until an oval track image (acetabular anterior column axial view) appeared. The oval shadow was clear only in one position as the angle of the C-arm was changed toward the caudal side of the operating table. A guide pin was put on the skin of the cadaver, and the location and tilting direction of the guide pin were adjusted under C-arm fluoroscopy until the pin's shadow became a point in the center of the oval track. Then, the guide pin was inserted into the bone using a battery-powered drill. The degree of inclination of the guide pin in the cadaver in the frontal and sagittal planes was measured using computed tomography (CT). RESULTS Axial views of the anterior column were found successfully in all of the pelvic specimens, and the guide pins were inserted accurately into the acetabular anterior column under C-arm fluoroscopic guidance. On the CT-reconstructed image, the average degree of angle between the guide pin and the sagittal plane was 33.6° (range 29.6°-36.5°). The average angle between the guide pin and the transverse plane was 59.1° (range 56.4°-63.2°). CONCLUSION This axial view of the acetabular anterior column is a novel X-ray projection which provides an optimal method for guiding percutaneous insertion of anterior column screws for acetabular fractures.
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Affiliation(s)
- Zhanle Zheng
- Orthopedics Trauma Center, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 86-050051, China
| | - Wenjuan Wu
- Department of Radiology, The Third Hospital of Hebei Medical University, Shijiazhuang, 86-050051, China
| | - Xian Yu
- Department of Endocrinology, The General Hospital of Hebei Province, Hebei Medical University, Shijiazhuang, 86-050051, China
| | - Jinshe Pan
- Orthopedics Trauma Center, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 86-050051, China
| | - Mahrukh Latif
- Department of Radiology, The Third Hospital of Hebei Medical University, Shijiazhuang, 86-050051, China
| | - Zhiyong Hou
- Orthopedics Trauma Center, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 86-050051, China
| | - Yingze Zhang
- Orthopedics Trauma Center, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 86-050051, China.
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63
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Lustenberger T, Wutzler S, Störmann P, Marzi I. The Role of Pelvic Packing for Hemodynamically Unstable Pelvic Ring Injuries. ACTA ACUST UNITED AC 2015. [DOI: 10.4137/cmtim.s12257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In patients with severe pelvic fractures, exsanguinating hemorrhage represents the major cause of death within the first 24 hours. Recently, multiple management algorithms have been proposed; however, the optimal treatment modalities, in particular, in the hemodynamically unstable patient with pelvic fracture are still a matter of debate. Mechanical pelvic stabilization by pelvic binder, anterior external fixator, and/or pelvic C-clamp constitutes the first treatment option in the hemodynamically unstable patient with pelvic fractures. The mechanically stabilized pelvic ring provides the basis for pelvic packing through a minimal extraperitoneal approach, which effectively controls venous bleeding and bleeding from the fractured bony surface. Patients with persistent hypotension and/or transfusion requirements should undergo angiography and selective embolization for definitive arterial control if necessary. This review article describes the current trend in the initial management of patients with pelvic fractures and hemodynamic instability, and focuses on the role of pelvic packing.
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Affiliation(s)
- Thomas Lustenberger
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Sebastian Wutzler
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Philipp Störmann
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany
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64
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Rommens PM, Ossendorf C, Pairon P, Dietz SO, Wagner D, Hofmann A. Clinical pathways for fragility fractures of the pelvic ring: personal experience and review of the literature. J Orthop Sci 2015; 20:1-11. [PMID: 25323921 PMCID: PMC4306730 DOI: 10.1007/s00776-014-0653-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 09/08/2014] [Indexed: 01/16/2023]
Abstract
Fragility fractures of the pelvic ring (FFP) are increasing in frequency and require challenging treatment. A new comprehensive classification considers both fracture morphology and degree of instability. The classification system also provides recommendations for type and invasiveness of treatment. In this article, a literature review of treatment alternatives is presented and compared with our own experiences. Whereas FFP Type I lesions can be treated conservatively, FFP Types III and IV require surgical treatment. For FFP Type II lessions, percutaneous fixation techniques should be considered after a trial of conservative treatment. FFP Type III lesions need open reduction and internal fixation, whereas FFP Type IV lesions require bilateral fixation. The respective advantages and limitations of dorsal (sacroiliac screw fixation, sacroplasty, bridging plate fixation, transsacral positioning bar placement, angular stable plate) and anterior (external fixation, angular stable plate fixation, retrograde transpubic screw fixation) pelvic fixations are described.
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Affiliation(s)
- Pol M. Rommens
- Department of Orthopaedics and Traumatology, University Medical Center, Johannes Gutenberg-University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Christian Ossendorf
- Department of Orthopaedics and Traumatology, University Medical Center, Johannes Gutenberg-University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Philip Pairon
- Department of Orthopaedics and Traumatology, University Medical Center, Johannes Gutenberg-University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Sven-Oliver Dietz
- Department of Orthopaedics and Traumatology, University Medical Center, Johannes Gutenberg-University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Daniel Wagner
- Department of Orthopaedics and Traumatology, University Medical Center, Johannes Gutenberg-University, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Alexander Hofmann
- Department of Orthopaedics and Traumatology, University Medical Center, Johannes Gutenberg-University, Langenbeckstrasse 1, 55131 Mainz, Germany
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65
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Wagner D, Kamer L, Rommens PM, Sawaguchi T, Richards RG, Noser H. 3D statistical modeling techniques to investigate the anatomy of the sacrum, its bone mass distribution, and the trans-sacral corridors. J Orthop Res 2014; 32:1543-8. [PMID: 24962021 DOI: 10.1002/jor.22667] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 05/19/2014] [Indexed: 02/04/2023]
Abstract
The complex anatomy of the sacrum makes surgical fracture fixation challenging. We developed statistical models to investigate sacral anatomy with special regard to trans-sacral implant fixation. We used computed tomographies of 20 intact adult pelves to establish 3D statistical models: a surface model of the sacrum and the trans-sacral corridor S1, including principal component analysis (PCA), and an averaged gray value model of the sacrum given in Hounsfield Units. PCA demonstrated large variability in sacral anatomy markedly affecting the diameters of the trans-sacral corridors. The configuration of the sacral alae and the vertical position of the auricular surfaces were important determinants of the trans-sacral corridor dimension on level S1. The statistical model of trans-sacral corridor S1 including the adjacent parts of the iliac bones showed main variation in length; however, the diameter was the main criterion for the surgically available corridor. The averaged gray value model revealed a distinct pattern of bone mass distribution with lower density particularly in the sacral alae. These advanced 3D statistical models provide a thorough anatomical understanding demonstrating the impact of sacral anatomy on positioning trans-sacral implants.
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Affiliation(s)
- Daniel Wagner
- AO Research Institute Davos, Clavadelerstrasse 8, Davos, 7270, Switzerland; Department of Trauma Surgery, Centre for Orthopaedics and Traumatology, University Medical Centre Mainz, Langenbeckstr. 1, Mainz, 55131, Germany
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66
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Crossover external fixator for acetabular fractures: a cadaver study. Eur J Trauma Emerg Surg 2014; 40:601-6. [PMID: 26814518 DOI: 10.1007/s00068-013-0362-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 12/01/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Dislocated acetabular fractures in polytraumatized patients are very challenging cases to deal with. Temporary stabilization by skeletal traction is difficult in these patients. A more effective solution can be an external fixation. OBJECTIVE The authors designed a new crossover external fixation frame for acetabular fracture. The aim of this study is the biomechanical testing of this frame on human cadavers. METHODS This study is an experiment on ten human cadavers. The acetabular fracture C2.2 was created. The stabilization effect of external fixation was compared with stabilization by large distractor. Femoral heads' shifts caused by standardized manipulation with the cadaver were obtained from X-ray pictures. RESULTS The mean total shift in stabilization technique by external fixation was 2.56 (1-4) mm. In stabilization by large distractor, the mean of the total shift after cadaver manipulation was 5.11 (0-10) mm. No significant differences were found between stabilization by external fixation and by large distractor (p = 0.066). CONCLUSIONS The stabilization of acetabular fracture C2.2 by a crossover external fixator is as effective as large distractor. The crossover external fixation could be a suitable solution for the temporary stabilization of acetabular fractures in polytraumatized patients. Subsequent studies including clinical trials are necessary to confirm the authors' suggestion.
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67
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Ekiz T, Vural S, Biçer S, Hatipoğlu C, Özgirgin N. Sacral Insufficiency Fracture in a Hemiplegic Patient. Rehabil Nurs 2014; 41:158-61. [PMID: 25163417 DOI: 10.1002/rnj.175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Timur Ekiz
- Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Seçil Vural
- Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Seda Biçer
- Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Cem Hatipoğlu
- Department of Radiology, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
| | - Neşe Özgirgin
- Department of Physical Medicine and Rehabilitation, Ankara Physical Medicine and Rehabilitation Training and Research Hospital, Ankara, Turkey
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68
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Alton TB, Firoozabadi R. Management of Pelvic Ring Fractures in the Geriatric Patient. CURRENT GERIATRICS REPORTS 2014. [DOI: 10.1007/s13670-014-0082-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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69
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Zong Z, Chen S, Jia M, Shen Y, Hua X, Liu D. Posterior iliac crescent fracture-dislocation: is it only rotationally unstable? Orthopedics 2014; 37:e435-40. [PMID: 24810819 DOI: 10.3928/01477447-20140430-53] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 11/08/2013] [Indexed: 02/03/2023]
Abstract
Posterior iliac crescent fracture-dislocation is generally considered rotationally unstable and vertically stable. The current study (1) investigated whether vertical instability may occur in posterior iliac crescent fracture-dislocation and (2) analyzed the clinical features of vertically unstable iliac crescent fracture-dislocation as well as treatment strategies. Patients with pelvic fracture who were treated in the authors' department from June 2009 to June 2012 were retrospectively reviewed. This study analyzed the clinical features, including incidence, hemodynamic state, associated injuries, injury severity score, and treatment methods for vertically unstable iliac crescent fracture-dislocation. Four patients had vertically unstable fracture-dislocation, accounting for 12.9% of all iliac crescent fracture-dislocations. All 4 patients were hemodynamically unstable on admission and had complications of associated injuries with a higher injury severity score. In 3 of the 4 patients, iliac crescent fracture-dislocations were reduced via the posterior approach at the initial stage and these patients underwent fixation with a plate. The remaining patient was initially given transcondylar traction because of severe complications and underwent open reduction and internal fixation (ORIF) via a posterior approach at a later stage. The outcomes of all 4 patients were rated as good or excellent by the Kobbe rating system at the last follow-up. Vertical instability may occur in iliac crescent fracture-dislocation. The authors propose ORIF of the fracture-dislocation via a posterior approach. When initial surgery is not possible because of severe associated organ injuries, the authors propose transcondylar traction to allow reduction of the sacroiliac joint and ORIF at a later stage.
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70
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Abstract
As with most fractures associated with osteoporosis, the incidence of pelvic ring injuries in this population of patients is rising rapidly. Osteoporotic pelvic ring injuries are exceedingly different in their etiology, natural history, and treatment from the more recognizable patterns in young patients with high-energy pelvic ring injuries. Recognition of a potentially unstable fracture pattern, careful evaluation of the ambulatory and functional status of each patient before injury, and the potential pitfalls and benefits of operative versus nonoperative care are critical to the effective treatment.
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Affiliation(s)
- Michael P Leslie
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06520-8071, USA.
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72
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Ossendorf C, Hofmann A, Rommens PM. [Selection of access and positioning for operative treatment of pelvic injuries. Decision-making strategies]. Unfallchirurg 2013; 116:227-37. [PMID: 23478900 DOI: 10.1007/s00113-012-2331-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Surgical treatment of pelvic ring injuries requires in-depth knowledge of the topographic anatomy of the pelvic bones, joints and soft tissue structures. A wide range of stabilizing techniques is available including bridging plate osteosynthesis, iliosacral compression screw osteosynthesis and transpubic positioning screws. In this article the different treatment strategies with the respective surgical approaches and patient positioning for pelvic ring fractures and combined lesions of the pelvic ring and acetabulum are presented. Pelvic ring lesions with rotational instability are approached from the anterior and occasionally from both the anterior and posterior based on the amount and localization of the instability. In vertically unstable lesions the most unstable part must be addressed first by reduction and fixation of the dislocated part to the axial skeleton. In combined fractures of the pelvis and acetabulum dorsal stabilization is carried out first.
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Affiliation(s)
- C Ossendorf
- Klinik und Poliklinik für Unfallchirurgie, Zentrum für muskuloskeletale Chirurgie, Universitätsmedizin Mainz
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73
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[Pelvic girdle and acetabulum]. Unfallchirurg 2013; 116:196-7. [PMID: 23455846 DOI: 10.1007/s00113-012-2328-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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74
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Lehmann W. Pelvic and acetabular fractures. Eur J Trauma Emerg Surg 2012; 38:487-8. [PMID: 26816251 DOI: 10.1007/s00068-012-0226-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 09/02/2012] [Indexed: 10/27/2022]
Affiliation(s)
- W Lehmann
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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