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Mennen AHM, Lommerse M, Hemke R, Willems HC, Maas M, Bloemers FW, Ponsen KJ, Van Embden D. Does regional implementation of a clinical pathway for older adult patients with pelvic fragility fractures after low-energy trauma improve patient outcomes (PELVIC): a multicentre, stepped-wedge, randomised controlled trial. BMJ Open 2024; 14:e083809. [PMID: 39142675 PMCID: PMC11331913 DOI: 10.1136/bmjopen-2023-083809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 07/30/2024] [Indexed: 08/16/2024] Open
Abstract
INTRODUCTION Patients with pelvic fragility fractures suffer from high morbidity and mortality rates. Despite the high incidence, there is currently no regional or nationwide treatment protocol which results in a wide variety of clinical practices. Recently, there have been new insights into treatment strategies, such as early diagnosis and minimally invasive operative treatment. The aim of this study is to implement an evidence-based and experience-based treatment clinical pathway to improve outcomes in this fragile patient population. METHODS AND ANALYSIS This study will be a regional stepped-wedge cluster randomised controlled trial. All older adult patients (≥50 years old) who suffered a pelvic fragility fracture after low-energetic trauma are eligible for inclusion. The pathway aims to optimise the diagnostic process, to guide the decision-making process for further treatment (eg, operative or conservative), to structure the follow-up and to provide guidelines on pain management, weight-bearing and osteoporosis workup. The primary outcome is mobility, measured by the Parker Mobility Score. Secondary outcomes are mobility measured by the Elderly Mobility Scale, functional performance, quality of life, return to home rate, level of pain, type and dosage of analgesic medications, the number of falls after treatment, the number of (fracture-related) complications, 1-year and 2-year mortality. Every 6 weeks, a cluster will switch from current practice to the clinical pathway. The aim is a total of 393 inclusions, which provides an 80% statistical power for an improvement in mobility of 10%, measured by the Parker mobility score. ETHICS AND DISSEMINATION The Medical Research Ethics Committee of Academic Medical Center has exempted the PELVIC study from the Medical Research Involving Human Subjects Act (WMO). Informed consent will be obtained using the opt-out method and research data will be stored in a database and handled confidentially. The final study report will be shared via publication without restrictions from funding parties and regardless of the outcome. TRIAL REGISTRATION NUMBER NCT06054165. PROTOCOL VERSION V.1.0, 19 July 2022.
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Affiliation(s)
- Anna H M Mennen
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Marte Lommerse
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Robert Hemke
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Hanna C Willems
- Department of Internal Medicine and Geriatrics, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Mario Maas
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Frank W Bloemers
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Kees Jan Ponsen
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Daphne Van Embden
- Department of Surgery, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
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Yamamoto N, Someko H, Tsuge T, Nakashima Y, Nakao S. Prevalence of fracture progression in fragility fractures of the pelvis: Systematic review and meta-analysis. Injury 2024; 55:111727. [PMID: 39032220 DOI: 10.1016/j.injury.2024.111727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/03/2024] [Accepted: 07/11/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Fragility fractures of the pelvis (FFP) are a growing problem in aging populations. Fracture progression (FP) occasionally occurs during FFP treatment; however, its prevalence remains unclear. This systematic review and meta-analysis aimed to assess the prevalence of FP among patients with FFP. METHODS We performed a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. All cohort studies that reported the prevalence of FP in patients with FFP were included. FP was defined as the appearance of additional pelvic fractures after the initial FFP. We searched the CENTRAL, MEDLINE, and EMBASE databases until April 2024. The pooled prevalence was generated using a random-effects model and presented as a 95 % confidence interval (CI) and prediction interval (PI). We assessed the risk of bias in each study using the Joanna Briggs Institute's Prevalence Critical Appraisal Tool. RESULTS This review included eight studies (925 patients). The pooled prevalence of FP in patients with FFP was 11 % (95 % CI, 5-19 %; 95 % PI, 0-44 %). Subgroup analysis showed that the pooled prevalence of FP in patients with FFP (conservative treatment vs. surgery for initial FFP) was 16 % (95 % CI, 9-24 %) and 2 % (95 % CI, 0-11 %), respectively (test for subgroup difference, P = 0.03). Additional analysis showed that in patients with FP, the pooled prevalence of the fractured site (ipsilateral site, contralateral site, and both sites) was 66 %, 12 %, and 19 %, respectively. The pooled prevalence of fractured bone (pubis, ischium, ilium, and sacrum) was 25 %, 0 %, 15 %, and 68 %, respectively. The risk of bias in the patient sampling method and sufficient data analysis in all included studies was high. CONCLUSION This review suggests that the prevalence of FP in patients with FFP is relatively high. Clinicians should recognize FP as a possible diagnosis in patients experiencing additional pain after FFP. However, further prospective studies with adequate patient sampling are required to confirm the true prevalence.
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Affiliation(s)
- Norio Yamamoto
- Department of Orthopedic Surgery, Minato Medical Coop-Kyoritsu General Hospital, Nagoya, Aichi, Japan; Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Okayama 700-8558, Japan.
| | - Hidehiro Someko
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Takahiro Tsuge
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Okayama 700-8558, Japan; Department of Rehabilitation, Kurashiki Medical Center, 250 Bakuro, Kurashiki, Okayama 710-8522, Japan
| | - Yuki Nakashima
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Hiroshima, Japan
| | - Shuri Nakao
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Division of Rehabilitation Medicine, Shimane University Hospital, 89-1 Enya-cho, Izumo, Shimane 693-8501, Japan
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Oda T, Kitada S, Hirase H, Takada Y, Iwasa K, Niikura T. Evaluation of a treatment protocol based on conservative therapy for fragility fractures of the pelvis. Eur J Trauma Emerg Surg 2024; 50:1173-1181. [PMID: 38393362 DOI: 10.1007/s00068-024-02469-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE In an aging society, fragility fractures of the pelvis (FFP) have increased significantly. However, there is no clear consensus on the timing and criteria for transitioning from conservative treatment to surgery for these fractures. Thus, we aimed to investigate the effects of our treatment protocol for FFP based on conservative treatment. METHODS We conducted a retrospective study including 74 patients with FFP at our institution between 2015 and 2021. All patients were treated conservatively for the first two weeks. During this period, only wheelchair transfer was allowed. If the patient could not walk after this period, surgery was performed. Fracture type (Rommens classification), walking ability, presence of complications after admission, presence of fracture union, and surgical treatment was investigated. Patients were divided into two groups: a stable group (type I/II) and an unstable group (type III/IV). RESULTS Fracture union was achieved in all patients. Thirteen patients developed complications after being admitted to our hospital; seven showed decreased walking ability, and six required surgeries. The stable and unstable groups comprised 47 and 27 patients, respectively. There were no statistically significant differences between the groups regarding the percentage of patients who developed complications or experienced decrease in walking ability. The percentage of patients who required surgery was significantly higher in the unstable group (p < 0.05). CONCLUSION Our FFP management protocol was effective regardless of fracture type. It is important to provide a period for careful assessment of instability, and to try to prevent fracture progression.
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Affiliation(s)
- Takahiro Oda
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Shimpei Kitada
- Orthopaedic Reconstruction Center, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan.
| | - Hitoshi Hirase
- Orthopaedic Reconstruction Center, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Yuma Takada
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Kenjiro Iwasa
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
- Orthopaedic Reconstruction Center, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
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Thiesen DM, Althoff G, Strahl A, Rolvien T, Frosch KH, Koepke LG, Arras C, Ballhause TM, Dalos D, Hartel MJ. Conservative versus operative treatment of FFP II fractures in a geriatric cohort: a prospective randomized pilot trial. Sci Rep 2023; 13:16124. [PMID: 37752331 PMCID: PMC10522702 DOI: 10.1038/s41598-023-43249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/21/2023] [Indexed: 09/28/2023] Open
Abstract
A clear recommendation regarding treatment strategy of fragility fractures of the pelvic ring is missing. The most typical fracture pattern is a lateral compression type injury with non-displaced fractures of the anterior pubic rami and a unilateral os sacrum fracture (FFP II). We hypothesized that operative treatment would be superior to conservative treatment. From October 2017 to April 2020, a randomized prospective non-blinded trial with n = 39 patients was carried out. Two arms with 17 operative versus 22 conservative cases were created. Inclusion criteria were a posterior pelvic ring fracture FFP type II, age over 60 years and acute fracture (< 3 weeks). Barthel index, pain level (VAS), quality of life (EQ-5D-3L), and Tinetti-Gait Test were determined on admission, at discharge, and after 3, 6, 12 and 24 months. Median follow-up was 12.9 months. The Barthel index (= 0.325), VAS (p = 0.711), quality of life (p = 0.824), and Tinetti-Gait Test (p = 0.913) showed no significant differences between the two groups after 12 months. Two patients switched from the conservative to the operative arm due to persistent immobilization and pain. The one-year mortality rate showed no significant difference (p = 0.175). Our hypothesis that surgical treatment is superior was refuted. No significant benefit was shown in terms of quality of life, mortality and pain levels. The results suggest a more differentiated treatment approach in the future, with initial conservative treatment preferred. A larger multi-center trial is required to confirm these findings.Trial registration: The study was retrospectively registered with the German Clinical Trials Registry (DRKS00013703) on 10/12/2018.
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Affiliation(s)
- Darius M Thiesen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Gerrit Althoff
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - André Strahl
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Trauma, Orthopaedic Surgery, and Sports Traumatology, BG Trauma Hospital Hamburg, Hamburg, Germany
| | - Leon-Gordian Koepke
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christian Arras
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Tobias M Ballhause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Dimitris Dalos
- UKE Athleticum, Center for Athletic Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian J Hartel
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Trauma, Orthopaedic Surgery, and Sports Traumatology, BG Trauma Hospital Hamburg, Hamburg, Germany
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Aigner R, Föhr J, Lenz J, Knauf T, Bäumlein M, Ruchholtz S, Oberkircher L, Hack J. Cemented Sacroiliac Screw Fixation versus Conservative Therapy in Fragility Fractures of the Posterior Pelvic Ring: A Matched-Pair Analysis of a Prospective Observational Study. J Clin Med 2023; 12:5850. [PMID: 37762790 PMCID: PMC10531520 DOI: 10.3390/jcm12185850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/20/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
The aim of this study was to compare the outcome of cemented sacroiliac screw fixation to that of conservative treatment in nondisplaced fragility fractures of the sacrum during a 12-month follow-up. Therefore, matched-pair analysis including 40 patients from a previously performed prospective observational study was conducted. Pain was assessed using the visual analogue scale (VAS), functional capabilities and mobility were assessed using the Barthel index, and health-related quality of life (HRQL) was assessed using the EQ-5D questionnaire at 6 weeks, 6 months, and 12 months after the fracture, respectively. No significant differences between the two groups were seen regarding pain. In the operative group, a significantly improved Barthel index was observed after 6 months. A significantly higher HRQL was identified after 6 weeks in the operative group. Their mobility was comparable between the two groups before the fracture; after 6 weeks, mobility was significantly improved in the operative group. After 12 months, no significant differences were found regarding the functional outcome, HRQL or mobility. The 1-year mortality rate was 25% in the conservative group versus 5% in the operative group (not statistically significant). The present study revealed favorable short-term outcomes concerning the functional outcome, HRQL and mobility after sacroiliac screw fixation. After 12 months, the outcomes were similar to those of the patients managed conservatively.
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Affiliation(s)
- Rene Aigner
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Jan Föhr
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Julia Lenz
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Tom Knauf
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Martin Bäumlein
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Steffen Ruchholtz
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
| | - Ludwig Oberkircher
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
- Department for Trauma Surgery, Orthopaedic Surgery and Arthroplasty, Medizin Campus Bodensee, 88048 Friedrichshafen, Germany
| | - Juliana Hack
- Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg GmbH, 35043 Marburg, Germany
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Putzeys G, Dekeyser T, Garré P, Chesser T, Pottel H. Posterior pelvic ring involvement detected with CT taken within a week of admission in acute fragility fractures of the pelvis (FFP) does not predict failure of conservative treatment: a retrospective cohort study. BMC Musculoskelet Disord 2023; 24:320. [PMID: 37087474 PMCID: PMC10122380 DOI: 10.1186/s12891-023-06439-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/18/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Acute low energy pubic rami fractures in the elderly receive primarily conservative treatment. There is debate to what extent posterior ring involvement, which is detected superiorly by CT compared to X-ray, has an impact on outcome and may require modified treatment. We want to demonstrate if posterior ring involvement has an influence on different types of outcome in primarily conservatively treated acute FFP, questioning the usefulness of early CT. Additionally we analysed the early fracture pattern in cases where conservative treatment failed with need for secondary surgery. METHODS A retrospective cohort study of 155 consecutive patients, recruited between 2009 and 2016, aged over 65 years diagnosed with an acute LE-PFr on X-ray at the emergency department of a single, level-one trauma centre and receiving an early CT. A set of outcome parameters was compared between patients with an isolated pubic rami fracture (CTia) and patients who had a combined posterior pelvic ring fracture (CTcp). RESULTS There were 155 patients of whom 85.2% were female with a mean age of 83 years. 76.8% of patients living at home returned home and 15.5% moved to a nursing home. Mortality rate during hospitalisation was 6.4% and 14.8% at one year post-trauma. Secondary fracture displacement occurred in 22.6%. Secondary surgery was performed in 6 cases (3.9%). Median hospitalisation length of stay was 21 days (range 0 to 112 days). There was no significant association between the subgroups and change in residential status (p = 0.65), complications during hospitalisation (p = 0.75), mortality rate during admission (p = 0.75) and at 1 year (p = 0.88), readmission within 30 days (p = 0.46) and need for secondary surgery (p = 0.2). There was a significant increased median length of stay (p = 0.011) and rate of secondary displacement (p = 0.015) in subgroup CTcp. Secondary displacement had no impact on in-hospital complications (p = 0.7) nor mortality rate during admission (p = 0.79) or at 1 year (0.77). Early CT in patients who underwent secondary surgery showed stable B2.1 lesions in 4 of 6 cases. CONCLUSIONS Our data suggest that early CT in patients with conservatively treated acute LE-PFr in order to detect posterior lesions, has limited value in predicting failure of conservative treatment.
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Affiliation(s)
- Guy Putzeys
- Orthopedic and Trauma Department, AZ Groeninge hospital, Kortrijk, Belgium.
| | | | - Patrick Garré
- Department of data management, AZ Groeninge hospital, Kortrijk, Belgium
| | | | - Hans Pottel
- Department of Public Health and Primary Care, KULeuven KULAK, Kortrijk, Belgium
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Zhu Z, Tan B, Wei D, Tang X, Yuan J, Hu J, Liao F. Percutaneous robot-assisted screw fixation for nondisplaced pelvic fractures: a good choice? INTERNATIONAL ORTHOPAEDICS 2023; 47:1601-1608. [PMID: 36991283 DOI: 10.1007/s00264-023-05794-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023]
Abstract
PURPOSE To compare the merits and demerits of percutaneous robot-assisted screw fixation for nondisplaced pelvic fractures with other treatments via long-term follow-up. METHODS This was a retrospective analysis of nondisplaced pelvic fractures treated between January 2015 and December 2021. The number of fluoroscopy exposures, operative duration, intraoperative blood loss, surgical complications, screw placement accuracy and Majeed score were compared among the nonoperative group (24 cases), open reduction and internal fixation (ORIF) group (45 cases), free-hand empirical screw fixation (FH) group (10 cases) and robot-assisted screw fixation (RA) group (40 cases). RESULTS There was less intraoperative blood loss in the RA and FH groups than in the ORIF group. The number of fluoroscopy exposures in the RA group was lower than that in the FH group but much higher than that in the ORIF group. There were five cases of wound infection in the ORIF group and no surgical complications in the FH or RA group. The medical expenses were higher in the RA group than in the FH group, with no significant difference from the ORIF group. The Majeed score was lowest in the nonoperative group three months after injury (64.5±12.0) but lowest in the ORIF group one year after injury (88.6±4.1). CONCLUSION Percutaneous RA for nondisplaced pelvic fractures is effective and minimally invasive and does not increase medical expenses compared with ORIF. Therefore, it is the best choice for patients with nondisplaced pelvic fractures.
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Affiliation(s)
- Zongdong Zhu
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# W. Sec 2, 1st Ring Rd, Qingyang District, Chengdu, 610072, China
| | - Bo Tan
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# W. Sec 2, 1st Ring Rd, Qingyang District, Chengdu, 610072, China
| | - Dan Wei
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# W. Sec 2, 1st Ring Rd, Qingyang District, Chengdu, 610072, China
| | - Xiaoming Tang
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# W. Sec 2, 1st Ring Rd, Qingyang District, Chengdu, 610072, China
| | - Jiabin Yuan
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# W. Sec 2, 1st Ring Rd, Qingyang District, Chengdu, 610072, China
| | - Jiang Hu
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# W. Sec 2, 1st Ring Rd, Qingyang District, Chengdu, 610072, China
| | - Feng Liao
- Department of Orthopaedics, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, 32# W. Sec 2, 1st Ring Rd, Qingyang District, Chengdu, 610072, China.
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Internal fixation of radiation-induced fragility fractures of the pelvis: a case series. Arch Orthop Trauma Surg 2023; 143:865-871. [PMID: 35107637 DOI: 10.1007/s00402-022-04358-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 01/14/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND The optimal treatment for radiation-induced fragility fractures of the pelvis (RI-FFP) is not well evaluated due to the rarity of the condition. PURPOSE The aim of this retrospective study was to assess the prevalence of RI-FFP, the radiological and clinical outcomes as well as the complications of patients treated with internal fixation. METHODS A retrospective review of our database was performed to identify all surgically treated patients with RI-FFP. Surgical stabilization was recommended for patients with FFP type III and FFP type IV. Surgical stabilization was also recommended after 5-7 days for patients with FFP type II in case of unsuccessful conservative treatment. Demographic data, fracture patterns according to the FFP classification of Rommens and Hofmann, type of treatment and surgery-related complications including nonunion, hardware failure, fracture progression (secondary fracture) or infection were documented. RESULTS Among 500 patients with FFP, the prevalence of patients with RI-FFP was 1% (5/500): 5 patients with a median age of 79 years (76-79). The median time interval from radiation to fracture was 18 months (18-24). All of them underwent internal fixation. Two patients experienced surgery-related complications, one due to hardware failure and one due to fracture progression. At median follow-up of 27 months, all fractures had healed. Patients reached a good level of mobility with a median Parker Mobility Score of 7 and suffered moderate pain with a median value of 2.5 on the numeric rating scale. CONCLUSION RI-FFP remains a rare injury (1%). In our experience, patients, who underwent surgical treatment, obtained a high level of mobility and a moderate pain score after 2 years of follow-up. Internal fixation can be recommended in RI-FFP. Because bone healing may be impaired due to previous irradiation, highly stable constructs are required to avoid fracture progression or revision surgery. LEVEL OF EVIDENCE III, retrospective study.
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Progression to Rommens type IIIa fragility fracture of the pelvis managed by delayed open reduction and interdigitating screw fixation: A case report. Trauma Case Rep 2023; 43:100773. [PMID: 36691632 PMCID: PMC9860480 DOI: 10.1016/j.tcr.2023.100773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 01/08/2023] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
Efficient management of fragility fractures of the pelvis (FFPs) is established during the acute phase of injury. However, a small number of FFPs exhibit fracture progression with increased instability over time. Fracture progression is typically seen in sacral fractures and rare in iliac fractures. Herein, we present the case of a 72-year-old woman with Rommens type IIIa FFP, following an isolated iliac fracture. It was successfully treated four months after the initial injury with retrograde suprapubic screw fixation via the anterior intra-pelvic approach and percutaneous lateral compression type-2 screw fixation using an interdigitating technique.
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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] [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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Ogawa R, Nishiwaki T, Yanagimoto S, Imabayashi H, Oya A. A Case of Fragility Fracture of the Pelvis Initially Diagnosed as Osteoarthritis of the Hip. Arthroplast Today 2022; 16:83-89. [PMID: 35662996 PMCID: PMC9160669 DOI: 10.1016/j.artd.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 11/28/2022] Open
Abstract
We present the case of a 58-year-old woman who presented with anterior groin pain, initially diagnosed with hip osteoarthritis (OA), scheduled for total hip arthroplasty, and subsequently diagnosed with an occult fragility fracture of the pelvis (FFP) by preoperative computed tomography (CT) examination. We diagnosed the patient with pre-existing hip OA and a bilateral sacrum and left pubic tubercle fracture that exacerbated the groin pain. We operated on the FFP followed by simultaneous bilateral total hip arthroplasty. Given the high prevalence of hip OA and the increasing incidence of FFP, comorbidity of these 2 entities should be ruled out. Even if hip OA is apparent, plain radiographs are insufficient to rule out FFP, necessitating a thorough clinical examination, followed by a CT examination if an FFP is suspected.
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Affiliation(s)
- Ryo Ogawa
- Department of Orthopaedic Surgery, Tokyo Saiseikai Central Hospital, Minato-ku, Tokyo, Japan
| | - Toru Nishiwaki
- Department of Orthopaedic Surgery, Japanese Shizuoka Red Cross Hospital, Shizuoka-shi, Shizuoka, Japan
| | - Shigeru Yanagimoto
- Department of Orthopaedic Surgery, Tokyo Saiseikai Central Hospital, Minato-ku, Tokyo, Japan
| | - Hideaki Imabayashi
- Department of Orthopaedic Surgery, Tokyo Saiseikai Central Hospital, Minato-ku, Tokyo, Japan
| | - Akihito Oya
- Department of Orthopaedic Surgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
- Corresponding author. Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinano-machi, Shinjuku-ku, Tokyo 160-8582, Japan. Tel.: +81 3 3353 1211.
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12
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Zhang H, Sun F, Li Y. Application of Smart Healthcare in Comparative Analysis of Effect of Early External Fixator and Plate Internal Fixation Treatment on Postoperative Complications and Lower Limb Function Recovery of Patients With Unstable Pelvic Fracture. Front Public Health 2022; 10:887123. [PMID: 35570973 PMCID: PMC9099004 DOI: 10.3389/fpubh.2022.887123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo comparatively analyze the effect of early external fixator and plate internal fixation treatment on postoperative complications and lower limb function recovery of patients with unstable pelvic fracture based on smart healthcare.MethodsThe clinical data of 98 patients with unstable pelvic fractures treated in our hospital from August 2018 to August 2021 were collected for retrospective analysis, and the patients were split into group A (plate internal fixation, n = 49) and group B (early external fixator treatment, n = 49) according to the surgical modalities. The time of operation, intraoperative blood loss, postoperative complications, etc. were compared between the two groups.ResultsBetween the two groups, group B had significantly better clinical indicators (P < 0.001), a greatly higher good rate of fracture reduction and postoperative Harris score (P < 0.05), and obviously lower VAS score and total incidence rate of postoperative complications (P < 0.05).ConclusionThrough the analysis based on smart healthcare, it is found that compared with plate internal fixation treatment, early external fixator treatment presents a better effect in treating patients with unstable pelvic fracture, because it is a reliable method to accelerate fracture healing, reduce postoperative complications, and improve lower limb function.
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Affiliation(s)
- Hongwei Zhang
- Department of Emergency, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Fang Sun
- Plastic Burn Beauty Center, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
| | - Yao Li
- Department of Orthopeadic Surgery, The First Affiliated Hospital of Jiamusi University, Jiamusi, China
- *Correspondence: Yao Li
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13
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Honda S, Ota S, Yamashita S, Yasuda T. Inverse association between sarcopenia and displacement in the early phase of fragility fractures of the pelvis. Osteoporos Sarcopenia 2022; 8:24-29. [PMID: 35415276 PMCID: PMC8987323 DOI: 10.1016/j.afos.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/21/2022] [Accepted: 03/13/2022] [Indexed: 11/27/2022] Open
Abstract
Objectives Fragility fractures of the pelvis (FFP) commonly occur in the frail elderly. Displacement in the posterior pelvic ring is recognized as the key sign of instability. This study aims to elucidate the relationship between computer tomography (CT)-based frailty markers and displacement of the posterior pelvic ring within 7 days after injury. Methods This retrospective study included 49 patients (42 females, 7 males) with FFP (type I 10, type II 24, type III 12, type IV 3). On a CT slice at the level of the third lumbar vertebra, skeletal muscle area, skeletal muscle radiation attenuation, and skeletal muscle index (SMI) were calculated as sarcopenia markers. Osteopenia was measured with trabecular region of interest attenuation technique on the same CT slice. Results There was no difference in the demographics between non-displaced and displaced FFP. CT-based data showed that patients with FFP had osteopenia. However, no difference was found between non-displaced and displaced FFP. SMI was higher in FFP types III/IV than non-displaced FFP when CT-based data on sarcopenia were compared among all patients. Female patients with FFP demonstrated similar results. Logistic regression analysis using the demographics and CT-based markers on sarcopenia and osteopenia revealed that SMI was a potential determinant of displacement of the posterior pelvic ring fractures. Conclusions There was inverse association between sarcopenia and displacement of the posterior pelvic ring in the early phase of FFP. Relatively preserved muscle may develop displacement in the elderly with osteopenia.
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Yoshimura S, Inoue M, Nakajima T, Kubota G, Sato Y, Arai T, Orita S, Eguchi Y, Inage K, Shiga Y, Watanabe A, Ohtori S, Aoki Y. Minimally Invasive "Crab-Shaped Fixation" for Treating Patients with Fragility Fractures of the Pelvis. Spine Surg Relat Res 2021; 5:425-430. [PMID: 34966870 PMCID: PMC8668208 DOI: 10.22603/ssrr.2020-0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/26/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction In the aging society, fragility fracture of the pelvis (FFP) has become a problem. Although strong and minimally invasive fixation is required in FFP surgery, reports on relevant surgical results are scarce. Crab-shaped fixation (CSF) is a spinopelvic fixation that involves reconstruction of the posterior pelvic ring using spinal instrumentation. This study aimed to evaluate the walking ability and perioperative complications of patients who underwent CSF for FFP. Methods We included patients diagnosed with unstable FFPs, including sacral fracture, who required hospitalization. Demographic data, such as age, sex, bone mineral density, and Rommens classification, were evaluated. Surgical findings included estimated blood loss, operation time, and perioperative complications. The improvement in postoperative walking ability was evaluated based on the length of the postoperative period before the initiation of walker training and whether walking aids were required at 6 months post-surgery, compared with those who received conservative treatment for FFP. Results Our study included 6 cases that received CSF and 16 cases that received conservative treatment, in which all were females and presented with sacral fractures. The average age of the surgical patients, the operation time, and the estimated blood loss were 79.5±14.7 years, 180.7±28.7 min, and 124.2±29.4 mL, respectively. The average length of the postoperative period prior to the initiation of walker training was 10.8±12.3 days, which was significantly shorter than that of conservative treatment. With regard to perioperative complications, poor reduction of fracture dislocation was observed in one case as well as surgical site infection in another case, but the walking ability improved in all cases. Conclusions We evaluated the results of the posterior pelvic ring reconstruction with CSF for patients with vertically unstable FFPs, including sacral fractures. CSF is minimally invasive and would be useful as it allowed walker training during the early postoperative period, which improved patients' walking ability even during the in situ pelvic ring reconstruction.
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Affiliation(s)
- Shin Yoshimura
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Masahiro Inoue
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Takayuki Nakajima
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Go Kubota
- Department of Orthopaedic Surgery, Chiba Prefectural Sawara Hospital, Sawara, Japan
| | - Yusuke Sato
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Takahito Arai
- Department of Orthopaedic Surgery, Kanazawa Hospital, Yokohama, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yawara Eguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kazuhide Inage
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Atsuya Watanabe
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, Togane, Japan
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15
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Saito Y, Tokutake K, Takegami Y, Yoshida M, Omichi T, Imagama S. Does surgical treatment for unstable fragility fracture of the pelvis promote early mobilization and improve survival rate and postoperative clinical function? Eur J Trauma Emerg Surg 2021; 48:3747-3756. [PMID: 34156485 DOI: 10.1007/s00068-021-01729-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 06/11/2021] [Indexed: 01/31/2023]
Abstract
PURPOSE This retrospective multicenter study aimed to compare rates of early mobilization and survival and functional outcome of surgical treatment (S) with that of conservative treatment (C) according to each unstable fragility fracture of the pelvis (FFP) classification type with displacement of the posterior component ≥ 5 mm. METHODS We analyzed 64 patients with unstable type III and IV FFP who could move and transfer themselves before injury and had ≥ 5 mm displacement of the posterior component. We compared survival rate, early mobilization, walking ability at final follow-up, and complications at admission for each type of surgical and conservative treatment. RESULTS Most of the unstable FFP were type IIIa and IVb in the study population. Type III comprised 40 cases (group S:13/group C:27) and type IV comprised 24 cases (group S:7/group C:17). There were no significant differences in 3 month and 1 year survival rates, although group C (III) had the tendency of higher mortality rate (p = 0.08). Mobilization (transferring to a wheelchair) was enabled significantly earlier in group S (III) than in group C (III) (p = 0.02), but in type IV, most patients enabled early mobilization even without surgical intervention. There were no significant differences in hospital complications and walking ability at final follow-up. CONCLUSION In this study, the superiority of surgical treatment for unstable FFP was not proven. However, the results suggest that type IVb may be a relatively stable type compared to type III and that type IVb should be considered separately from bilaterally complete unstable sacral fractures due to high-energy trauma.
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Affiliation(s)
- Yuki Saito
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Katsuhiro Tokutake
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Shouwa-ku, Nagoya, Aichi, 466-8550, Japan.
| | - Yasuhiko Takegami
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masahiro Yoshida
- Department of Emergency Medicine, Fujita Health University Hospital, Nagoya, Japan
| | - Toshifumi Omichi
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shiro Imagama
- Department of Orthopedic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Kolk RHE, Loggers SAI, van der List JP, Schakenraad D, de Nooij L, Bijlsma TS. Fracture progression in fragility fractures of the pelvis: A case report. TRAUMA-ENGLAND 2021. [DOI: 10.1177/14604086211015065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Fragility fractures of the pelvis (FFP) are becoming increasingly common as our population ages. Usually treated conservatively the concept of fracture progression is little recognized but can have important consequences for the patient if missed. Case report A patient with a FFP presented with increase of pain after initial conservative treatment. Additional imaging revealed extensive fracture progression resulting in an unstable pelvic ring, requiring surgical intervention. Most FFPs are currently treated conservatively. However, initially stable FFPs can progress into more unstable fracture patterns that may require invasive treatment. Conclusion Physicians should be aware of fracture progression and concomitant posterior ring fractures in case of prolonged or recurrent pain or mobilization difficulties. Careful follow-up and awareness might help to prevent or treat debilitation in an early phase and improve outcomes.
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Affiliation(s)
- Roos HE Kolk
- Department of Emergency Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | | | | | - Ditmar Schakenraad
- Department of Emergency Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Linda de Nooij
- Department of Emergency Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Taco S Bijlsma
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands
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Abstract
BACKGROUND Pelvic fractures are typical for frail geriatric patients. They are characterized by increasing pain and loss of mobility. As geriatric pelvic fractures differ from the typical high velocity injuries, Rommens and Hofmann recommended a new classification for fragility fractures of the pelvis (FFP) in 2013. In addition to the location of the fracture they also assessed the degree of dislocation. OBJECTIVE Compared to known fracture classifications of the pelvis, the FFP classification appears complex. Therefore, this study was designed to investigate the interobserver reliability of the FFP classification. MATERIAL AND METHODS The members of the Section of Geriatric Traumatology (DGOU) were presented with 10 DICOM data sets with fractures of the pelvis for classification. As a reference the classification of P.M. Rommens, the author of the FFP, was established. RESULTS In this study 24 consultants (47%) and 27 (53%) residents took part. Also, six radiologists were invited to participate. A total of 493 assessments were made. In 184 (37%) cases there was agreement with the reference, in 183 (37%) computed tomography images the fractures were classified lower, in 26 (26%) higher than the reference. This initially resulted in a Cohens κ coefficient of 0.36. This corresponds to a sufficient agreement (fair) according to Garbuz. With the reduction of the classification to four main groups, the Cohens κ coefficient increased to a satisfactory value. CONCLUSION The reasons for the partly low agreement could be the participants' lack of experience and an inaccurate description of the classification levels. In the end, however, the FFP classification is the only one that meaningfully represents pelvic fractures of geriatric and frail patients. By simplifying to the four main groups, a better interobserver reliability is achieved. For a successful treatment, however, attention to the individual patient and the "fracture personality" is essential.
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Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases. Eur J Trauma Emerg Surg 2020; 47:11-19. [DOI: 10.1007/s00068-020-01480-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 08/24/2020] [Indexed: 12/20/2022]
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Functional treatment strategy for fragility fractures of the pelvis in geriatric patients. Eur J Trauma Emerg Surg 2020; 47:21-27. [PMID: 32862316 DOI: 10.1007/s00068-020-01484-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/24/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE We propose a functional treatment strategy for fragility fractures of the pelvis (FFP) in geriatric patients; patients with such fractures normally undergo 10 days of conservative therapy with full-weight bearing within pain limits. Conservative therapy for FFP is continued for patients who can stand with assistance, and surgical stabilization is recommended for patients with difficulty in auxiliary standing at 10 day postadmission. This study aimed to compare the outcomes of functional treatment between geriatric patients with FFP type I/II and those with FFP type III/IV, as described by Rommens et al. METHODS: We conducted a retrospective study of 84 geriatric patients who underwent functional treatment for FFP. Based on the results of the first examination, the patients were allocated to the following FFP types: type I/II (n = 53) and type III/IV (n = 31). Change in functional mobility scale described by Graham et al. from before injury to the final follow-up were compared between the groups. RESULTS There was no significant difference in the functional mobility scale (0.25 ± 0.70 vs. 0.23 ± 0.56, p = 0.889) between FFP type I/II and FFP type III/IV. CONCLUSION The outcomes of the functional treatment for FFP for the geriatric patients did not differ significantly between the radiographic classifications. Functional treatment could, therefore, be a treatment option for almost all radiographic types of FFP, especially for geriatric patients. Further investigations are warranted.
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Mobility and mortality of 340 patients with fragility fracture of the pelvis. Eur J Trauma Emerg Surg 2020; 47:29-36. [PMID: 32860102 DOI: 10.1007/s00068-020-01481-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To investigate prognosis of patients with fragility fracture of the pelvis (FFP) treated in a single trauma unit in Japan. METHODS We retrospectively investigated 340 consecutive patients with FFP (40 men, 300 women; average age, 82.5 years) treated in our facility from April 2012 to April 2019. Fractures were categorized according to the Rommens classification. Patients' mechanism of injury, existence of hip implant, standing and walking abilities (using the Majeed score), and 1-year mortality rate were evaluated. RESULTS According to the Rommens classification, there were 84 type Ia, 2 type Ib, 24 type IIa, 78 type IIb, 51 type IIc, 40 type IIIa, 1 type IIIb, 4 type IIIc, 1 type IVa, 51 type IVb, and 3 type IVc fractures. Sixteen patients (4.7%) received surgical treatments. Twenty-eight patients (8.2%) had no memory of a traumatic event, and 61 (18%) had implants from a previous hip surgery. A total of 176 patients (52%) were followed up for ≥ 1 year, and 70 (39.8%) and 67 (38.1%) patients had recovery of standing and walking abilities, similar to those before the injury. The operative group (7/9 = 77.8%) had a higher proportion of patients who regained their standing and walking abilities at the 1-year follow-up than the conservative group. The 1-year mortality rate of the patients who could be followed for ≥ 1 year was 6.7%. CONCLUSION According to our data, 4.7% of patients were indicated for surgery, and only < 40% of patients were able to regain their pre-injury standing and walking abilities at 1 year after the injury. FFP may greatly affect an elderly's activities of daily living and may lead to prognosis similar to patients with proximal hip fractures. To regain the walking ability of patients with FFP, more aggressive indication of surgical treatment may be considered depending on the patient's background. Further examinations are necessary to determine the surgical indications and treatment protocol for FFP.
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Hartensuer R, Lodde MF, Keller J, Eveslage M, Stolberg-Stolberg J, Riesenbeck O, Raschke MJ. Safety, Effect and Feasibility of Percutaneous SI-Screw with and without Augmentation-A 15-Year Retrospective Analysis on over 640 Screws. J Clin Med 2020; 9:jcm9082660. [PMID: 32824548 PMCID: PMC7463525 DOI: 10.3390/jcm9082660] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/11/2020] [Accepted: 08/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Minimally invasive sacroiliac-screw (SI-screw) fixation of the pelvis is used in energy trauma (Arbeitsgemeinschaft für Osteosynthesefragen (AO) classified) and fragility fractures (Fragility Fracture of the Pelvis (FFP) classified). However, available clinical data are based on small case series and biomechanical data seem to be contradictory. METHODS The present single center retrospective cohort study investigated percutaneous SI-screw fixation and augmentation over 15 years. Groups were compared concerning the general epidemiological data, mobilization, complication rates, duration of stay, and safety of SI-screw insertion. Multivariable analyses were performed using logistic regression. RESULTS Between 2005 and March 2020, 448 patients with 642 inserted SI-screws were identified. Iatrogenic neurological impairment was documented in 2.47% and correlated with screw misplacement. There was an increased complication risk in patients with AO type C over patients with AO type B and in FFP II over FFP III/IV patients. Cement-augmented FFP patients showed a 25% reduced stay in hospital and a reduced complication risk. Cement-associated complications were seen in 22% without correlation to neurologic impairment. CONCLUSIONS The present study confirms the safety and usability of percutaneous SI-screw fixation, despite specific risks. Cement augmentation seems to reduce the complication risk in FFP patients and shorten hospital stay for some reasons, without increased specific complications or correlated neurological impairment.
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Affiliation(s)
- René Hartensuer
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
- Correspondence: ; Tel.: +49-251-83-59204
| | - Moritz F. Lodde
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Jonas Keller
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Muenster, 48149 Münster, Germany;
| | - Josef Stolberg-Stolberg
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Oliver Riesenbeck
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
| | - Michael J. Raschke
- Department of Trauma-, Hand- and Reconstructive Surgery, University of Muenster, 48149 Münster, Germany; (M.F.L.); (J.K.); (J.S.-S.); (O.R.); (M.J.R.)
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Pfeufer D, Becker CA, Faust L, Keppler AM, Stagg M, Kammerlander C, Böcker W, Neuerburg C. Load-Bearing Detection with Insole-Force Sensors Provides New Treatment Insights in Fragility Fractures of the Pelvis. J Clin Med 2020; 9:jcm9082551. [PMID: 32781675 PMCID: PMC7463446 DOI: 10.3390/jcm9082551] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 02/02/2023] Open
Abstract
Background: Due to an aging society, more and more surgeons are confronted with fragility fractures of the pelvis (FFPs). The aim of treatment of such patients should be the quickest possible mobilization with full weight-bearing. Up to now however, there are no data on loading of the lower extremities in patients suffering FFPs. We hypothesized to find differences in loading of the lower limbs. Methods: 22 patients with a mean age of 84.1 years were included. During gait analysis with insole-force sensors, loading on the lower extremities was recorded during early mobilization after index fracture. Results: Especially the average peak force showed differences in loading, as the affected limb was loaded significantly less {59.78% (SD ± 16.15%) of the bodyweight vs. 73.22% (SD ± 14.84%) (p = <0.001, effect size r = 0.58)}. Furthermore, differences in loading in between the fracture patterns of FFPs were observed. Conclusion: This study shows that it is possible to reliably detect the extremity load, with the help of an insole device, in patients presenting with fragility fractures of the pelvis. There is great potential to improve the choice and time of treatment with insole-force sensors in FFPs in future.
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Yamamoto N, Noda T, Sukegawa S, Inoue T, Kawasaki K, Ozaki T. Vacuum phenomenon in pelvic fractures. Injury 2020; 51:1618-1621. [PMID: 32386839 DOI: 10.1016/j.injury.2020.03.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/16/2020] [Accepted: 03/29/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Vacuum phenomenon (VP) in closed pelvic fracture is a rare disorder. This study aimed to examine the prevalence and clinical findings of VP in closed pelvic fracture. METHODS We retrospectively reviewed 197 patients with closed pelvic fracture who presented to our institution from January 2012 to December 2018. Pelvic fractures were diagnosed by plain radiography and computed tomography (CT). First, we investigated the prevalence and clinical findings of VP in pelvic fractures. Second, we compared the clinical findings between pelvic fracture with and without VP. Finally, VP in pelvic fracture was evaluated clinically and radiologically. RESULTS VP in pelvic fractures was detected by CT in 9 (3.6%) of the 197 patients with pelvic fractures. Patients with VP had a significantly greater proportion of fracture progression than those without VP (42.9% vs. 11.3%, P = 0.02). Patients with VP had a greater proportion of fragility fractures of the pelvis (FFP), and a lesser proportion of bone union than those without VP, although the differences were not significant. In nine pelvic fractures with VP, all sacral fractures were classified as type 1 according to the Denis classification, and all pubic fractures were classified as type 1 according to the Nakatani classification. Two (22.2%) nonunion in nine pelvic fractures with VP occurred at the pubic fracture site alone. CONCLUSIONS Orthopedic clinicians should be aware of the potential of CT for detecting VP in pelvic fractures, especially in the course of FFP progression.
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Affiliation(s)
- Norio Yamamoto
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, Japan.
| | - Tomoyuki Noda
- Department of Musculoskeletal traumatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shintaro Sukegawa
- Department of Oral and Maxillofacial Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Tomohiro Inoue
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, Japan
| | - Keisuke Kawasaki
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical science, Okayama, Japan
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