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Lee AK, Marecek GS, Collinge CA. Standardization and Reproducibility of Dynamic Stress Testing for Occult Pelvic Ring Instability. J Am Acad Orthop Surg 2024:00124635-990000000-01048. [PMID: 39018575 DOI: 10.5435/jaaos-d-23-00165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 05/16/2024] [Indexed: 07/19/2024] Open
Abstract
INTRODUCTION Examination under anesthesia (EUA) (stress fluoroscopy) is commonly done after pelvic ring injury to identify occult instability because unstable disruptions may displace causing morbidity. The force applied during EUA for these injuries has not been standardized. The purpose of this study was to examine the forces used during the EUA by experienced orthopaedic trauma pelvic surgeons. METHODS Orthopaedic traumatologists performed simulated EUA on a cadaver at two North American pelvis and acetabular courses using internal rotation (IR), external rotation, and push-pull maneuvers while wearing a handheld dynamometer to measure force. All surgeons used a comparable method, and each performed EUA multiple times. Maximum forces were measured in Newton (N). RESULTS Eighteen surgeons participated. Four had been practicing for <5 years, six for 5 to 10 years, six for 11 to 20 years, and two for >20 years. Surgeons applied a force ranging from 40.4 to 374.9 N during IR, 72.9 to 338.4 N during external rotation, and 25 to 323 N during push-pull, with notable variability seen between surgeons. Three surgeons (18%) had >50-N variability on serial trials of a single EUA maneuver (IR). DISCUSSION This is the first study evaluating the forces applied during pelvic EUA used to assess ring stability. Notable variability existed among surgeons performing EUA and in serial examinations by the same surgeon. Additional study is needed to standardize the displacement measured and threshold for instability that guides management.
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Affiliation(s)
- Adam Keith Lee
- From the University of Chicago Medical Center, Chicago, IL (Lee), Cedars Sinai Medical Center, Los Angeles, CA (Marecek), and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, TX (Collinge)
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Patterson JT, Parry JA, Working ZM, McKibben NA, Baca J, Duong A, Senior J, Kim A, Marchand LS, O'Hara N. Patient Preferences for Operative Versus Nonoperative Treatment of LC1 Pelvis Fracture: A Discrete Choice Experiment. J Orthop Trauma 2024; 38:291-298. [PMID: 38442188 DOI: 10.1097/bot.0000000000002794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVES To quantify how patients with lateral compression type 1 (LC1) pelvis fracture value attributes of operative versus nonoperative treatment. METHODS DESIGN Discrete choice experiment. SETTING Three US Level 1 trauma centers. PATIENT SELECTION CRITERIA Adult survivors of an LC1 pelvis treated between June 2016 and March 2023 were identified from institutional registries. The choice experiment was administered as a survey from March through August 2023. OUTCOME MEASURES AND COMPARISONS Participants chose between 12 hypothetical comparisons of treatment attributes including operative or nonoperative care, risk of death, severity of pain, risk of secondary surgery, shorter hospital stay, discharge destination, and independence in ambulation within 1 month of injury. The marginal utility of each treatment attribute, for example, the strength of participants' aggregate preference for an attribute as indicated by their survey choices, was estimated by multinomial logit modeling with and without stratification by treatment received. RESULTS Four hundred forty-nine eligible patients were identified. The survey was distributed to 182 patients and collected from 72 patients (39%) at a median 2.3 years after injury. Respondents were 66% female with a median age of 59 years (IQR, 34-69 years). Before injury, 94% ambulated independently and 75% were working; 41% received operative treatment. Independence with ambulation provided the highest relative marginal utility (21%, P < 0.001), followed by discharge to home versus skilled nursing (20%, P < 0.001), moderate versus severe postdischarge pain (17%, P < 0.001), shorter hospital stay (16%, P < 0.001), secondary surgery (15%, P < 0.001), and mortality (10%, P = 0.02). Overall, no relative utility for operative versus nonoperative treatment was observed (2%, P = 0.54). However, respondents strongly preferred the treatment they received: operative patients valued operative treatment (utility, 0.37 vs. -0.37, P < 0.001); nonoperative patients valued nonoperative treatment (utility, 0.19 vs. -0.19, P < 0.001). CONCLUSIONS LC1 pelvis fracture patients valued independence with ambulation, shorter hospital stay, and avoiding secondary surgery and mortality in the month after their injury. Patients preferred the treatment they received rather than operative versus nonoperative care.
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Affiliation(s)
- Joseph T Patterson
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Joshua A Parry
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
| | | | | | - Joseph Baca
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Andrew Duong
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Joshua Senior
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Annabel Kim
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | | | - Nathan O'Hara
- University of Maryland Medical Center, Baltimore, MD
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Elsissy JG, Ruckle DE, LeBrun C, Johnson JP. Pelvic Ring Injuries: Stable or Not? J Am Acad Orthop Surg 2024; 32:99-107. [PMID: 37816188 DOI: 10.5435/jaaos-d-23-00470] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 08/29/2023] [Indexed: 10/12/2023] Open
Abstract
Pelvic ring injuries occur in varying severity and in vastly different patient demographics. Knowledge regarding which of these injuries require surgical intervention and which can be managed nonsurgically continues to evolve. Previous studies have shown validated criteria for sacral fractures and the posterior ring, explored the role of examination under anesthesia, and other forms of dynamic imaging. Although there is substantial information available, a comprehensive synthesis of this information is lacking. This article provides a comprehensive review of radiographic markers suggestive of stability, discusses treatment strategies, and proposes a treatment algorithm that is easily understood and applicable to not only those with a trauma background but also the general orthopaedic surgeon who will see these injuries frequently while on call.
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Affiliation(s)
- Joseph G Elsissy
- From the Department of Orthopedic Surgery (Elsissy), Chief of Orthopaedic Traumatology, Arrowhead Regional Medical Center, Colton, CA, the Department of Orthopedic Surgery (Ruckle), Loma Linda University Health Loma Linda, CA, the Department of Orthopedic Surgery (LeBrun), Chief of Orthopaedic Traumatology, Riverside Community Hospital, Riverside, CA, and the Department of Orthopedic Surgery (Johnson), University of Alabama at Birmingham, Birmingham, AB
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Patterson JT, Mayfield CK, Gary JL, Chung P, Hasegawa IG, Becerra JA. Pelvic binder radiography detects occult instability in cadaveric simulated lateral compression type I (LC1) pelvic fractures. Injury 2023; 54:111067. [PMID: 37777368 DOI: 10.1016/j.injury.2023.111067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
OBJECTIVES Occult instability in minimally displaced lateral compression (LC) pelvic ring injuries may have clinical relevance for treatment. We describe two novel LC pelvis fracture stress examinations - pelvic binder stress radiography (PBR) and pelvic binder stress bladder manometry (PBM) - which do not require sedation, anesthesia, patient transport, or radiation of personnel. METHODS A biomechanical study was performed with five fresh elderly cadavers. Sequential osteotomies of the pelvis simulated increasingly unstable LC pelvis fracture patterns (OTA/AO 61A2.2, 61B1.1a, 61B1.1b, 61B2.1). Compressive force was quantitatively applied using a pelvic binder and scale. Pelvis fracture displacement was measured on AP and inlet fluoroscopic views. Pelvic bladder pressure (PBM) was measured using a Foley catheter as a water column. RESULTS Fracture displacement strongly correlated with force applied (R2=0.600-0.963). PBR discriminated between simulated LC injuries. Mean displacement of 61B1.1b injuries >1cm was observed at 3.8kg on AP view and 5kg on inlet view. Mean displacement of 61B1.1a injuries >1cm was observed at 8.2kg on AP view and 9.3kg on inlet view. 61A2.2 injuries did not displace >1cm at forces up to 10kg. >95% of 61B1.1a and 61B1.1b injuries displaced >1cm at 10kg. PBM moderately correlated with force applied (R2=0.517-0.842) but did not discriminate between LC injuries. CONCLUSIONS PBR is feasible, precisely quantified occult mechanical instability in simulated LC pelvis fractures in response to reproducible applied force, and discriminated between simulated LC pelvis fractures. PBM did not discriminate between simulated LC fractures. A clinical trial to validate the safety and efficacy of PBR for assessing occult instability in LC pelvis fracture is warranted.
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Affiliation(s)
- Joseph T Patterson
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery.
| | - Cory K Mayfield
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Joshua L Gary
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Phillip Chung
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Ian G Hasegawa
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Jacob A Becerra
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
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Brostowitz NJ, Heimke IM, Furdock RJ, Vallier HA. Postmobilization Plain Radiography After Lateral Compression Type 1 Pelvic Ring Injury Does Not Affect Treatment. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202311000-00005. [PMID: 37947428 PMCID: PMC10635594 DOI: 10.5435/jaaosglobal-d-23-00182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/15/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION The purpose of this study was to describe the practice of postmobilization radiography after lateral compression type 1 pelvis ring injury. We hypothesized that postmobilization radiographs would be more frequent over time and would not influence treatment. METHODS Displacement of pelvis ring injury on initial and final plain radiographs was measured. Frequency of postmobilization radiography was determined, and the impact on treatment and final radiographical outcome were assessed. RESULTS Of the 156 patients reviewed, 98 (62.8%) were women and mean age was 60.1 years. Thirty-three of 156 patients (21.2%) had a postmobilization radiograph. Over 5 years, radiographs increased to 67% of presenting patients. None of the patients who received postmobilization plain radiographs (n = 33) had any change in clinical plan afterward; all continued with nonsurgical care. Initial fracture characteristics and alignment were no different for patients with postmobilization radiographs. Final alignment was unchanged in nearly 70%. Overall, 74% of all nonsurgical patients experienced no change in alignment, with similar rates among the patients with postmobilization radiographs. DISCUSSION Patients with an lateral compression type 1 fracture demonstrated no changes in care after receiving postmobilization radiographs. However, the frequency of postmobilization radiographs increased over time, denoting opportunities to reduce costs and to improve efficiency and safety.
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Zou M, Duan X, Li M, Ma L, Fang M, Sun J. Comparison of the two surgery methods combined with accelerated rehabilitation in the treatment of lateral compression type 1 pelvic fractures in the elderly. J Orthop Surg Res 2023; 18:734. [PMID: 37759296 PMCID: PMC10537174 DOI: 10.1186/s13018-023-04219-0] [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: 08/08/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Treating lateral compression type 1 (LC1) pelvic ring injuries in older patients is controversial. This study evaluated surgical treatments combined with ERAS for treating LC1 pelvic fractures in the elderly. METHODS In this retrospective study, patients who underwent surgery with INFIX (supra-acetabular spinal pedicle screws, and a subcutaneous connecting rod; the experimental group) or superior pubic ramus cannulated screw (the control group) fixation of LC1 pelvic fracture from January 2019 to January 2022 were reviewed. Injury radiography and computed tomography were performed to determine the Young-Burgess classification. All patients performed standardized early rehabilitation exercises after surgery and were followed up for > 12 months. After surgery, the Matta score and the visual analog scale (VAS) were evaluated, and the postoperative weight-bearing time and the length of stay (LOS) were recorded. The Barthel index and the Majeed score were evaluated at 4 months after surgery and at the last follow-up. RESULTS Fifty-three patients were included. Thirty-two patients included in the experimental group had a mean age of 75.0 ± 6.2 (range, 66-86) years, and the other 21 patients in the control group had a mean age of 74.6 ± 4.6 (range, 68-83) years. The mean follow-up time was 13.1 ± 1.6 (range, 12-18) months in the experimental group and 13.4 ± 1.3 (range, 12-16) months in the control group. There were no significant differences in follow-up time between the groups (P > 0.05). The mean VAS score, time to weight-bearing, and LOS were 2.0 ± 0.7 (range, 1-3), 1.1 ± 0.3 (range, 1-2) d, and 5.8 ± 0.9 (range, 4-7) d in the experimental group and 2.3 ± 1.2 (range, 1-5), 2.5 ± 1.6 (range, 1-7) d, and 6.1 ± 1.6 (range, 5-11) d in the control group, respectively. Between the two groups, there was a significant difference in the postoperative time to weight-bearing (P < 0.05), while there was no significant difference in the LOS (P > 0.05). No bedrest-related complications occurred in either group. The Matta score was 90.6% in the experimental group and 90.4% in the control group (P > 0.05). At the 4-months follow-up, the experimental group had a better Barthel index and Majeed score compared with the control group, which were 86.1 ± 6.2 (range, 70-95) vs. 81.2 ± 4.1 (range, 75-90) and 86.3 ± 3.3 (range, 78-91) vs. 80.3 ± 3.9 (range, 76-86), respectively. The experimental group had better early rehabilitation effect than the control group. There was no significant difference in Barthel index and Majeed score between the two groups at the last follow-up (P > 0.05). CONCLUSION Both INFIX and intramedullary superior pubic ramus cannulated screws can successfully treat LC1 pelvic fractures and reduce bed rest complications among older patients.
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Affiliation(s)
- Min Zou
- Department of Orthopedics, Chengdu Second People’s Hospital, Chengdu, 610017 Sichuan People’s Republic of China
| | - Xin Duan
- Department of Orthopedics, No. 1 People’s Hospital of Chengdu, Chengdu, 610041 Sichuan People’s Republic of China
| | - Mufan Li
- Department of Orthopedics, Chengdu Second People’s Hospital, Chengdu, 610017 Sichuan People’s Republic of China
| | - Liangyu Ma
- Department of Orthopedics, Chengdu Second People’s Hospital, Chengdu, 610017 Sichuan People’s Republic of China
| | - Miao Fang
- Department of Orthopedics, Chengdu Second People’s Hospital, Chengdu, 610017 Sichuan People’s Republic of China
| | - Jiachen Sun
- Department of Orthopaedic Surgery, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009 People’s Republic of China
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Tucker NJ, Scott BL, Heare A, Stacey SC, Mauffrey C, Parry JA. Nonoperative management of minimally displaced lateral compression type 1 (LC1) injuries with comminuted rami fractures is associated with late displacement. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03646-3. [PMID: 37542555 DOI: 10.1007/s00590-023-03646-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/11/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE Rami comminution has been found to be predictive of lateral compression type 1 (LC1) injury instability on examination under anesthesia (EUA) and lateral stress radiographs (LSR). The purpose of this study was to evaluate how rami comminution and subsequent operative vs. nonoperative management impact the late displacement of these injuries. METHODS Retrospective review of a prospectively collected LC1 database was performed to identify all patients with minimally displaced LC1 injuries (< 1 cm) and follow-up radiographs over a four-year period (n = 125). Groups were separated based on the presence of rami comminution and subsequent management, including rami comminution/operative (n = 49), rami comminution/nonoperative (n = 54), and no comminution/nonoperative (control group, n = 22). The primary outcome was late fracture displacement, analyzed as both a continuous variable and as late displacement ≥ 5 mm. RESULTS As a continuous variable, late fracture displacement was lower in the comminuted rami/operative group as compared to the comminuted rami/nonoperative group (PD: -3.0 mm, CI: -4.8 to -1.6 mm, p = 0.0002) and statistically non-different from control. Late displacement ≥ 5 mm was significantly more prevalent in the comminuted rami/nonoperative group than in the comminuted rami/operative and no comminution/nonoperative groups (control)(PD: -33.9%, CI: -49.0% to -16.1%, p = 0.0002 and PD: -30.0%, CI: -48.2% to -6.5%, p = 0.02, respectively). CONCLUSION Late fracture displacement was greatest in the group with rami comminution/nonoperative management. Rami comminution, which has been previously associated with dynamic displacement on EUA and LSR, is also associated with a higher incidence of late displacement when managed nonoperatively. LEVEL OF EVIDENCE Level III, prognostic retrospective cohort study.
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Affiliation(s)
- Nicholas J Tucker
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Bryan L Scott
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Austin Heare
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stephen C Stacey
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cyril Mauffrey
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua A Parry
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA.
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.
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Keltz E, Keren Y, Jain A, Stephens T, Rovitsky A, Ghrayeb N, Norman D, Peled E. Surgical stabilisation in equivocal pelvic ring injuries - Into the grey zone. Injury 2023; 54:110887. [PMID: 37453290 DOI: 10.1016/j.injury.2023.110887] [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: 01/06/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 07/18/2023]
Abstract
Pelvic ring injuries comprise a spectrum of bony, ligamentous and muscular injuries, described by several common classification systems. However, the majority of injuries lie in areas of intermediate severity, where complexity and variable nature make it extremely hard to define in detail. This fact and associated injuries make it extremely difficult to conduct randomised control trials, with purpose to direct treatment guidelines. Thus, special interest and expertise are required by pelvic trauma surgeons, while surgical indications and fixation methods rely on their experience, at least in part. Namely, a significant grey zone of indication exists. As fixation methods evolve, specifically percutaneous fixation using osseous fixation pathways, some injuries in which morbidity bound with surgical fixation was considered too high relative to its benefits, may be considered eligible for surgical treatment nowadays. Moreover, due to significant progress in the treatment of the acute polytrauma casualties, the survival rate increased over the years, emphasizing the effect of long-term morbidity and functional outcome of pelvic ring injuries. The purpose of this manuscript is to describe the equivocal areas of controversies, hence "the grey zone", and to provide the readership with up-to-date published data. We aimed to collect and detail clinical and radiological clues in the diagnosis of intermediate unstable anterior-posterior compression and lateral compression injuries, and for the selection of treatment methods and sequence. Recent publications have provided some insights into specific injury features that are correlated with increased chance of instability, pain and delay in ambulation. Specific focus is given to the utility of examination under anaesthesia in selected cases. Other publications surveyed the shared experience of pelvic trauma surgeons as for the classification, indication and treatment sequence of pelvic ring injuries. Although the data hasn't matured yet to a comprehensive treatment algorithm, it may serve clinicians well when making treatment decisions in the grey zone of pelvic ring injuries, and serve as a basis for future prospective studies.
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Affiliation(s)
- Eran Keltz
- Department of Orthopedic Surgery, Alfred Health, Melbourne, Victoria, Australia.
| | - Yaniv Keren
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Arvind Jain
- Department of Orthopedic Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Terry Stephens
- Department of Orthopedic Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Alexey Rovitsky
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Nabil Ghrayeb
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Doron Norman
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Eli Peled
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
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Tucker NJ, Scott BL, Heare A, Stacey SC, Mauffrey C, Parry JA. Combined Anterior-Posterior versus Posterior-Only Fixation of Stress-Positive Minimally Displaced Lateral Compression Type 1 (LC1) Pelvic Ring Injuries. J Orthop Trauma 2023; 37:189-194. [PMID: 36395075 DOI: 10.1097/bot.0000000000002519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To compare hospital outcomes and late displacement between stress-positive minimally displaced lateral compression type 1 (LC1) pelvic ring injuries treated with combined anterior-posterior versus posterior-only fixation. DESIGN Retrospective comparative cohort. SETTING Urban level-one trauma center. PATIENTS/PARTICIPANTS LC1 injuries managed operatively. INTERVENTION Anterior-posterior versus posterior-only fixation. MAIN OUTCOME MEASUREMENTS Physical therapy (PT) clearance, discharge location, hospital length of stay (LOS), inpatient morphine equivalent doses (MED), and fracture displacement at follow-up. RESULTS Groups were similar in demographic and injury characteristics (age, high energy mechanism, ASA score, stress displacement, and rami/sacral fracture classifications). Anterior-posterior fixation resulted in longer operative times (median difference (MD): 27.0 minutes, 95% confidence interval (CI): 17.0 to 40.0, P < 0.0001) and had a trend of increased estimated blood loss (MD: 10 mL, CI: 0 to 30, P = 0.07). Patients with anterior-posterior fixation required less inpatient MEDs (MD: -180.0, CI: -341.2 to -15.0, P = 0.02), were more likely to clear PT by discharge (100% vs. 70%, proportional difference (PD): 30%, CI: 2.0%-57.2%, P = 0.02), were less likely to discharge to rehabilitation facilities (0% vs. 30%, PD: 30%, CI: 2.0%-57.2%, P = 0.02), and had a trend of less days to clear PT after surgery (MD: -1, CI: -2 to 0, P = 0.09) and decreased LOS (MD: -1, CI: -4 to 1, P = 0.17). Late fracture displacement did not differ between groups. CONCLUSION Anterior-posterior fixation of LC1 injuries was associated with an improved early hospital course-specifically, reduced inpatient opioid use and an increased number of patients who could clear PT and discharge home. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nicholas J Tucker
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Bryan L Scott
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
| | - Austin Heare
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Stephen C Stacey
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Cyril Mauffrey
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Joshua A Parry
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
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Comparing Emergency Department Stress of Lateral Compression Type 1 Pelvis Fractures With a Validated Instability Scoring System. J Am Acad Orthop Surg 2023; 31:e451-e458. [PMID: 36727708 DOI: 10.5435/jaaos-d-22-00160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 12/12/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Lateral compression type 1 (LC1) pelvic ring injuries represent a heterogeneous group of fractures with controversial surgical indications. Recently, multiple institutions have suggested the safety and reliability of an emergency department (ED) stress to evaluate for occult instability. The purpose of this study was to correlate ED stress examination of LC1 pelvis fractures against a validated fracture instability scoring system. METHODS This was a retrospective review of a consecutive series of 70 patients presenting with minimally displaced LC1 fractures at a level 1 academic trauma center. All patients were stressed in the ED radiology suite, and displacement was measured by comparing calibrated stress radiographs with static radiographs (>10 mm displacement defined positivity). ED stress results were compared with radiographic scores assigned according to the validated Beckmann scoring system (score <7: stable-nonsurgical recommendation; score 7 to 9: indeterminant recommendation; and score >9: unstable-surgical recommendation). RESULTS Thirteen patients had a positive ED stress examination, and 57 patients stressed negative. The mean displacement was significantly different between the three groups (Beckmann 5 to 6: 3.31 mm, SD = 2.4; Beckmann 7 to 9: 4.23 mm, SD = 3.2; Beckmann 10+: 12.1 mm, SD = 8.6; P < 0.001). Zero of 18 patients in the stable group stressed positive, and only 3 of 38 patients in the indeterminant group stressed positive (7.9%). Finally, 10 of 14 patients in the unstable group stressed positive (71.4%; P < 0.001). Sacral displacement (P = 0.001), superior ramus location (P < 0.02), and sacral columns (P < 0.001) significantly predicted ED stress positivity in multivariate analysis. CONCLUSIONS Comparison of a validated instability scoring system with ED stress examination of minimally displaced LC1 fractures in awake and hemodynamically stable patients showed excellent correlation. This suggests that the ED stress examination is a useful diagnostic adjunct. LC1 fracture characteristics should be analyzed to determine which pelvic fracture characteristics determine occult instability before stress examination. LEVEL OF EVIDENCE Level III diagnostic.
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11
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Muacevic A, Adler JR, Hormazabal J. Revisiting Non-operative Treatment of Lateral Compression Pelvic Fractures, Analysis of Rehabilitation, and Radiologic Outcomes in a Historical Cohort Using Today's Association of Osteosynthesis (AO) Stability Criteria. Cureus 2022; 14:e32101. [PMID: 36601154 PMCID: PMC9803861 DOI: 10.7759/cureus.32101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Type I lateral compression pelvic fractures (LC-I) have historically been treated conservatively. Inferior outcomes in a distinctive subset of these injuries have been reported, therefore their management has shifted towards surgery. Revisiting the historical series of LC-I allows us to determine whether non-operative management of these unstable patterns results in poorer outcomes. The objective was to evaluate the differences in the rehabilitation progress, fracture consolidation, and displacement in non-operatively treated LC-I fractures that would be considered unstable using today's Association of Osteosynthesis (AO) criteria. METHODS We conducted a retrospective review of conservatively treated LC-I injuries in a single-level I trauma center between June 2010 and June 2014. Patients were distributed in stable (group A) and unstable (group B) groups according to the 2018 AO classification. Time to walk independently (TWI), time to return to work (TRW), fracture consolidation, and displacement were analyzed. RESULTS 34 patients, mean age of 45.5 ±14.5 years, were included. Mean TWI in groups A and B were 71.2 ±31.9 and 105.9 ±50.9 days (p=0.027). Mean TRW was 106 ±51.3 and 157 ±84 days in groups A and B, respectively (p=0.038). A difference in mean TWI and TRW of 34.7 and 51.3 days between groups was observed. No significant differences in fracture consolidation or displacement were observed. CONCLUSION Unstable fractures presented significantly longer TWI and TRW. The revised AO classification contributes to the identification of fracture patterns that correlate with prolonged rehabilitation in which additional treatment strategies might be considered.
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Anterior Pelvic Ring Fracture Pattern Predicts Subsequent Displacement in Lateral Compression Sacral Fractures. J Orthop Trauma 2022; 36:550-556. [PMID: 35583370 DOI: 10.1097/bot.0000000000002407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine if anterior pelvic fracture pattern in lateral compression (LC) sacral fractures correlates with subsequent displacement on examination under anesthesia (EUA) or follow-up in both nonoperative and operative cases. DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENTS Two hundred twenty-seven skeletally mature patients with traumatic LC (OTA/AO 61B1.1, 61B2.1-2, and 61B3.1-2) pelvic ring injuries treated nonoperatively, with EUA, or with pelvic fixation were included. INTERVENTION The study intervention included retrospective review of patients' charts and radiographs. MAIN OUTCOME MEASUREMENT Displacement on EUA or follow-up radiographs (both operative and nonoperative) correlated with anterior pelvic ring fracture pattern. RESULTS Independent of sacral fracture pattern (complete or incomplete), risk of subsequent displacement on EUA or at follow-up after both nonoperative and operative treatments correlated strongly with ipsilateral superior and inferior pubic rami fractures that were either comminuted (95.6%, P < 0.001) or oblique (100%, P < 0.001). Patients with transverse or lack of inferior pubic ramus fracture did not displace (0%, P < 0.001). Out of 21 LC injuries treated with posterior-only fixation, displacement at follow-up occurred in all 11 patients (100%) with comminuted and/or oblique superior and inferior pubic rami fractures. Nakatani zone I and II rami fractures correlated most with risk of subsequent displacement. CONCLUSIONS Unstable anterior fracture patterns are characterized as comminuted and/or oblique fractures of ipsilateral superior and inferior pubic rami. EUA should be strongly considered in these patients to disclose occult instability, for both complete and incomplete sacral fracture patterns. Additionally, these unstable anterior fracture patterns are poor candidates for posterior-only fixation and supplemental anterior fixation should be considered. Irrespective of sacral fracture pattern (complete or incomplete), nonoperative management is successful in patients with transverse or lack of inferior pubic ramus fractures. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Varma JR, Foxall-Smith M, Donovan R, Whitehouse MR, Rogers C, Acharya M. Surgical Versus Non-surgical Treatment of Unstable Lateral Compression Type I (LC1) Injuries of the Pelvis With Complete Sacral Fractures in Non-fragility Fracture Patients: A Systematic Review. Cureus 2022; 14:e29239. [PMID: 36262937 PMCID: PMC9573782 DOI: 10.7759/cureus.29239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 11/05/2022] Open
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Tucker NJ, Heare A, Stacey SC, Mauffrey C, Parry JA. The lateral stress radiograph: an effective alternative to examination under anesthesia for identifying occult instability in minimally displaced lateral compression pelvic ring injuries. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03373-1. [PMID: 36056970 DOI: 10.1007/s00590-022-03373-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE The purpose of this study was to review the practice of utilizing lateral stress radiographs (LSRs) to identify occult instability (≥ 10 mm of dynamic displacement on LSRs) of minimally displaced lateral compression type 1 (LC1) pelvic ring injuries and to evaluate for associations between instability and patient demographics, injury characteristics, and hospital course. METHODS A retrospective review of a prospective registry from 2018 to 2022 identified 151 patients with LC1 injuries. LSRs were obtained in 86.8% (131/151) of patients. Three (2.2%) patients were excluded for malrotation of LSRs, leaving 128 patients for analysis. RESULTS The median maximum dynamic displacement on LSRs was 12.2 mm (IQR: 5.9 to 17.3). Occult instability was present in 62.5% (80/128) of patients and was associated with older age (Median difference 11.0 years, 95% CI 3.0 to 20.0), Nakatani type 1 rami fractures (73.7% vs. 47.9%, p = 0.001), and rami fracture comminution (Proportional difference 58.7%, 95% CI 42.8 to 71.3%), but not gender, high-energy mechanism, bilateral rami fractures, Denis classification, sacral fracture completeness, or sacral comminution. Patients with occult instability took longer to ambulate 15 feet and clear physical therapy (PT), were more likely to be unable to clear PT by hospital day 3 or by time of discharge, had longer hospital stays, and were more likely to require rehabilitation facilities. CONCLUSION LSRs were obtained in a majority of patients. Occult instability was frequently present and associated with older age, comminuted distal pubic rami fractures, longer hospital stays, longer times to mobilize and clear PT, and an increased need for rehabilitation facilities.
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Affiliation(s)
- Nicholas J Tucker
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, Denver, CO, MC 0188, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Austin Heare
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, Denver, CO, MC 0188, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stephen C Stacey
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, Denver, CO, MC 0188, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cyril Mauffrey
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, Denver, CO, MC 0188, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua A Parry
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, Denver, CO, MC 0188, USA.
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.
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Tucker NJ, Kelley N, Strage KE, Mauffrey C, Parry JA. Pelvic ring injuries after alpine ski and snowboard accidents. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03331-x. [PMID: 35831489 DOI: 10.1007/s00590-022-03331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/23/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE The purpose of this study was to analyze the patient/injury characteristics and associated hospital course of patients sustaining traumatic pelvic ring injuries after alpine ski and snowboard accidents at a level one trauma center in the Rocky Mountain region. METHODS Patient/injury characteristics were obtained from patients presenting with pelvic ring injuries after alpine ski (n = 55) and snowboard (n = 9) accidents. Characteristics and outcomes analyzed included mechanism of injury, pelvic ring classification (Young-Burgess and Tile), hospital admission, physical therapy (PT) clearance, ambulation, length of stay, inpatient morphine milligram equivalents (MME), and discharges to rehabilitation facility. RESULTS Snowboarders were more often younger, male, tobacco/substance users, and more likely to be injured by a fall from height than skiers. There were no differences in injury classification or hospital course outcomes between alpine sports. Most common injuries included lateral compression type 1 (LC1) injuries (37.5%), isolated pubic ramus fractures (31.3%), and isolated iliac wing fractures (15.6%). LC1 injuries were unstable in 50% of cases and associated with increased admissions (proportional difference: 47.5%, CI: 23.8-64.5%, p = 0.0002), longer time to PT clearance (median difference(MD): 1.0 day, CI: 0-2.0, p = 0.03), longer LOS (MD: 2.0, CI: 0-2.0, p = 0.02), and increased inpatient MMEs (MD: 197.9 MME, CI: 30.0-420.0, p = 0.02), as compared to other pelvic ring injuries. CONCLUSION The majority of pelvic ring injuries from alpine ski and snowboard accidents were LC1 injuries, half of which were unstable, resulting in longer hospital stays, time to PT clearance/ambulation, and opioid use.
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Affiliation(s)
- Nicholas J Tucker
- Department of Orthopedics, Denver Health Medical Center, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Naomi Kelley
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Katya E Strage
- Department of Orthopedics, Denver Health Medical Center, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Cyril Mauffrey
- Department of Orthopedics, Denver Health Medical Center, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua A Parry
- Department of Orthopedics, Denver Health Medical Center, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA.
- University of Colorado School of Medicine, Aurora, CO, USA.
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DeKeyser GJ, Kellam PJ, Haller JM, Higgins TF, Marchand LS, Rothberg DL. Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable. J Bone Joint Surg Am 2022; 104:336-344. [PMID: 34921551 DOI: 10.2106/jbjs.21.00737] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Occult instability of lateral compression type-1 (LC1) pelvic ring injuries may be determined with a fluoroscopic stress examination under anesthesia (EUA) performed in the operating room. We hypothesized that LC1 injuries, similar to some fractures of the extremities, could be radiographically stressed for stability in the emergency department (ED). Our primary objective was to determine if stress examination of LC1 fractures could be safely and accurately performed in the ED and could be tolerated by patients. METHODS A prospective, consecutive series of 70 patients with minimally displaced LC1 pelvic injuries (<10-mm displacement on presentation) underwent stress examinations performed by the on-call orthopaedic resident in the ED radiology suite. The stress examination series included static 40° inlet, internal rotation stress inlet, and external rotation stress inlet views. Pelvic fractures that had positive stress results (≥10 mm of overlap of the rami) were indicated for a surgical procedure. These fractures also underwent EUA in order for the 2 techniques to be compared. RESULTS All patients tolerated the ED stress examination without general anesthetic or hemodynamic instability. Fifty-seven patients (81%) had negative stress results and were allowed to bear weight. All patients with negative stress results who had 3-month follow-up went on to radiographic union without substantial displacement. For the patients with a positive stress result in the ED, the mean displacement was 15.15 mm (95% confidence interval [CI], 10.8 to 19.4 mm) for the ED stress test and 15.60 mm (95% CI, 11.7 to 19.4 mm) for the EUA (p = 0.86). Two patients with a negative ED stress test did not mobilize during their hospitalization and underwent EUA and conversion to a surgical procedure. Thus, a total of 11 patients underwent both stress testing in the ED and EUA; no patient had a positive result on one test but a negative result on the other. CONCLUSIONS ED stress examination of LC1 injuries is a safe and reliable method to determine pelvic ring stability. The displacement measured in the ED stress examination is similar to the displacement measured under general anesthesia. Furthermore, a negative ED stress examination predicts successful nonoperative treatment. Given the results of this study, we encourage the use of stress examination in the ED for LC1-type injuries involving complete sacral fractures only. Widescale adoption of this streamlined protocol may substantially diminish cost, anesthetic risk, and potential operations for patients. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Graham J DeKeyser
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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Tucker NJ, Mauffrey C, Parry JA. Unstable minimally displaced lateral compression type 1 (LC1) pelvic ring injuries have a similar hospital course as intertrochanteric femur fractures. Injury 2022; 53:481-487. [PMID: 34911634 DOI: 10.1016/j.injury.2021.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 12/03/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to evaluate how the hospital course of minimally displaced LC1 fractures, with and without occult instability, compares with that of intertrochanteric femur fractures. PATIENTS AND METHODS Retrospective comparative cohort analysis at an urban level one trauma center of 40 consecutive patients with an isolated LC1 pelvic ring injury and 40 age/sex matched patients with an isolated intertrochanteric femur fracture was performed. Medical records and radiographs were reviewed for patient and injury characteristics, including demographics, displacement, time to surgery, ambulation, physical therapy (PT) clearance, hospital length of stay (LOS), and inpatient morphine milligram equivalents (MME). RESULTS The LC1 pelvic ring injury group included 26 (65%) patients with ≥ 10 mm of displacement on lateral stress radiographs. The unstable LC1 group, compared to the stable LC1 group, had a greater LOS (median difference (MD): 2 days, 95% confidence interval (CI): 1 to 4, p = 0.0004), longer time to ambulate 15 feet (MD: 1 day, CI: 1 to 2, p = 0.0002), longer time to clear PT (MD: 2 days, CI: 1 to 3, p = 0.0003), and more inpatient MMEs (MD: 386 MME, CI: 225.8 to 546.7, p = 0.0002). The unstable LC1 and intertrochanteric fracture groups had no detectable differences in LOS (p = 0.24), days to ambulate 15 feet (p = 0.46), days to clear PT (p = 0.95), and inpatient MMEs (p = 0.06). CONCLUSION Patients with minimally displaced unstable LC1 injuries had worse hospital courses than stable LC1 injuries and similar hospital courses as intertrochanteric femur fractures. These findings emphasize the associated morbidity of unstable LC1 injuries. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
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Affiliation(s)
- Nicholas J Tucker
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO 80204, United States
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO 80204, United States; Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Joshua A Parry
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO 80204, United States; Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO, United States.
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Wang P, Ali SH, Fei C, Zhang B, Wei X, Wang H, Cong Y, Deng H, Fu Y, Zhang K, Zhuang Y. Management of LC Type I (LC-1) Pelvic Injuries with Complete Sacral Fracture: Comparison of Solitary Anterior Fixation with Combined Anterior-Posterior Fixation. BIOMED RESEARCH INTERNATIONAL 2022; 2022:3918794. [PMID: 35087907 PMCID: PMC8789421 DOI: 10.1155/2022/3918794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/08/2021] [Accepted: 12/16/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Management of LC-1 type pelvic injuries, particularly in patients with complete sacral fracture (LC-1 PICSF, OTA type 61-B2.1), remains controversial. Specific indications for solitary fixation remain unclear, and there is a paucity of outcomes data in comparison to combined fixation. We undertook a retrospective study in patients with LC-1 PICSFs to compare outcomes between solitary anterior fixation and combined anterior-posterior fixation. METHODS A retrospective cohort study was conducted with enrollment from 2016 to 2018 at a single tertiary-referral center in China. Adults with operatively managed LC-1 PICSFs were enrolled. Patients with sacral displacement < 1 cm as assessed by axial CT received solitary anterior ring fixation (group A); patients with displacement ≥ 1 cm received combined fixation of both the anterior and posterior rings (group B). Reduction was confirmed by manipulation under anesthesia. Patients followed up for at least 24 months postoperatively. Primary outcome was function (Majeed score). Secondary outcomes included intraoperative characteristics, pain (VAS score), quality of fracture reduction (Tornetta and Matta radiographic grading), rate of nonunion, early weight-bearing status, and complication rate. RESULTS 68 (89%) of 76 enrolled patients completed follow-up. Patients in group A exhibited improved operative times, less time under fluoroscopy, and less blood loss as compared to group B. There were no significant differences between groups A and B regarding quality of fracture reduction, rate of union, functional outcomes, or rate of complications. Notably, group B patients were more likely to achieve full early weight-bearing. CONCLUSION LC-1 PFCSFs can get benefits from ORIF; the treatment algorithm should be differently made following the degree of the sacral fractures displacement. Less than 1 cm sacral fracture displacement may get good functional outcomes from solitary anterior fixation. However, for the sacral fractures displacement greater or equal to 1 cm, both the anterior and posterior pelvic rings should be surgical stabilization.
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Affiliation(s)
- Pengfei Wang
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Syed Haider Ali
- Institute for Global Orthopaedics & Traumatology, University of California, 2550 23rd St., Bldg.9, 2nd Floor San Francisco, CA, 94110 San Francisco, USA
| | - Chen Fei
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Binfei Zhang
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Xing Wei
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Hu Wang
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Yuxuan Cong
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Hongli Deng
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Yahui Fu
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Kun Zhang
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Yan Zhuang
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
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Zhang BF, Wang J, Zhang YM, Cheng HG, Cheng QY, Cao WW. The morphological mapping of lateral compression type 1 pelvic fracture and pelvic ring stability classification: a finite element analysis. J Orthop Surg Res 2021; 16:675. [PMID: 34789299 PMCID: PMC8597293 DOI: 10.1186/s13018-021-02818-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/01/2021] [Indexed: 11/14/2022] Open
Abstract
Purpose This finite element analysis assessed lateral compression (LC-1) fracture stability using machine learning for morphological mapping and classification of pelvic ring stability. Methods Computed tomography (CT) files of LC-1 pelvic fractures were collected. After morphological mapping and producing matrix data, we used K-means clustering in unsupervised machine learning to classify the fractures. Based on these subtypes, we manually added fracture lines in ANSYS software. Finally, we performed a finite element analysis of a normal pelvis and eight fracture subtypes based on von Mises stress and total deformation changes. Results A total of 218 consecutive cases were analyzed. According to the three main factors—zone of sacral injury and completion, pubic ramus injury side, and the sagittal rotation of the injured hemipelvis—the LC-1 injuries were classified into eight subtypes (I–VIII). No significant differences in stress or deformation were observed between unilateral and bilateral public ramus fractures. Subtypes VI and VIII showed the maximum stress while subtypes V–VIII showed the maximum deformation in the total pelvis and sacrum. The subtypes did not differ in superior public ramus deformation. Conclusions Complete fracture of sacrum zones 2/3 may be a feature of unstable LC-1 fractures. Surgeons should give surgical strategies for subtypes V–VIII.
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Affiliation(s)
- Bin-Fei Zhang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China.
| | - Jun Wang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China
| | - Yu-Min Zhang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China
| | - Hui-Guang Cheng
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China
| | - Qian-Yue Cheng
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China
| | - Wen-Wen Cao
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China
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Validation of Relative Motion Measurement Method of Lateral Compression Pelvic Fractures During Examination Under Anesthesia. J Orthop Trauma 2021; 35:e289-e292. [PMID: 33252442 DOI: 10.1097/bot.0000000000002026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine if the relative distance between the acetabular teardrops on unstressed and lateral compressive stress examination under anesthesia (EUA) pelvic fluoroscopic images is reproducible between independent reviewers. DESIGN Retrospective database review. SETTING Level 1 trauma center. PATIENTS/INTERVENTION Fifty-eight patients with a lateral compression type 1 pelvic ring injury who underwent EUA. MAIN OUTCOME MEASURE Validation of EUA objective measurements between blinded, independent reviewers using interclass and intraclass correlation coefficients. RESULTS There was excellent interobserver and intraobserver reliability between all reviewers. Values for each intraclass correlation coefficients (including 95% confidence intervals) were between 0.96 (0.95-0.098) and 0.99 (0.99-0.99) for all measurements. P values were <0.0001 for all measured parameters. CONCLUSIONS The relative change in distance between the acetabular tear drops during lateral compressive EUA of lateral compression type 1 pelvic injuries is reliable between independent reviewers. This allows for accurate, objective measurement of pelvic motion independent of patient size or body habitus. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Tucker D, Carney J, Nguyen A, Alluri RK, Lee A, Marecek G. Examination Under Anesthesia Improves Agreement on Mechanical Stability: A Survey of Experienced Pelvic Surgeons. J Orthop Trauma 2021; 35:e241-e246. [PMID: 33252448 DOI: 10.1097/bot.0000000000001996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess agreement among experts in pelvic fracture management regarding stability and need for operative repair of lateral compression-type pelvic fractures with static radiographs compared to static radiographs and examination under anesthesia (EUA). SETTING Online survey. PATIENTS/PARTICIPANTS Ten patients who presented to our level-1 trauma center with a pelvic ring injury were selected. Vignettes were distributed to 11 experienced pelvic surgeons. INTERVENTION Examination under anesthesia. MAIN OUTCOME MEASUREMENTS Agreement regarding pelvic fracture stability and need for surgical fixation. RESULTS Agreement on stability was achieved in 4 (40%) cases without EUA compared to 8 (80%) cases with EUA. Interreviewer reliability was poor without EUA and moderate with EUA (0.207 vs. 0.592). Agreement on need to perform surgery was achieved in 5 (50%) cases compared to 6 (60%) cases with EUA. Interreviewer reliability was poor without EUA and moderate with EUA (0.250 vs. 0.432). For reference cases with agreement, surgeons were able to predict stability or instability using standard imaging in 57 of a possible 88 reviewer choices (64.8%) compared to 82 of 88 choices (93.2%) with the addition of EUA (P < 0.0001). CONCLUSIONS EUA increased agreement among experienced pelvic surgeons regarding the assessment of pelvic ring stability and the need for operative intervention. Further research is necessary to define specific indications for which patients may benefit from EUA.
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Affiliation(s)
- Douglass Tucker
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - John Carney
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Aileen Nguyen
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Ram K Alluri
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Adam Lee
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Geoffrey Marecek
- Department of Orthopaedic Surgery, Cedar-Sinai Medical Center, Los Angeles, CA
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Kuršumović K, Hadeed M, Bassett J, Parry JA, Bates P, Acharya MR. Lateral compression type 1 (LC1) pelvic ring injuries: a spectrum of fracture types and treatment algorithms. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:841-854. [PMID: 33860399 DOI: 10.1007/s00590-021-02935-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
Lateral compression type 1 (LC1) fractures are the commonest pelvic ring injury. However, they represent a heterogenous spectrum of injury mechanisms and fracture patterns, resulting in a lack of strong evidence for a universally agreed treatment algorithm. Although consensus exists that LC1 fractures have a preserved posterior ligamentous complex and are vertically stable, controversy persists around defining internal rotational instability. As such, treatment strategies extend from routine non-operative management through to dynamic imaging such as examination under anaesthetic (EUA) or stress radiographs to guide fixation algorithm. Multiple protocols sit between these two, all with slightly different thresholds for advocating surgery or otherwise, exemplifying a broad lack of consensus that is not seen for other, more severe, grades of pelvic ring injury. In the following review we discuss the evolving concepts of pelvic ring instability and management, starting from a historical perspective, through to current trends and controversies in LC1 fracture treatment. Emerging directions for research and emerging pharmacological and surgical treatments/technologies are also considered and expert commentary from 3 leading centres provided. The distinction is made between LC1 fracture arising from high-energy trauma and those following low-energy falls from standing height (so-called fragility fractures of the pelvis-FFP), since these two patient groups have different functional requirements and medical vulnerabilities. Issues pertaining to FFP are considered separately.
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Affiliation(s)
- Kenan Kuršumović
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Michael Hadeed
- Department of Orthopaedic Surgery, Denver Health Medical Centre, University of Colorado School of Medicine, Denver, CO, USA
| | - James Bassett
- Department of Trauma and Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Joshua A Parry
- Department of Orthopaedic Surgery, Denver Health Medical Centre, University of Colorado School of Medicine, Denver, CO, USA
| | - Peter Bates
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, The Royal London Hospital, London, UK.
| | - Mehool R Acharya
- Department of Trauma and Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
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Kanakaris NK, Ciriello V, Stavrou PZ, West RM, Giannoudis PV. Deep infection following reconstruction of pelvic fractures: prevalence, characteristics, and predisposing risk factors. Eur J Trauma Emerg Surg 2021; 48:3701-3709. [PMID: 33683381 PMCID: PMC9532299 DOI: 10.1007/s00068-021-01618-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/09/2021] [Indexed: 12/21/2022]
Abstract
Purpose To identify the incidence, risk factors, and treatment course of patients who developed deep infection following fixation of pelvic fractures. Methods Over a period of 8 years patients who underwent pelvic reconstruction in our institution and developed postoperative infection were included. Exclusion criteria were pathological fractures and infections that were not secondary to post-traumatic reconstruction. The mean time of follow-up was 43.6 months (33–144). For comparison purposes, we randomly selected patients that underwent pelvic fracture fixation from our database (control group). A logistic regression was fitted to patient characteristics including age, sex, ISS, and diabetic status. Results Out of 858 patients, 18 (2.1%) (12 males), with a mean age of 41 (18–73) met the inclusion criteria. The control group consisted of 82 patients with a mean age of 41 years (18–72). The mean ISS was 27.7 and 17.6 in the infection and control group, respectively. The mean time from pelvic reconstruction to the diagnosis of infection was 20 days (7–80). The median number of trips to theatre was 3 (1–16). Methicillin-resistant Staphylococcus aureus (MRSA) was the most frequently isolated organism in the years prior to 2012. Eradication was achieved in 93% of the patients. The most important risk factors for deep infection were ISS (OR 1.08, 1.03–1.13), posterior sacral approach (OR 17.03, 1.49–194.40), and diabetes (OR 36.85, 3.54–383.70). Conclusion In this retrospective case–control study, deep infection following pelvic trauma was rare. A number of patient-, injury- and surgery-related factors have shown strong correlation with this serious complication.
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Affiliation(s)
- Nikolaos Konstantinou Kanakaris
- Academic Department of Trauma and Orthopaedic Surgery, Leeds General Infirmary, Clarendon Wing, Floor D, Great George Street, Leeds, LS1 3EX, UK.
| | - Vincenzo Ciriello
- Academic Department of Trauma and Orthopaedics, School of Medicine, Leeds Teaching Hospitals, University of Leeds, Leeds, UK
| | - Petros Zoi Stavrou
- Academic Department of Trauma and Orthopaedics, School of Medicine, Leeds Teaching Hospitals, University of Leeds, Leeds, UK
| | | | - Peter Vasiliou Giannoudis
- Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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Huang H, Zhang BF, Liu P, Deng HL, Wang PF, Wang H, Li BF, Cong YX, Zhuang Y. The traditional experience strategy (TES) and combined ultrasonography examination (CUE) for the treatment of lateral compression type 1 pelvic fractures: a historical control study. BMC Musculoskelet Disord 2021; 22:110. [PMID: 33494747 PMCID: PMC7836564 DOI: 10.1186/s12891-021-03993-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 01/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is difficult to judge the stability of lateral compression type-1 (LC-1) pelvic fracture, as it is often based on static images of the pelvis. Compared with the traditional experience strategy, ultrasonography examination may be able to distinguish operative and conservative patients before definitive treatment. However, in previous studies, we have not compared the outcomes between traditional experience strategy (TES group) and combined ultrasonography examination (CUE group). Thus, the aim of the study is comparing the differences between TES and CUE strategy, to identify the value of ultrasonography examination. METHODS Medical records system for patients with LC-1 pelvic fractures who were treated with TES and CUE strategy were included. Patients' baseline characteristics, treatment strategy, and function were recorded at follow-up. Functional outcomes were evaluated using the Majeed grading system. RESULTS In total, 77 patients with LC-1 pelvic fractures were included in the study. There were 42 and 35 patients in TES and CUE group, respectively. Compared to TES group (69 %), there were less proportion patients chosen the operative treatment in CUE group (43 %, P = 0.021). The volume of intraoperative blood loss in CUE operative group was more than TES operative group (P = 0.037). There were more patients with complete sacral fracture in CUE operative group than TES operative group (P = 0.002). The Majeed scores in CUE conservative group was higher than TES conservative group (P = 0.008). The overall Majeed scores in CUE group was higher than that in TES group (P = 0.039). CONCLUSIONS The ultrasonography examination could relatively accurately identify the unstable LC-1 pelvis than the traditional experience strategy, the operative rate could be reduced and the overall function of LC-1 patients could be improved under the ultrasonography examination. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hai Huang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Bin-Fei Zhang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Ping Liu
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Hong-Li Deng
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Peng-Fei Wang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Hu Wang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Bao-Feng Li
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Yu-Xuan Cong
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China.
| | - Yan Zhuang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China.
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The Lateral Stress Radiograph Identifies Occult Instability of Lateral Compression Pelvic Ring Injuries Without Sedation. J Orthop Trauma 2020; 34:567-571. [PMID: 33065655 DOI: 10.1097/bot.0000000000001805] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine if pelvic ring displacement on the lateral stress radiograph (LSR) correlated with displacement on examination under anesthesia (EUA). DESIGN Retrospective cohort study. SETTING Urban Level I trauma center. PATIENTS/PARTICIPANTS Twenty consecutive patients with unilateral minimally displaced LC1 injuries with complete sacral fractures. INTERVENTION An anteroposterior pelvis radiograph taken in the lateral decubitus position (LSR) was performed on awake patients before EUA in the operating room. MAIN OUTCOME MEASUREMENTS Correlation between ≥1 cm of pelvic ring displacement on the LSR and EUA. RESULTS The LSR demonstrated ≥1 cm of displacement in 11 of the 20 patients (55%). All of these patients had ≥1 cm of displacement on EUA and underwent surgical fixation. The remaining 9 patients with <1 cm of displacement on the LSR also had <1 cm of displacement on EUA and were managed nonoperatively. CONCLUSIONS The LSR reliably identified occult instability in LC1 pelvic ring injuries and demonstrated 100% correlation with EUA. In contrast to EUA, the LSR does not require sedation and normalizes the amount of force applied to determine instability. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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A Survey to Assess Agreement Between Pelvic Surgeons on the Outcome of Examination Under Anesthesia for Lateral Compression Pelvic Fractures. J Orthop Trauma 2020; 34:e304-e308. [PMID: 32815841 DOI: 10.1097/bot.0000000000001759] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess agreement among pelvic surgeons regarding the interpretation of examination under anesthesia (EUA), the methodology by which EUA should be performed, and the definition of a positive examination. DESIGN Survey. PATIENTS/PARTICIPANTS Ten patients who presented to our Level 1 trauma center with a pelvic ring injury were selected as clinical vignettes. Vignettes were distributed to 15 experienced pelvic surgeons. INTERVENTION Examination under anesthesia. MAIN OUTCOME MEASUREMENTS Agreement regarding pelvic fracture stability (defined as >80% similar responses), need for surgical fixation, definition of an unstable EUA, and method of performing EUA. RESULTS There was agreement that a pelvic fracture was stable or unstable in 8 (80%) of 10 cases. There was agreement that fixation was required or not required in 6 (60.0%) of 10 cases. Seven (46.7%) surgeons endorsed performing a full 15-part EUA, whereas the other 8 (53.3%) used an abbreviated or alternative method. Eight (53.3%) surgeons provided a definition of what constitutes a positive EUA, whereas the remaining 7 did not endorse adhering to a strict definition. CONCLUSIONS Pelvic surgeons generally agree on what constitutes a positive or negative EUA but not necessarily the implications of a positive or negative examination. There is no clear consensus among surgeons regarding the method of performing EUA nor regarding the definition of a positive EUA. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
Lateral compression type 1 pelvic fractures comprise a spectrum of injuries of varying stability. The clinician should be cognizant of signs and symptoms of instability including complete sacral fractures, bilateral ramus fractures, displacement greater than 1 cm, high-energy mechanism, and inability to bear weight. Management of these injuries is controversial, but the clinician should consider examination under anesthesia and potentially surgical stabilization.
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Barnfield S, Ingram J, Halliday R, Griffin X, Greenwood R, Kandiyali R, Thompson J, Glynn J, Beasant L, McArthur J, Bates P, Acharya M. TULIP: a randomised controlled trial of surgical versus non-surgical treatment of lateral compression injuries of the pelvis with complete sacral fractures (LC1) in the non-fragility fracture patient-a feasibility study protocol. BMJ Open 2020; 10:e036588. [PMID: 32047021 PMCID: PMC7044852 DOI: 10.1136/bmjopen-2019-036588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Lateral compression type 1 (LC1) pelvic fractures are the most common type of pelvic fracture. The majority of LC1 fractures are considered stable. Fractures where a complete sacral fracture is present increases the degree of potential instability and have the potential to displace over time. Non-operative management of these unstable fractures may involve restricted weight bearing and significant rehabilitation. Frequent monitoring with X-rays is also necessary for displacement of the fracture. Operative stabilisation of these fractures may be appropriate to prevent displacement of the fracture. This may allow patients to mobilise pain-free, quicker. METHODS AND ANALYSIS The study is a feasibility study to inform the design of a full definitive randomised controlled trial to guide the most appropriate management of these injuries. Participants will be recruited from major trauma centres and randomly allocated to either operative or non-operative management of their injuries. A variety of outcome instruments, measuring health-related quality of life, functional outcome and pain, will be completed at several time points up to 12 months post injury. Qualitative interviews will be undertaken with participants to explore their views of the treatments under investigation and trial processes.Eligibility and recruitment to the study will be analysed to inform the feasibility of a definitive trial. Completion rates of the measurement instruments will be assessed, as well as their sensitivity to change and the presence of floor or ceiling effects in this population, to inform the choice of the primary outcome for a definitive trial. ETHICS AND DISSEMINATION Ethical approval for the study was given by the South West-Central Bristol NHS Research Ethics Committee on 2nd July 2018 (Ref; 18/SW/0135). The study will be reported in relevant specialist journals and through presentation at specialist conferences. TRIAL REGISTRATION NUMBER ISRCTN10649958.
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Affiliation(s)
- Steven Barnfield
- Department of Trauma & Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Jenny Ingram
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Ruth Halliday
- Department of Trauma & Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Xavier Griffin
- Nuffield Dept of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Rosemary Greenwood
- University Hospitals Bristol NHS Foundation Trust, Level 3 Education Centre, Bristol, UK
| | | | - Julian Thompson
- Department of Anaesthetics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Joel Glynn
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Lucy Beasant
- Bristol Medical School, University of Bristol, Bristol, UK
| | - John McArthur
- Department of Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Peter Bates
- Department of Orthopaedics, Barts Health NHS Trust, London, UK
| | - Mehool Acharya
- Department of Trauma & Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
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Zhang BF, Lei JL, Zhang H, Wang PF, Wang H, Cong YX, Huang H, Zhuang Y. Use of ultrasonography for evaluation of stability of lateral compression type 1 (LC-1) pelvic fractures to assist determination of treatment strategy. J Orthop Surg Res 2019; 14:7. [PMID: 30616655 PMCID: PMC6323740 DOI: 10.1186/s13018-018-1047-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 12/21/2018] [Indexed: 11/10/2022] Open
Abstract
Background Lateral compression type1 (LC-1) pelvic fractures represent a wide spectrum of heterogeneous injuries. These include both stable and unstable patterns; however, determining whether a LC-1 fracture is stable or unstable is a challenge, and the method used to evaluate fracture stability is complicated. Methods We prospectively collected and analyzed data from 22 patients with LC-1 pelvic fractures, who underwent ultrasonography and a pelvic compression and separation test, in order to evaluate the role of ultrasonography in determining fracture stability and assist decision-making for treatment strategy. Results Twenty-two patients (15 men and 7 women) were included in the study. Following an ultrasound examination, 10 patients were classified into the stable group and 12 into the unstable group. In total, 13 patients received conservative treatment and 9 underwent surgery. At follow-up, there were no differences in fracture healing times or fracture-related complications between the two groups. The Majeed score was comparable between the two groups and most patients recovered well. There was a moderate degree of consistency in Kappa values (Kappa = 0.571, P = 0.01) between the classification of stability and the final treatment received. In addition, the sensitivity of ultrasonography was 66.67% and the specificity was 76.92%. Conclusions In conclusion, ultrasonography is a useful tool for diagnosing the stability of LC-1 pelvic fractures and assists the determination of treatment strategy. Left-right mobility ≥ 0.3 cm may be used as the criterion for determining instability. Trial registration ChiCTR-DDD-16008722.
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Affiliation(s)
- Bin-Fei Zhang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Jin-Lai Lei
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Hong Zhang
- Department of Ultrasound Medicine, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Peng-Fei Wang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Hu Wang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Yu-Xuan Cong
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Hai Huang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Yan Zhuang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China.
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Wang H, Fu YH, Ke C, Zhuang Y, Zhang K, Wei X, Li Z, Lei JL, Zhang BF, Liu P. Minimally invasive stabilisation of posterior pelvic ring instabilities with pedicle screws connected to a transverse rod. INTERNATIONAL ORTHOPAEDICS 2017; 42:681-686. [DOI: 10.1007/s00264-017-3714-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 12/03/2017] [Indexed: 11/30/2022]
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Tosounidis TH, Mauffrey C, Giannoudis PV. Optimization of technique for insertion of implants at the supra-acetabular corridor in pelvis and acetabular surgery. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:29-35. [PMID: 28660437 PMCID: PMC5754460 DOI: 10.1007/s00590-017-2007-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 06/24/2017] [Indexed: 12/04/2022]
Abstract
The technique for application of implants at the sciatic buttress has been well described in the pelvic and acetabular fracture reconstruction literature. We described a new use of the inlet–obturator oblique view for the identification of the anterior inferior iliac spine, which is the entry point of implants, and we provide a detailed fluoroscopic and radiographic description of this view. A small series of 15 patients who underwent an application of an anterior inferior pelvic external (supra-acetabular) fixator via this technique is presented. We consider the use of the obturator oblique for the identification of the entry point unnecessary, and we advocate for the use of only the inlet–obturator oblique and iliac oblique views when implants are applied to the sciatic buttress.
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Affiliation(s)
- Theodoros H Tosounidis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, Leeds, LS1 3EX, UK. .,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, West Yorkshire, Leeds, LS7 4SA, UK.
| | | | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, Leeds, LS1 3EX, UK.,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, West Yorkshire, Leeds, LS7 4SA, UK
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Tosounidis TH, Sheikh HQ, Kanakaris NK, Giannoudis PV. The use of external fixators in the definitive stabilisation of the pelvis in polytrauma patients: Safety, efficacy and clinical outcomes. Injury 2017; 48:1139-1146. [PMID: 28363753 DOI: 10.1016/j.injury.2017.03.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/22/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To analyse the complications and outcomes (functional/radiographic) of Pelvic External Fixators applied as part of the definitive fixation in polytrauma patients. DESIGN A single center retrospective chart review. SETTING A level-1 trauma center. PATIENTS AND METHODS We reviewed all the polytrauma patients (ISS>16) between 2007 and 2012 that had a PEF applied more than 30days. Complications including infection, aseptic loosening, neurological injury, loss of reduction, non-union and mal-union were recorded. Pelvic asymmetry and Deformity Index (DI) were measured at the immediate postoperative radiographs and final follow-up. The functional outcome at final follow up was estimated using a scale previously reported by Chiou et al. RESULTS 59 patients with mean age of 38.4 (16 - 81) years and mean ISS score 28 (16- 66) were included. The PEFs were applied for mean duration of 56 (30-104) days. The average follow-up was 403days. 22 injuries were type B and 37 type C (AO/OTA). The most common symptomatic complications were pin site infection in 11 (18.6%) and loosening in 5 (8.5%) cases. 44 (74.5%) patients had satisfactory functional outcome. The immediate post-operative and final asymmetry and DI were compared between the two pelvic injury groups (type B and C fractures). The difference in displacement progression was more for type C injuries (p=0.034) but no correlation to the functional outcome was evident. CONCLUSION PEF can be used as definitive alternative stabilization method in specific situations at polytrauma setting. Radiological displacement occurred in both type B and C injuries but the clinical outcome was not correlated to this displacement. Complications related to PEF do not affect the final clinical outcome. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Theodoros H Tosounidis
- Academic Department of Trauma & Orthopaedic Surgery, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA West Yorkshire, Leeds, UK.
| | - Hassaan Qaiser Sheikh
- Academic Department of Trauma & Orthopaedic Surgery, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK.
| | - Nikolaos K Kanakaris
- Academic Department of Trauma & Orthopaedic Surgery, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK.
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA West Yorkshire, Leeds, UK.
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Crescent fractures of the pelvis treated by open reduction and internal fixation: a critique of Day’s guidelines. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:1089-1095. [DOI: 10.1007/s00590-017-1982-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/17/2017] [Indexed: 10/19/2022]
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Advanced Imaging Lacks Clinical Utility in Treating Geriatric Pelvic Ring Injuries Caused by Low-Energy Trauma. J Orthop Trauma 2017; 31:194-199. [PMID: 27984444 DOI: 10.1097/bot.0000000000000761] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Is advanced imaging necessary in the evaluation of pelvic fractures caused by low-energy trauma in elderly patients? DESIGN Retrospective review. SETTING Single institution, Level 1 Trauma Center. PATIENTS Age ≥60 years old treated for low-energy traumatic pelvic ring injuries. INTERVENTION None. MAIN OUTCOMES Posterior pelvic ring injuries diagnosed on advanced imaging, radiographic displacement, admission status, hospital length of stay, change in weight-bearing status recommendations, and whether operative treatment was pursued. RESULTS Eighty-seven patients met the inclusion criteria, of which 42 had advanced imaging to evaluate the posterior pelvic ring (10 magnetic resonance imaging, 32 computed tomography). More posterior pelvic ring injuries were identified with advanced imaging compared with radiographs alone (P < 0.001). There was no statistically significant difference in rate of admission (P = 0.5) or hospital length of stay (P = 0.31) between patients with radiographs alone compared with patients evaluated with radiographs plus advanced imaging. The rate of displacement >1 cm at presentation and 6-week follow-up was unaffected by the presence of a posterior injury diagnosed on advanced imaging. Treatment for all 87 patients remained weight-bearing as tolerated with assist device irrespective of advanced imaging findings, and no patient underwent surgical intervention by 12-week follow-up. CONCLUSIONS Despite frequent identification of posterior pelvic ring injuries in patients evaluated with advanced imaging, admission status, length of hospital stay, radiographic displacement, and treatment recommendations were unaffected by these findings. The use of advanced imaging in elderly patients with low-energy traumatic pelvic ring fractures may not be necessary. LEVEL OF EVIDENCE Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Hagen J, Castillo R, Dubina A, Gaski G, Manson TT, O’Toole RV. Does Surgical Stabilization of Lateral Compression-type Pelvic Ring Fractures Decrease Patients' Pain, Reduce Narcotic Use, and Improve Mobilization? Clin Orthop Relat Res 2016; 474:1422-9. [PMID: 26304045 PMCID: PMC4868153 DOI: 10.1007/s11999-015-4525-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Debate remains over the role of surgical treatment in minimally displaced lateral compression (Young-Burgess, LC, OTA 61-B1/B2) pelvic ring injuries. Lateral compression type 1 (LC1) injuries are defined by an impaction fracture at the sacrum; type 2 (LC2) are defined by a fracture that extends through the posterior iliac wing at the level of the sacroiliac joint. Some believe that operative stabilization of these fractures limits pain and eases mobilization, but to our knowledge there are few controlled studies on the topic. QUESTIONS/PURPOSES (1) Does operative stabilization of LC1 and LC2 pelvic fractures decrease patients' narcotic use and lower their visual analog scale pain scores? (2) Does stabilization allow patients to mobilize earlier with physical therapy? METHODS This retrospective study of LC1 and LC2 fractures evaluated patients treated definitively at one institution from 2007 to 2013. All patients treated surgically, all nonoperative LC2, and all nonoperative LC1 fractures with complete sacral injury were included. In general, LC1 or LC2 fractures with greater than 10 mm of displacement and/or sagittal/axial plane deformity on static radiographs were treated surgically. One hundred fifty-eight patients in the LC1 group (107 [of 697 screened] nonoperative, 51 surgical) and 123 patients in the LC2 group (78 nonoperative, 45 surgical) met inclusion criteria. The surgical and nonoperative groups were matched for fracture type. To account for differences between patients treated surgically and nonoperatively, we used propensity modeling techniques incorporating treatment predictors. Propensity scores demonstrated good overlap and were used as part of multiple variable regression models to account for selection bias between the surgically treated and nonoperative groups. Patient-reported pain scores and narcotic administration were tallied in 24-hour increments during the first 24 hours of hospitalization, at 48 hours after intervention, and in the 24 hours before discharge. Time from intervention to mobilization out of bed was recorded; intervention was defined as the date of definitive surgical intervention or the day the surgeon determined the patient would be treated without surgery. RESULTS There was no difference in the narcotics distributed to any of the groups with the exception that the patients with surgically treated LC2 fractures used, on average (mean [95% confidence interval]) 40.2 (-72.9 to -7.6) mg morphine less at the 48-hour mark (p = 0.016). In general, there were no differences between the groups' pain scores. The surgically treated patients with LC1 fractures mobilized 1.7 (-3.3 to -0.01) days earlier (p = 0.034) than their nonoperative counterparts. There was no difference in the LC2 cohort in terms of time to mobilization between those treated with and without surgery. CONCLUSIONS There were few differences in pain scores and morphine use between the surgical and nonoperative groups, and the differences observed likely were not clinically important. We found no evidence that surgical stabilization of certain LC1 and LC2 pelvic fractures improves patients' pain, decreases their narcotic use, and improves time to mobilization. A randomized trial of patients with similar fractures and similar degrees initial displacement would help remove some of the confounders present in this study. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Jennifer Hagen
- University of Florida, 3450 Hull Road, Gainesville, FL 32608 USA
| | - Renan Castillo
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Andrew Dubina
- University of Maryland School of Medicine, Baltimore, MD USA
| | - Greg Gaski
- IU Health Methodist, Indianapolis, IN USA
| | - Theodore T. Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD USA
| | - Robert V. O’Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD USA
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Höch A, Schneider I, Todd J, Josten C, Böhme J. Lateral compression type B 2-1 pelvic ring fractures in young patients do not require surgery. Eur J Trauma Emerg Surg 2016; 44:171-177. [PMID: 27138008 DOI: 10.1007/s00068-016-0676-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 04/21/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE According to Young and Burgess, type B 2-1 pelvic fractures are a type of lateral compression fracture (LC-1) and are the most common pelvic injury at all ages. Although they are considered unstable in rotation and despite biomechanical recommendations for anterior stabilization, most authors recommend non-operative treatment. However, studies comparing outcomes and complications regarding operative versus non-operative treatment are still scarce. METHODS Seventy-one patients aged under 65 years with a type B 2-1 pelvic fracture were treated between 2006 and 2011. Patients in Group I (n = 35) were treated non-operatively and patients in Group II (n = 36) were treated operatively. Postoperative complications, clinical course, and follow-up (VAS for Pain, SF 36, EQ-5D) of at least 1 year postoperatively were evaluated. RESULTS Our data show that operatively treated patients had a significantly higher complication rate. Preoperatively, the only significant difference between the non-operative and operative groups was the amount of anterior fracture dislocation and the presence of an isolated pelvic ring fracture. In the postoperative follow-up, no significant differences were found regarding pain or quality of life. CONCLUSION Type B 2-1 pelvic ring fractures in young patients should be treated non-operatively.
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Affiliation(s)
- A Höch
- Department of Orthopaedics, Trauma and Plastic Surgery, Center for Musculoskeletal Research, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - I Schneider
- Department of Orthopaedics, Trauma and Plastic Surgery, Center for Musculoskeletal Research, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - J Todd
- Department of Orthopaedics, Trauma and Plastic Surgery, Center for Musculoskeletal Research, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - C Josten
- Department of Orthopaedics, Trauma and Plastic Surgery, Center for Musculoskeletal Research, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - J Böhme
- Department of Orthopaedics, Trauma and Plastic Surgery, Center for Musculoskeletal Research, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
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Tosounidis TH, Sheikh H, Giannoudis PV. Pelvic Fractures in Paediatric Polytrauma Patients: Classification, Concomitant Injuries and Early Mortality. Open Orthop J 2015; 9:303-12. [PMID: 26312114 PMCID: PMC4541306 DOI: 10.2174/1874325001509010303] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/26/2015] [Accepted: 05/18/2015] [Indexed: 11/26/2022] Open
Abstract
Purpose of this Study : To review the characteristics, concomitant injuries and mortality in children with polytrauma and associated pelvic fractures treated in a Level-I Trauma Centre. Materials and Methods : Between December 2003 and November 2013, 49 children with an Injury Severity Score (ISS) of 16 or greater and a pelvic fracture met the inclusion criteria and were evaluated. The mortality, transfusion requirements and length of intensive care unit stay were correlated with the ISS, Abbreviated Injury Scale, concomitant limb and spine fractures, and type of pelvic ring injury (AO/OTA classification). Results : The mean ISS at presentation was 31.4 (range 16 to 57). 19 (38.7%) patients sustained a Type A, 27 (55.1%) a Type B and 3 (6.2%) a Type C injury. Head and face trauma was present in 33 (67.3%) cases. Blood transfusion during the resuscitation process was necessitated in six (12.2%) patients. Thirty-eight (77.5%) patients were managed non-operatively for their pelvic injuries. The mean duration of hospital stay was 23.9 days (range 1 to 146 days). In this cohort of polytrauma paediatric patients there were five (10.2%) mortalities (all suffered an associated head trauma ) within 30 days from the initial injury. Conclusion: Severe head injury and a high ISS are significantly associated with mortality in children with pelvic fractures. These patients have a high incidence of concomitant spine and chest injuries Hemorrhage due to pelvic injuries is rare. Severe head injuries predict a longer ICU stay in this population.
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Affiliation(s)
- Theodoros H Tosounidis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds and Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK
| | - Hassaan Sheikh
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds and Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds and Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK
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Courtney PM, Taylor R, Scolaro J, Donegan D, Mehta S. Displaced inferior ramus fractures as a marker of posterior pelvic injury. Arch Orthop Trauma Surg 2014; 134:935-9. [PMID: 24740699 DOI: 10.1007/s00402-014-1993-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Injuries to the anterior or posterior pelvic ring rarely occur in isolation. Disruption to the anterior pelvic ring, indicated by a fracture of the superior or inferior pubic ramus, or injury to the pubic symphysis, may be indicative of additional pelvic ring disruption. The purpose of this retrospective study was to determine whether displaced inferior pubic ramus fractures warrant a more detailed investigation of the posterior ring in an effort to predict unstable posterior pelvic ring injuries. MATERIALS AND METHODS All patients with a displaced inferior ramus fracture on AP pelvic radiograph were identified at a single level I trauma center over a 5-year period. Complete pelvic radiographs and computed tomography scans were then evaluated for additional pelvic ring injuries. The data were analyzed using the chi-square test to determine the association between inferior ramus fractures and posterior pelvic ring injury. RESULTS Sixty-three of the 93 patients with a fracture of the inferior ramus (68 %) were found to have a posterior ring injury; 60 % of these injuries were unstable. Patients with concurrent superior ramus fractures were more likely to have a posterior ring injury (p < 0.001) and an unstable pelvis (p = 0.018). Of those with a displaced unilateral inferior ramus fracture, parasymphyseal involvement was associated with higher incidence of posterior ring injury (p = 0.047) and pelvic instability (p = 0.028). CONCLUSION The anterior pelvic ring can be used to help identify unstable injuries to the posterior pelvis. Patients with displaced inferior pubic ramus fractures warrant a detailed examination of their posterior ring to identify additional injuries and instability.
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Affiliation(s)
- P Maxwell Courtney
- Orthopaedic Trauma and Fracture Service, Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA, 19104, USA,
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Anterior decompression with single segmental spinal interbody fusion for Denis type B thoracolumbar burst fracture: a midterm follow-up study. INTERNATIONAL ORTHOPAEDICS 2013; 37:2205-9. [PMID: 24162182 DOI: 10.1007/s00264-013-2095-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 08/20/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Our goal was to observe the midterm results of a case series of Denis type B thoracolumbar burst fracture treated with anterior decompression with single segmental spinal Interbody fusion. METHODS Twenty patients with Denis type B thoracolumbar burst fractures underwent anterior decompression with single segmental spinal Interbody fusion. They underwent clinical and radiologic follow-up for at least three years after the surgery. RESULTS The mean follow-up period lasted 57 months. To the last follow-up, there were no cases of internal fixation loosening, failure and other complications. Titanium mesh or interbody bone grafts were in good position. Spinal kyphosis was not observed. Interbody fusion was achieved for all cases. The average fusion time was 4.5 months. Based on visual analogue scale (VAS) pain scores, percentage of vertebral body height loss and Cobb angle, the difference was statistically significant between the preoperative period and postoperative one year or final follow-up (P < 0.05). Results at postoperative one year and final follow-up were better than the preoperative period. However, the difference was not significant between postoperative one year and final follow-up (P > 0.05). CONCLUSIONS Good midterm results on clinical and radiologic evaluation of anterior decompression with single segmental spinal Interbody fusion for suitable patients with Denis type B thoracolumbar burst fracture can be achieved. The incident rate of relative complications is low.
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Yu X, Tang M, Zhou Z, Peng X, Wu T, Sun Y. Minimally invasive treatment for pubic ramus fractures combined with a sacroiliac joint complex injury. INTERNATIONAL ORTHOPAEDICS 2013; 37:1547-54. [PMID: 23756715 DOI: 10.1007/s00264-013-1954-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 05/21/2013] [Indexed: 01/13/2023]
Abstract
PURPOSE Fractures of the pubic rami due to low energy trauma are common in the elderly, with an incidence of 26 per 100,000 people per year in those aged more than 60 years. The purpose of this study was to evaluate the clinical application of this minimally invasive technique in patients with pubic ramus fractures combined with a sacroiliac joint complex injury, including its feasibility, merits, and limitations. METHODS Fifteen patients with pubic ramus fractures combined with sacroiliac joint injury were treated with the minimally invasive technique from June 2008 until April 2012. The quality of fracture reduction was evaluated according to the Matta standard. RESULTS Fourteen cases were excellent (93.3 %), and one case was good (6.7 %). The fracture lines were healed 12 weeks after the surgery. The 15 patients had follow-up visits between four to 50 months (mean, 22.47 months). All patients returned to their pre-injury jobs and lifestyles. One patient suffered a deep vein thrombosis during the peri-operative period. A filter was placed in the patient before the surgery and was removed six weeks later. There was no thrombus found at the follow-up visits of this patient. CONCLUSION The minimally invasive technique in patients with pubic ramus fractures combined with a sacroiliac joint complex injury provided satisfactory efficacy.
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Affiliation(s)
- Xiaowei Yu
- Department of Orthopaedic Surgery, Shanghai Sixth People's Hospital, Shanghai Jiaotong University School of Medicine, No. 600, Yishan Rd, Shanghai, 200011, People's Republic of China
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Digiorgi D. Spinal manipulation under anesthesia: a narrative review of the literature and commentary. Chiropr Man Therap 2013; 21:14. [PMID: 23672974 PMCID: PMC3691523 DOI: 10.1186/2045-709x-21-14] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 05/04/2013] [Indexed: 02/07/2023] Open
Abstract
As exhibited throughout the medical literature over many decades, there is a lack of uniformity in the manner in which spine pain patients have historically qualified for and received manipulation under anesthesia (MUA). Also, for different professions that treat the same types of spinal conditions via the same means, fundamental MUA decision points vary within the published protocols of different professional associations. The more recent chiropractic literature communicates that the evidence to support the efficacy of MUA of the spine remains largely anecdotal. In addition, it has been reported that the types of spinal conditions most suitable for MUA are without clear-cut consensus, with various indications for MUA of the low back resting wholly upon the opinions and experiences of MUA practitioners. This article will provide a narrative review of the MUA literature, followed by a commentary about the current lack of high quality research evidence, the anecdotal and consensus basis of existing clinical protocols, as well as related professional, ethical and legal concerns for the chiropractic practitioner. The limitations of the current medical literature related to MUA via conscious/deep sedation need to be recognized and used as a guide to clinical experience when giving consideration to this procedure. More research, in the form of controlled clinical trials, must be undertaken if this procedure is to remain a potential treatment option for chronic spine pain patients in the chiropractic clinical practice.
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Affiliation(s)
- Dennis Digiorgi
- DC, CHCQM, CCIC, Consultant Practice- Whitestone, New York, USA.
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