1
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Pass B, Schoeneberg C. [Conservative fracture treatment in old people]. Z Gerontol Geriatr 2024; 57:321-329. [PMID: 38832983 DOI: 10.1007/s00391-024-02314-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/20/2024] [Indexed: 06/06/2024]
Abstract
The numbers of osteoporotic fractures will increase due to the demographic change, which particularly affects the proximal femur, pelvis, proximal humerus, wrist and vertebral column. Surgical treatment is superior to conservative treatment of proximal femoral fractures. Non-dislocated fractures of the wrist can also be treated with a plaster cast but studies suggest that the results in the first 12 months are better after surgical treatment. The situation is similar for fractures of the proximal humerus and non-dislocated fractures in particular can also be treated conservatively. A score and classification were recently developed for making decisions on the treatment of osteoporotic vertebral fractures. Fractures of the anterior and posterior pelvic ring can be treated conservatively with the patient under sufficient analgesia as long as there is no substantial dislocation. The highest priority in geriatric traumatology is fast remobilization.
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Affiliation(s)
- B Pass
- Klinik für Orthopädie und Unfallchirurgie, Alfried Krupp Krankenhaus, Hellweg 100, 45276, Essen, Deutschland
| | - C Schoeneberg
- Klinik für Orthopädie und Unfallchirurgie, Alfried Krupp Krankenhaus, Hellweg 100, 45276, Essen, Deutschland.
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2
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Sassara GM, Smakaj A, De Mauro D, Righini R, Arnone A, Rovere G, El Ezzo O, Farsetti P, Tarantino U, Liuzza F. Evaluating Treatment Outcomes for Pelvic Insufficiency Fractures: A Systematic Review. J Clin Med 2024; 13:3176. [PMID: 38892887 PMCID: PMC11172805 DOI: 10.3390/jcm13113176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/12/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Pelvic insufficiency fractures (PIF) are typical in geriatric populations with reduced bone quality, most commonly in elderly postmenopausal women. These fractures are usually caused by low-energy forces over the bones during ordinary life and cause disabling pain. Treatment options range from conservative to operative. The aim of this study is to assess the outcomes of treatments for pelvic insufficiency fractures, determining optimal approaches between surgical intervention and conservative management. Methods: This literature review systematically examines articles focusing on patients with PIF, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and using PubMed, Medline, and the Cochrane Library database. We took into account only full-text articles in indexed journals with available English abstracts, considering data about patient demographics, surgery, and outcomes. Results: After screening 128 articles, this study reviewed 20 manuscripts involving 1499 patients, mostly elderly females and focusing on sacrum fractures. Common treatments included conservative methods and sacroplasty, with a few complications reported. Osteoporosis was the prevalent comorbidity, and the survival rate post-treatment was high at 92.3%. Mobility outcomes varied, with some patients experiencing significant autonomy loss. The average follow-up period was over 17 months. Conclusions: This study found a cautious approach to surgery (timing of three weeks), which is reserved only for specific patterns, and it leads to increased autonomy and a lower risk of mortality. Due to the lack of pre- and postoperative scores as well as conflicting results, it is imperative to undertake further studies and research to be able to compare the alternative treatments efficiently.
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Affiliation(s)
- Giulia Maria Sassara
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00136 Rome, Italy; (G.M.S.); (D.D.M.); (A.A.); (O.E.E.); (F.L.)
- Department of Geriatrics and Orthopaedic Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Amarildo Smakaj
- Department of Geriatrics and Orthopaedic Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
- Department of Biomedicine and Prevention, “Tor Vergata” University of Rome, 00133 Rome, Italy
- Department of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, 00133 Rome, Italy; (P.F.); (U.T.)
| | - Domenico De Mauro
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00136 Rome, Italy; (G.M.S.); (D.D.M.); (A.A.); (O.E.E.); (F.L.)
- Department of Geriatrics and Orthopaedic Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
- Department of Public Health, Orthopedic Unit, Federico II University, 80131 Naples, Italy
| | - Roberta Righini
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00136 Rome, Italy; (G.M.S.); (D.D.M.); (A.A.); (O.E.E.); (F.L.)
- Department of Geriatrics and Orthopaedic Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Adele Arnone
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00136 Rome, Italy; (G.M.S.); (D.D.M.); (A.A.); (O.E.E.); (F.L.)
- Department of Geriatrics and Orthopaedic Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Giuseppe Rovere
- Department of Geriatrics and Orthopaedic Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
- Department of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, 00133 Rome, Italy; (P.F.); (U.T.)
| | - Omar El Ezzo
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00136 Rome, Italy; (G.M.S.); (D.D.M.); (A.A.); (O.E.E.); (F.L.)
- Department of Geriatrics and Orthopaedic Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
| | - Pasquale Farsetti
- Department of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, 00133 Rome, Italy; (P.F.); (U.T.)
- Department of Clinical Sciences and Translational Medicine, “Tor Vergata” University of Rome, 00133 Rome, Italy
| | - Umberto Tarantino
- Department of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, 00133 Rome, Italy; (P.F.); (U.T.)
- Department of Clinical Sciences and Translational Medicine, “Tor Vergata” University of Rome, 00133 Rome, Italy
| | - Francesco Liuzza
- Department of Aging, Neurological, Orthopaedic and Head-Neck Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00136 Rome, Italy; (G.M.S.); (D.D.M.); (A.A.); (O.E.E.); (F.L.)
- Department of Geriatrics and Orthopaedic Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy;
- Department of Biomedicine and Prevention, “Tor Vergata” University of Rome, 00133 Rome, Italy
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3
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Arand C, Mehler D, Sauer A, Hartung C, Gercek E, Rommens PM, Wagner D. Do we need to fix the anterior fracture component in insufficiency fractures of the pelvis? A biomechanical comparison on an FFP type IIIc fracture in an osteoporotic pelvic bone model. Injury 2023; 54:111096. [PMID: 37833233 DOI: 10.1016/j.injury.2023.111096] [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] [Received: 06/29/2023] [Revised: 09/27/2023] [Accepted: 10/02/2023] [Indexed: 10/15/2023]
Abstract
There is a growing understanding of the specific characteristics of insufficiency fractures of the pelvis and of general requirements for the treatment of affected patients with focus on early mobilization and effective pain reduction as the main goals of therapy. While there is consensus on the significance of achieving stability of the dorsal pelvic ring structures there is still an open discussion about the potential benefits of additional stabilization of an anterior fracture component. Within a biomechanical test setup, two established methods of dorsal fracture fixation were tested under axial loading (25-1200 N; 1000 test cycles) on an explicit osteoporotic bone model (n = 32) with a standardized FFP type IIIc fracture with and without additional fixation of the anterior fracture component. Dorsal fixation was performed with and long and a short 7.3 mm cannulated screw in S1 in one group (n = 16), and a trans sacral bar with an additional short 7.3 mm cannulated screw in S1 in the other group (n = 16). Half of the samples received a 7.3 mm cannulated retrograde transpubic screw for anterior fixation. The fixation with the trans sacral bar and the additional anterior screw fixation showed the highest rate of stability (p = 0.0014), followed by the double SI-screw fixation with stabilization of the anterior fracture (p = 0.0002). During testing, we observed the occurrence of new sacral fractures contralateral to the initial fracture in 22/32 samples. The results let us assume that stabilization of an additional anterior fracture component relevantly improves the stability of the entire ring construct and might prevent failure of the dorsal stabilization or further fracture progression.
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Affiliation(s)
- Charlotte Arand
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany.
| | - Dorothea Mehler
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Anne Sauer
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Christian Hartung
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Erol Gercek
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Pol M Rommens
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany
| | - Daniel Wagner
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Langenbeckstraße 1, Mainz 55131, Germany; Department of Orthopedics and Trauamtology, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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4
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Mennen AHM, Oud S, Halm JA, Peters RW, Willems HC, Van Embden D. Pelvic Ring Fractures in Older Adult Patients-Assessing Physician Practice Variation among (Orthopedic) Trauma Surgeons. J Clin Med 2023; 12:6344. [PMID: 37834988 PMCID: PMC10573883 DOI: 10.3390/jcm12196344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/15/2023] Open
Abstract
PURPOSE Pelvic fractures in older adults are a major public health problem and socioeconomic burden. The standard of care has changed over the past years, and there is limited consensus on which patients benefit from surgical fixation. There is currently no nationwide treatment protocol to guide the decision-making process. Therefore, the aim of this survey was to provide more insight into if, when, and why patients with a fragility fracture of the pelvis (FFPs) would be considered for additional imaging and surgical fixation by treating physicians. METHODS An online clinical vignette-based survey of hypothetical scenarios was sent out to all orthopedic and trauma surgeons in the Netherlands. The questionnaire comprised multiple-choice questions and radiographic images. Differences between subgroups were calculated using the X2 test or the Fisher exact test. RESULTS 169 surgeons responded to the survey, with varying levels of experience and working in different types of hospitals. In a patient with a simple pubic ramus fracture and ASA 2 or ASA 4, 32% and 18% of the respondents would always advise a CT scan for further analysis. In the same patients, 11% and 31% of the respondents would not advise a CT scan, respectively. When presented with three cases of increasing severity of co-morbidity (ASA) and/or increasing age and/or different clinical presentation of an FFP type 3c on a CT scan, an increasing number of respondents would not consider surgical fixation. There was significant variation in practice patterns between the respondents who do not work in a hospital performing pelvic and acetabular (P&A) fracture surgery and those who do work in a P&A referral hospital. Most respondents (77%) refer patients 1-5 times a year to an expert center for surgical fixation. CONCLUSION There is currently a wide variety of clinical practices regarding the imaging and management of FFPs, which seems to be influenced by the type of hospital the patients are presented to. A regional or national evidence-based treatment protocol should be implemented to ensure a more uniform approach.
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Affiliation(s)
- Anna H. M. Mennen
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Sharon Oud
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jens A. Halm
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Rolf W. Peters
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Hanna C. Willems
- Department of Internal Medicine and Geriatrics, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Daphne Van Embden
- Department of Surgery, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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5
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Thiesen DM, Althoff G, Strahl A, Rolvien T, Frosch KH, Koepke LG, Arras C, Ballhause TM, Dalos D, Hartel MJ. Conservative versus operative treatment of FFP II fractures in a geriatric cohort: a prospective randomized pilot trial. Sci Rep 2023; 13:16124. [PMID: 37752331 PMCID: PMC10522702 DOI: 10.1038/s41598-023-43249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/21/2023] [Indexed: 09/28/2023] Open
Abstract
A clear recommendation regarding treatment strategy of fragility fractures of the pelvic ring is missing. The most typical fracture pattern is a lateral compression type injury with non-displaced fractures of the anterior pubic rami and a unilateral os sacrum fracture (FFP II). We hypothesized that operative treatment would be superior to conservative treatment. From October 2017 to April 2020, a randomized prospective non-blinded trial with n = 39 patients was carried out. Two arms with 17 operative versus 22 conservative cases were created. Inclusion criteria were a posterior pelvic ring fracture FFP type II, age over 60 years and acute fracture (< 3 weeks). Barthel index, pain level (VAS), quality of life (EQ-5D-3L), and Tinetti-Gait Test were determined on admission, at discharge, and after 3, 6, 12 and 24 months. Median follow-up was 12.9 months. The Barthel index (= 0.325), VAS (p = 0.711), quality of life (p = 0.824), and Tinetti-Gait Test (p = 0.913) showed no significant differences between the two groups after 12 months. Two patients switched from the conservative to the operative arm due to persistent immobilization and pain. The one-year mortality rate showed no significant difference (p = 0.175). Our hypothesis that surgical treatment is superior was refuted. No significant benefit was shown in terms of quality of life, mortality and pain levels. The results suggest a more differentiated treatment approach in the future, with initial conservative treatment preferred. A larger multi-center trial is required to confirm these findings.Trial registration: The study was retrospectively registered with the German Clinical Trials Registry (DRKS00013703) on 10/12/2018.
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Affiliation(s)
- Darius M Thiesen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Gerrit Althoff
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - André Strahl
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Trauma, Orthopaedic Surgery, and Sports Traumatology, BG Trauma Hospital Hamburg, Hamburg, Germany
| | - Leon-Gordian Koepke
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christian Arras
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Tobias M Ballhause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Dimitris Dalos
- UKE Athleticum, Center for Athletic Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian J Hartel
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Trauma, Orthopaedic Surgery, and Sports Traumatology, BG Trauma Hospital Hamburg, Hamburg, Germany
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6
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Putzeys G, Dekeyser T, Garré P, Chesser T, Pottel H. Posterior pelvic ring involvement detected with CT taken within a week of admission in acute fragility fractures of the pelvis (FFP) does not predict failure of conservative treatment: a retrospective cohort study. BMC Musculoskelet Disord 2023; 24:320. [PMID: 37087474 PMCID: PMC10122380 DOI: 10.1186/s12891-023-06439-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/18/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Acute low energy pubic rami fractures in the elderly receive primarily conservative treatment. There is debate to what extent posterior ring involvement, which is detected superiorly by CT compared to X-ray, has an impact on outcome and may require modified treatment. We want to demonstrate if posterior ring involvement has an influence on different types of outcome in primarily conservatively treated acute FFP, questioning the usefulness of early CT. Additionally we analysed the early fracture pattern in cases where conservative treatment failed with need for secondary surgery. METHODS A retrospective cohort study of 155 consecutive patients, recruited between 2009 and 2016, aged over 65 years diagnosed with an acute LE-PFr on X-ray at the emergency department of a single, level-one trauma centre and receiving an early CT. A set of outcome parameters was compared between patients with an isolated pubic rami fracture (CTia) and patients who had a combined posterior pelvic ring fracture (CTcp). RESULTS There were 155 patients of whom 85.2% were female with a mean age of 83 years. 76.8% of patients living at home returned home and 15.5% moved to a nursing home. Mortality rate during hospitalisation was 6.4% and 14.8% at one year post-trauma. Secondary fracture displacement occurred in 22.6%. Secondary surgery was performed in 6 cases (3.9%). Median hospitalisation length of stay was 21 days (range 0 to 112 days). There was no significant association between the subgroups and change in residential status (p = 0.65), complications during hospitalisation (p = 0.75), mortality rate during admission (p = 0.75) and at 1 year (p = 0.88), readmission within 30 days (p = 0.46) and need for secondary surgery (p = 0.2). There was a significant increased median length of stay (p = 0.011) and rate of secondary displacement (p = 0.015) in subgroup CTcp. Secondary displacement had no impact on in-hospital complications (p = 0.7) nor mortality rate during admission (p = 0.79) or at 1 year (0.77). Early CT in patients who underwent secondary surgery showed stable B2.1 lesions in 4 of 6 cases. CONCLUSIONS Our data suggest that early CT in patients with conservatively treated acute LE-PFr in order to detect posterior lesions, has limited value in predicting failure of conservative treatment.
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Affiliation(s)
- Guy Putzeys
- Orthopedic and Trauma Department, AZ Groeninge hospital, Kortrijk, Belgium.
| | | | - Patrick Garré
- Department of data management, AZ Groeninge hospital, Kortrijk, Belgium
| | | | - Hans Pottel
- Department of Public Health and Primary Care, KULeuven KULAK, Kortrijk, Belgium
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7
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Internal fixation of radiation-induced fragility fractures of the pelvis: a case series. Arch Orthop Trauma Surg 2023; 143:865-871. [PMID: 35107637 DOI: 10.1007/s00402-022-04358-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 01/14/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND The optimal treatment for radiation-induced fragility fractures of the pelvis (RI-FFP) is not well evaluated due to the rarity of the condition. PURPOSE The aim of this retrospective study was to assess the prevalence of RI-FFP, the radiological and clinical outcomes as well as the complications of patients treated with internal fixation. METHODS A retrospective review of our database was performed to identify all surgically treated patients with RI-FFP. Surgical stabilization was recommended for patients with FFP type III and FFP type IV. Surgical stabilization was also recommended after 5-7 days for patients with FFP type II in case of unsuccessful conservative treatment. Demographic data, fracture patterns according to the FFP classification of Rommens and Hofmann, type of treatment and surgery-related complications including nonunion, hardware failure, fracture progression (secondary fracture) or infection were documented. RESULTS Among 500 patients with FFP, the prevalence of patients with RI-FFP was 1% (5/500): 5 patients with a median age of 79 years (76-79). The median time interval from radiation to fracture was 18 months (18-24). All of them underwent internal fixation. Two patients experienced surgery-related complications, one due to hardware failure and one due to fracture progression. At median follow-up of 27 months, all fractures had healed. Patients reached a good level of mobility with a median Parker Mobility Score of 7 and suffered moderate pain with a median value of 2.5 on the numeric rating scale. CONCLUSION RI-FFP remains a rare injury (1%). In our experience, patients, who underwent surgical treatment, obtained a high level of mobility and a moderate pain score after 2 years of follow-up. Internal fixation can be recommended in RI-FFP. Because bone healing may be impaired due to previous irradiation, highly stable constructs are required to avoid fracture progression or revision surgery. LEVEL OF EVIDENCE III, retrospective study.
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8
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Hutchings L, Roffey DM, Lefaivre KA. Fragility Fractures of the Pelvis: Current Practices and Future Directions. Curr Osteoporos Rep 2022; 20:469-477. [PMID: 36342642 DOI: 10.1007/s11914-022-00760-9] [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] [Accepted: 08/31/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE OF REVIEW To summarise the current evidence and clinical practices for patients with fragility fractures of the pelvis (FFP). RECENT FINDINGS FFPs are an increasingly prevalent and recognised problem in the elderly population. Recent evidence indicates they have a significant impact on function, morbidity and mortality. While traditional management of FFPs was predominantly non-surgical, surgical options have been increasingly used, with a range of surgical methods available. To date, limited consensus exists on the optimal strategy for suitable patient selection, and clinical trials in this population have proved problematic. The management of FFPs requires a multi-faceted approach to enhance patient care, including adequate pain control, minimisation of complications and optimisation of medical management. Early return to mobilisation should be a key treatment goal to maintain functional independence. The selection of patients who will maximally benefit from surgical treatment, and the most appropriate surgical strategy to employ, remains contentious.
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Affiliation(s)
- Lynn Hutchings
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Darren M Roffey
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Kelly A Lefaivre
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada.
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada.
- Division of Orthopaedic Trauma, Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, 3rd Floor, DHCC, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
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9
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Pieroh P, Hohmann T, Gras F, Märdian S, Pflug A, Wittenberg S, Ihle C, Blankenburg N, Dallacker-Losensky K, Schröder T, Herath SC, Palm HG, Josten C, Stuby FM, Wagner D, Höch A. A computed tomography based survey study investigating the agreement of the therapeutic strategy for fragility fractures of the pelvis. Sci Rep 2022; 12:2326. [PMID: 35149706 PMCID: PMC8837654 DOI: 10.1038/s41598-022-04949-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 01/04/2022] [Indexed: 11/09/2022] Open
Abstract
Treatment recommendations for fragility fractures of the pelvis (FFP) have been provided along with the good reliable FFP classification but they are not proven in large studies and recent reports challenge these recommendations. Thus, we aimed to determine the usefulness of the FFP classification determining the treatment strategy and favored procedures in six level 1 trauma centers. Sixty cases of FFP were evaluated by six experienced pelvic surgeons, six inexperienced surgeons in training, and one surgeon trained by the originator of the FFP classification during three repeating sessions using computed tomography scans with multiplanar reconstruction. The intra-rater reliability and inter-rater reliability for therapeutic decisions (non-operative treatment vs. operative treatment) were moderate, with Fleiss kappa coefficients of 0.54 (95% confidence interval [CI] 0.44–0.62) and 0.42 (95% CI 0.34–0.49). We found a therapeutic disagreement predominantly for FFP II related to a preferred operative therapy for FFP II. Operative treated cases were generally treated with an anterior–posterior fixation. Despite the consensus on an anterior–posterior fixation, the chosen procedures are highly variable and most plausible based on the surgeon’s preference.
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Affiliation(s)
- Philipp Pieroh
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany. .,Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany. .,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany.
| | - Tim Hohmann
- Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Florian Gras
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Jena, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Sven Märdian
- Centre for Musculoskeletal Surgery, Charité-University Medicine Berlin, Berlin, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Alexander Pflug
- Department of Trauma-, Hand- and Reconstructive Surgery, University Hospital Jena, Jena, Germany
| | - Silvan Wittenberg
- Centre for Musculoskeletal Surgery, Charité-University Medicine Berlin, Berlin, Germany
| | - Christoph Ihle
- BG Trauma Center, Eberhard Karls University, Tuebingen, Germany
| | - Notker Blankenburg
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Kevin Dallacker-Losensky
- Trauma Research Group, Department of Orthopedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, Bundeswehrhospital Ulm, Ulm, Germany
| | - Tanja Schröder
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Steven C Herath
- BG Trauma Center, Eberhard Karls University, Tuebingen, Germany.,Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Hans-Georg Palm
- Trauma Research Group, Department of Orthopedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, Bundeswehrhospital Ulm, Ulm, Germany.,Address: Department of Orthopedic and Trauma Surgery, University Hospital Erlangen, Erlangen, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Fabian M Stuby
- Department of Trauma Surgery, BG Trauma Centre Murnau, Murnau am Staffelsee, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Daniel Wagner
- Department of Orthopedics and Traumatology, University Medical Center Mainz, Mainz, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
| | - Andreas Höch
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.,German Pelvic Injury Register, German Society of Traumatology, Berlin, Germany
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10
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Nuber S, Ritter B, Fenwick A, Förch S, Wanzl M, Nuber M, Mayr E. Midterm follow-up of elderly patients with fragility fractures of the pelvis: A prospective cohort-study comparing operative and non-operative treatment according to a therapeutic algorithm. Injury 2022; 53:496-505. [PMID: 34629169 DOI: 10.1016/j.injury.2021.09.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 09/20/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The treatment of fragility fractures of the pelvis (FFP) is a challenge. The variations of non-operative- and of operative treatment are manifold and a structured treatment algorithm is lacking. The purpose of this study was to evaluate the outcome of elderly patients with a FFP who were treated with a therapeutic algorithm based on the FFP-classification. PATIENTS AND METHODS In a prospective cohort study 154 patients (mean age: 81.8 ±.61 (65-96); female: (86.8%; 131/154). BMI: 23.7 ±.34 (15-43)) with a FFP after inadequate mono trauma were treated according to a strict therapeutic algorithm between 04/2016 and 12/2018. According to a classification based on CT-scans either a standardized operative treatment or conservative therapy was induced and the outcome regarding objective measurements of mobility, pain, need for analgesics and mortality during hospital stay and after one year was analyzed. RESULTS 82/154 participants (53.2%) were assigned to the conservative treatment group and 72 participants (46.8%) to the operative treatment group. The overall one-year survival rate was 78.1% (118/151). The survival of the operative treatment group was 90.7% (49/54) and significantly higher than the survival of the conservative treatment group (74.7%; 56/75; p=.023). The one-year follow up showed a high dispersion of the pain level in the operatively treated patients and a significantly higher mean in comparison to conservatively treated patients. Both treatment groups showed increasing numbers of patients with unlimited mobilization but also immobile patients. Overall in 31.0% (18/58) of the operative participants and in 14.9% (14/93) of the non-operatively treated participants complications occurred (p=.04). CONCLUSION The strict compliance to the presented treatment algorithm of FFP with an operative strategy starting from FFP IIc leads to a significantly lower mortality within one year in comparison to the conservatively treated patients. The worst outcome and the highest mortality was seen in patients who refused the recommendation of operative stabilization. The results of this study justify to proceed with the strict classification dependent treatment algorithm and also support the early switch-over to operative treatment of patients with failed conservative therapy in FFP I to FFP IIb.
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Affiliation(s)
- Stefan Nuber
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany.
| | - Benedikt Ritter
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
| | - Annabel Fenwick
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
| | - Stefan Förch
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
| | - Maximilian Wanzl
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
| | - Monika Nuber
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
| | - Edgar Mayr
- Department of Trauma, Orthopedics, Plastic and Hand Surgery, University Medicine, Stenglinstraße 2, D-86156 Augsburg, Germany
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11
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Graul I, Strube P, Vogt S, Matziolis G, Brodt S, Hölzl A. Does Total Hip Arthroplasty Influence the Development and Localization of Sacral Insufficiency Fractures? J Bone Joint Surg Am 2022; 104:139-144. [PMID: 34807876 DOI: 10.2106/jbjs.21.00218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Sacral insufficiency fractures (SIFs) are fractures related to reduced bone strength. In a previous study, we noticed that many patients with SIF had undergone total hip arthroplasty (THA). Therefore, the purpose of the present study was to research the localization of clinically apparent SIFs in relation to unilateral THA as well as the influence of unilateral THA on bone mineral density changes in the sacrum. METHODS In this retrospective study, 171 patients with SIFs were screened for unilateral THA. In the group of patients with SIF and THA, the rate of SIF ipsilateral and contralateral to the side of the THA was determined. In a second cohort of 39 THA patients with healthy bone, changes in bone mineral density at the sacral alae ipsilateral and contralateral to the THA were analyzed by use of computed tomography immediately postoperatively and at the 1-year follow-up. RESULTS Of the 171 patients with SIF, 50 (40 female; mean age, 79 years; range, 54 to 101 years) were previously treated with THA. Of the 50, 31 patients were treated with unilateral THA. The proportion of patients with an SIF contralateral to the THA was 42% (13 of 31) and ipsilateral to the THA was 19% (6 of 31). Twelve patients had bilateral SIFs. The mean age of the THA group without SIF was 62 years (range, 49 to 79 years); 17 were female. The median bone mineral density decreased significantly (p = 0.023), from 35.0 to 13.0 HU, at the sacral ala contralateral to the THA, whereas the decrease of ipsilateral bone mineral density, from 24.0 to 17.0 HU, was not significant (p = 0.361). CONCLUSIONS The proportion of patients with an SIF contralateral to a THA was twice as high as that of patients with an SIF ipsilateral to a THA. These findings are supported by the second cohort's decrease in bone mineral density at the sacral ala contralateral to the THA at 1 year after surgery. We conclude that THA can lead to spatially different remodeling of the sacrum, possibly affecting the development of SIFs. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Isabel Graul
- Department of Orthopedics, Campus Eisenberg, University of Jena, Eisenberg, Germany
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12
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Oberkircher L, Masaeli A, Hack J, Figiel J, Bliemel C, Ruchholtz S, Krüger A. Pull-out strength evaluation of cement augmented iliac screws in osteoporotic spino-pelvic fixation. Orthop Traumatol Surg Res 2021; 107:102945. [PMID: 33895387 DOI: 10.1016/j.otsr.2021.102945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Spino-pelvic fixation has been widely accepted for surgical treatment of sacral tumor, scoliosis surgery and pelvic fractures. Cement augmentation of screws is an option to improve implant stability in osteoporotic bone quality. Aim of the present study is to compare iliac screw fixation without cement fixation and two cement application options in a biomechanical testing. HYPOTHESIS Cement augmentation of iliac screws leads to superior pull-out strength. MATERIAL AND METHODS Thirty female and osteoporotic human iliac bones were used. Three operation treatment groups were generated: Screw fixation (cannulated screws) without cement augmentation [Operation treatment (OT) A], screw fixation with cement augmentation before screw placement (cannulated screws) (OT B) and screw fixation with perforated screws and cement augmentation after screw placement (OTC). Pull-out tests were performed with a rate of 6mm/min. A load versus displacement curve was generated. Maximum pull-out force (N) was measured in the load-displacement curve. RESULTS Paired group 1 (OT A vs. OT B): Screw fixation without cement augmentation: 592.6N±335.07 and screw fixation with cement augmentation before screw placement: 996N±287.43 (p=0.0042). Paired group 2 (OT A vs. OT C): screw fixation without cement augmentation: 716.2N±385.86 and fenestrated screw fixation with cement augmentation after screw placement: 1324.88N±398.76 (p=0.0489). Paired group 3 (OT B vs. OT C): Screw fixation with cement augmentation before screw placement: 1077.2±486.66 and fenestrated screw fixation with cement augmentation after screw placement: 1298.2N±726.19 (p=0.3286). DISCUSSION Regarding iliac screw fixation for spino-pelvic ostesynthesis in osteoporotic bone, cement augmentation is significantly superior to solid iliac screw fixation respecting pull-out-strength. Nevertheless, further biomechanical studies are needed to verify these findings. LEVEL OF EVIDENCE Not applicable; biomechanical cadaver study.
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Affiliation(s)
- Ludwig Oberkircher
- Philipps University Marburg, Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany.
| | - Adrian Masaeli
- Philipps University Marburg, Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany
| | - Juliana Hack
- Philipps University Marburg, Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany
| | - Jens Figiel
- Department of diagnostic and interventional radiology, Philipps University Marburg, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany
| | - Christopher Bliemel
- Philipps University Marburg, Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany
| | - Steffen Ruchholtz
- Philipps University Marburg, Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany
| | - Antonio Krüger
- Department of trauma surgery, orthopaedics, spine surgery and pediatric trauma surgery, Asklepios Hospital Lich, Goethestrasse 4, 35423 Lich, Germany
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13
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Wilson DGG, Kelly J, Rickman M. Operative management of fragility fractures of the pelvis - a systematic review. BMC Musculoskelet Disord 2021; 22:717. [PMID: 34419037 PMCID: PMC8380328 DOI: 10.1186/s12891-021-04579-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/02/2021] [Indexed: 02/07/2023] Open
Abstract
Background The incidence of osteoporotic pelvic fractures in elderly patient is rising. This brings an increasing burden on health and social care systems as these injuries often lead to prolonged hospital admissions, loss of independence, morbidity and mortality. Some centres now advocate stabilisation of these injuries to reduce pain, facilitate early mobilisation, decrease hospital stay and restore independence. A systematic review of the literature was planned to establish the evidence for this intervention. Methods A systematic review was performed according to PRISMA guidelines. A clinical librarian performed a search of the following databases: NHS Evidence, TRIP, the Cochrane Database of Systematic Reviews, MEDLINE and EMBASE. Seventeen eligible studies were identified with 766 patients. Results The quality of evidence was poor with no good quality randomised trials. The majority of injuries were minimally displaced. Posterior ring injuries were most often stabilised with percutaneous screws which were sometimes augmented with void filler. A number of techniques were described for stabilisation of the anterior ring although fixation of the anterior ring was frequently not performed. There was consistent evidence from the included studies that operative intervention significantly improved pain. Complications were minimal but there were increased failure rates when a single unaugmented sacroiliac joint screw was used. The limited availability of non-operative comparators made it difficult to draw firm conclusions about the efficacy of surgical over non-surgical management in these patients. Conclusions Operative management of fragility fractures of the pelvis should be considered for patients failing a brief period of non-operative management, however prospective randomised trials need to be performed to provide improved evidence for this intervention. Surgeons should consider which fixation techniques for fragility fractures of the pelvis are robust enough to allow immediate weightbearing, whilst minimising operative morbidity and post-operative complications. PROSPERO Systematic Review ID: CRD42020171237. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04579-w.
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Affiliation(s)
- Daniel G G Wilson
- Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia. .,, Present address: Brighton, UK.
| | - Joshua Kelly
- Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia
| | - Mark Rickman
- Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia.,Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, SA, 5005, Australia
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14
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Arand C, Wagner D, Richards RG, Noser H, Kamer L, Gehweiler D, Hopf J, Rommens PM. Anatomical evaluation of the transpubic screw corridor based on a 3D statistical model of the pelvic ring. Sci Rep 2021; 11:16677. [PMID: 34404906 PMCID: PMC8371146 DOI: 10.1038/s41598-021-96219-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 08/04/2021] [Indexed: 11/20/2022] Open
Abstract
Retrograde transpubic screw fixation is a common procedure for the treatment of anterior pelvic ring fractures. With its sparing surgical approach and significant pain relief after screw fixations allowing early mobilisation, it has gained importance especially in the treatment of insufficiency fractures in elderly patients. However, positioning of transpubic screw osteosynthesis is not always possible due to narrowness and curvature of the screw corridor. The aim of the present study was to evaluate availability and length of the screw corridor using a 3D statistical model of the pelvic ring consisting out of 150 uninjured pelves. Virtual bore probes with a diameter of 7.5 mm were analysed as to accessibility, length and grey value distribution in Hounsfield Unit (HU). A transpubic corridor with a diameter of ≥ 7.5 mm was available in 185 of 300 investigated superior pubic rami with mean screw length of 131.7 mm. Accessibility of the screw corridor was higher in males than in females. However, screw length showed no systematic differences between the sexes or ethnicities. Analysis of the grey value distribution demonstrated the strongest bone to be located at the lateral ilium and the supraacetabular region.
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Affiliation(s)
- Charlotte Arand
- Department of Orthopaedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Daniel Wagner
- Department of Orthopaedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
| | | | - Hansrudi Noser
- AO Research Institut, Clavadelerstrasse 8, 7270, Davos, Switzerland
| | - Lukas Kamer
- AO Research Institut, Clavadelerstrasse 8, 7270, Davos, Switzerland
| | | | - Johannes Hopf
- Department of Orthopaedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Pol M Rommens
- Department of Orthopaedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
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15
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Schmerwitz I, Jungebluth P, Bartels S, Hockertz T. [Angle stable plate for treatment for insufficiency fractures of the pelvis (minimally invasive posterior locked compression plate) : Video article]. Unfallchirurg 2021; 124:680-684. [PMID: 34236449 PMCID: PMC8386502 DOI: 10.1007/s00113-021-01039-x] [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] [Subscribe] [Scholar Register] [Accepted: 06/08/2021] [Indexed: 11/28/2022]
Abstract
Operationsziel Belastungsstabile Versorgung des Beckenringes mit hoher
Primärstabilität. Indikation Instabilität und ausbleibende Mobilisierbarkeit bei osteoporotischen
Beckenbrüchen. Kontraindikationen Dekubitalgeschwüre, Infekte. Operationstechnik Minimal-invasive winkelstabile Versorgung durch 4,5 LCP (locked compression
plate, DePuy Synthes, Zuchwil, Schweiz) von dorsal. Weiterbehandlung Sofortige Mobilisation mit Vollbelastung, Röntgenverlaufskontrolle. Evidenz Die Nachuntersuchung eines Kollektivs von 34 Patienten zeigte keine
Implantatlockerungen sowie eine vergleichsweise niedrige
Strahlenexposition. Video online Die Online-Version dieses Beitrags (10.1007/s00113-021-01039-x) enthält das Video zur hier beschriebenen Operationstechnik
„Winkelstabile Platte zur Behandlung der Insuffizienzfrakturen des
Beckens“.
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Affiliation(s)
- Imke Schmerwitz
- Klinik für orthopädische Chirurgie, Sporttraumatologie und Unfallchirurgie, Städtisches Klinikum Wolfenbüttel, Alter Weg 80, 38302, Wolfenbüttel, Deutschland.
| | - Philipp Jungebluth
- Klinik für orthopädische Chirurgie, Sporttraumatologie und Unfallchirurgie, Städtisches Klinikum Wolfenbüttel, Alter Weg 80, 38302, Wolfenbüttel, Deutschland
| | - Stephan Bartels
- Klinik für orthopädische Chirurgie, Sporttraumatologie und Unfallchirurgie, Städtisches Klinikum Wolfenbüttel, Alter Weg 80, 38302, Wolfenbüttel, Deutschland
| | - Thomas Hockertz
- Klinik für orthopädische Chirurgie, Sporttraumatologie und Unfallchirurgie, Städtisches Klinikum Wolfenbüttel, Alter Weg 80, 38302, Wolfenbüttel, Deutschland
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16
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Mendel T, Schenk P, Ullrich BW, Hofmann GO, Goehre F, Schwan S, Klauke F. Mid-term outcome of bilateral fragility fractures of the sacrum after bisegmental transsacral stabilization versus spinopelvic fixation. Bone Joint J 2021; 103-B:462-468. [PMID: 33641427 DOI: 10.1302/0301-620x.103b3.bjj-2020-1454.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Minimally invasive fixation of pelvic fragility fractures is recommended to reduce pain and allow early mobilization. The purpose of this study was to evaluate the outcome of two different stabilization techniques in bilateral fragility fractures of the sacrum (BFFS). METHODS A non-randomized, prospective study was carried out in a level 1 trauma centre. BFFS in 61 patients (mean age 80 years (SD 10); four male, 57 female) were treated surgically with bisegmental transsacral stablization (BTS; n = 41) versus spinopelvic fixation (SP; n = 20). Postoperative full weightbearing was allowed. The outcome was evaluated at two timepoints: discharge from inpatient treatment (TP1; Fitbit tracking, Zebris stance analysis), and ≥ six months (TP2; Fitbit tracking, Zebris analysis, based on modified Oswestry Disability Index (ODI), Majeed Score (MS), and the 12-Item Short Form Survey 12 (SF-12). Fracture healing was assessed by CT. The primary outcome parameter of functional recovery was the per-day step count; the secondary parameter was the subjective outcome assessed by questionnaires. RESULTS Overall, no baseline differences were observed between the BTS and SP cohorts. In total, 58 (BTS = 19; SP = 39) and 37 patients (BTS = 14; SP = 23) could be recruited at TP1 and TP2, respectively. Mean steps per day at TP1 were median 308 (248 to 434) in the BTS group and 254 (196 to 446) in the SP group. At TP2, median steps per day were 3,759 (2,551 to 3,926) in the BTS group and 3,191 (2,872 to 3,679) in the SP group, each with no significant difference. A significant improvement was observed in each group (p < 0.001) between timepoints. BTS patients obtained better results than SP patients in ODI (p < 0.030), MS (p = 0.007), and SF-12 physical status (p = 0.006). In all cases, CT showed sufficient fracture healing of the posterior ring. CONCLUSION Both groups showed significant outcome improvement and sufficient fracture healing. Both techniques can be recommended for BFFS, although BTS was superior with respect to subjective outcome. Step-count tracking represents a reliable method to evaluate the mobility level. Cite this article: Bone Joint J 2021;103-B(3):462-468.
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Affiliation(s)
- Thomas Mendel
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Halle, Germany.,Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Jena, Jena, Germany
| | - Philipp Schenk
- Research Executive Department, BG Klinikum Bergmannstrost Halle, Halle, Germany
| | | | - Gunther Olaf Hofmann
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Halle, Germany.,Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Jena, Jena, Germany
| | - Felix Goehre
- Department of Neurosurgery, BG Klinikum Bergmannstrost Halle, Halle, Germany
| | - Stefan Schwan
- Department of Biological and Macromolecular Materials, Fraunhofer Institute for Microstructure of Materials and Systems IMWS, Halle, Germany
| | - Friederike Klauke
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Halle, Germany.,Department of Trauma, Hand and Reconstructive Surgery, Universitätsklinikum Jena, Jena, Germany
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17
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Lang P, Schwabe K, Riesner HJ, Friemert B, Stuby F, Palm HG. Epidemiological and Therapeutic Developments in Pelvic Ring Fractures Type C from 2004 to 2014 - a Retrospective Data Analysis of 2,042 Patients in the German Pelvic Register (DGU). ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2021; 160:172-182. [PMID: 33477178 DOI: 10.1055/a-1298-4949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pelvic ring fractures type C present a special challenge due to their high instability, the possible accompanying injuries and the high mortality rate of up to 18.9%. The aim of this retrospective analysis was to use the data from the DGU pelvic register to identify changes in the epidemiology and therapy for type C pelvic ring fractures between 2004 and 2014. MATERIALS AND METHODS 2,042 patients with type C pelvic ring injury were retrospectively included. Three time periods with roughly equal patient groups were specified and differences in epidemiology and the type of therapy were evaluated. For the surgical cases, the time of the operation, the duration of the operation, blood loss, the location of the fracture and the type of osteosynthesis were evaluated and the reduction result was recorded. RESULTS For the period under review, there is an age shift in the incidence of a type C pelvic ring fracture towards older age. The isolated pelvic injury has increased, while the proportion of pelvic injuries in the context of polytrauma has steadily decreased. Complications and mortality decreased as a percentage. The tendency towards minimally invasive procedures could be shown in the surgical care. Navigated procedures in the area of the pelvic ring have so far not proven successful. CONCLUSIONS We were able to show that the majority of the patients are increasingly old, that there is no relevant trauma in the history and that there is an increase in the isolated pelvic fracture type C and a decrease in the number of polytraumatised or multiply injured patients. In conjunction with mortality from pelvic ring injuries, the successes of standardised, pelvic-specific emergency management, an adapted time of operation outside the vulnerable phase and stable osteosynthesis care, which enable early functional follow-up treatment, are also evident.
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Affiliation(s)
- Patricia Lang
- Clinic for Trauma Surgery and Orthopaedics, German Federal Armed Forces Hospital Ulm, Germany
| | - Kerstin Schwabe
- Clinic for General, Visceral and Thoracic Surgery, German Federal Armed Forces Hospital Ulm, Germany
| | - Hans-Joachim Riesner
- Clinic for Trauma Surgery and Orthopaedics, German Federal Armed Forces Hospital Ulm, Germany
| | - Benedikt Friemert
- Clinic for Trauma Surgery and Orthopaedics, German Federal Armed Forces Hospital Ulm, Germany
| | | | - Hans-Georg Palm
- University Surgical Clinic - Orthopaedic Surgery, University Clinics Erlangen, Germany
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18
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Modified therapy concepts for fragility fractures of the pelvis after additional MRI. PLoS One 2020; 15:e0238773. [PMID: 33031459 PMCID: PMC7544090 DOI: 10.1371/journal.pone.0238773] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/24/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Fractures of the pelvic ring in elderly patients have increased in frequency over time. These injuries are associated with a high morbidity and have a socio-economic impact. The diagnostic procedures and their influence of therapy decisions are still controversial. METHODS In a retrospective study, we investigate the value of additional MRI examination on therapy decision of fragility fractures of the pelvis. The evaluation of all patients with pelvic fractures without adequate trauma and with performed CT and MRI was conducted at three large German hospitals. The imaging procedure took place within a maximum interval of 4 weeks. After evaluation of the imaging, the resulting therapeutic consequences either based on CT alone or on CT and MRI were reviewed by experienced pelvic surgeons. RESULTS Of 754 patients with pelvic injuries, 67 (age 80 +/- 9.7 years, f: m 54:13) could be included. The detection of vertical fractures in CT (n = 40 unilateral, n = 11 bilateral) could be increased by the additional MRI (n = 44 unilateral, n = 23 bilateral). A horizontal fracture component was identified in CT in 9.0% (n = 6) vs. MRI in 25.4% (n = 17) of the cases. An anterior pelvic ring injury was detected in 71.6% (n = 44; 4x bilateral) in CT, in 80.6% in MRI (n = 50, 4 bilateral). Additive MRI imaging increased the decision rate for surgical therapy from 20.9% (n = 14) to 31.3% (n = 21). CONCLUSIONS The results of this study further support the value of bone marrow edema detection by MRI diagnostics (or dual source CT which showed promising initial results) for the detection of pelvic ring fractures. For the first time, the study identifies an additional therapeutic consequence by an increased rate of surgical procedures.
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Lang P, Sterneder M, Riesner HJ, Hackenbroch C, Friemert B, Palm HG. Fragility Fractures of the Pelvic Ring – Does the Evidence of Oedema Lead us to More Surgeries? ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2020; 159:503-512. [DOI: 10.1055/a-1192-7583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Abstract
Introduction The choice of therapy for fragility fractures of the pelvis (FFP) is largely determined by the diagnosed fracture morphology. It is now unclear whether the change in diagnostic options – sensitive detection of fracture oedema in the sacrum using MRI and dual-energy computed tomography (DECT) – has an impact on the therapeutic consequences. The aim of this retrospective study was therefore to evaluate the change in the diagnostics used and the resulting therapy regimen in our patient population.
Materials and Methods We performed a monocentric-retrospective analysis of 196 patients with a fragility fracture of the pelvis in our clinic (national TraumaZentrum® DGU and SAV approval) in the period from 2008 to 2017. We examined changes in epidemiology, diagnostics/classification and therapy of the pelvic ring fractures treated by us.
Results The diagnostic procedures used are subject to a clear change towards oedema detection using MRI and DECT. The graduation has changed towards more severe forms of fracture after FFP. There is now also an increasing proportion of patients treated by surgery (2008 – 2009: 5.3% vs. 2015 – 2017: 60.3%).
Conclusion We were able to show that the introduction of sensitive diagnostic procedures coincided with a higher classification of the fractures. It is also noteworthy that the increase in operations is not only due to a higher degree of classification; also in relative terms, more patients are operated on within type FFP II.
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Affiliation(s)
- Patricia Lang
- Department for Trauma and Orthopaedic, Reconstructive and Septic Surgery, Sports Traumatology, German Military Hospital in Ulm
| | - Manuel Sterneder
- Department for Trauma and Orthopaedic, Reconstructive and Septic Surgery, Sports Traumatology, German Military Hospital in Ulm
| | - Hans-Joachim Riesner
- Department for Trauma and Orthopaedic, Reconstructive and Septic Surgery, Sports Traumatology, German Military Hospital in Ulm
| | - Carsten Hackenbroch
- Clinic for Diagnostic Radiology and Neuroradiology, German Military Hospital in Ulm
| | - Benedikt Friemert
- Department for Trauma and Orthopaedic, Reconstructive and Septic Surgery, Sports Traumatology, German Military Hospital in Ulm
| | - Hans-Georg Palm
- Department for Trauma and Orthopaedic, Reconstructive and Septic Surgery, Sports Traumatology, German Military Hospital in Ulm
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Hackenbroch C, Merz C, Palm HG, Friemert B, Stuby F, Lang P. Magnetic Resonance Imaging in Pelvic Fractures – Part 2: Gaining Information and Clinical Therapeutic Relevance. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:360-368. [DOI: 10.1055/a-0965-7686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Background Magnetic resonance and computed tomography (MRI, CT) has been known to compare the sensitivity for the detection of pelvic fractures with others. It is unclear whether MRI imaging beyond CT leads to therapy change. The aim of our study is to determine the information gained from MRI in the diagnosis of pelvic fractures and to reduce the effects on the form of therapy.
Patients and Methods In a retrospective, clinical study, 31 patients with pelvic fracture and CT and MRI imaging (median 81 ± 20 years, 22 female and 9 male) were examined. There was a classification according to AO classification for adequate or FFP classification for inadequate fractures. In addition, vascular, muscular, haematomatous and organic concomitant injuries as well as bone marrow edema and additional secondary findings requiring evaluation were evaluated. The type of therapy (conservative vs. surgical) and a possible type of therapy change were documented for each patient. Exact test according to Fisher was tested orienting.
Results Overall, MRI showed a greater fracture rate of pelvic fractures in 29% (n = 9) patients than CT. Four type I fractures according to FFP classification were identified as type II fractures and 4 type II fractures as type IV fractures. One type B1 fracture according to AO classification was found to be C2 fracture on MRI. Fisherʼs Exact Test found that the parameters “adequacy of trauma” and “fracture type change” by MRI were p = 0.38. MRI showed a total of 82 concomitant injuries, CT 31. Overall, MRI gained information in 75% (n = 24) of all patients examined. A change from conservative to operative after MRI took place in 2 patients. No patient was surgically changed from planned surgery to conservative. The extent to which MRI caused changes within one form of therapy (conservative, operative) could not be determined retrospectively. In 18% of patients with an inadequate fracture, however, according to the literature, the treatment regimen would have
changed pro forma.
Conclusion In summary, it can be stated that the MRI in our study provided an information gain in the case of adequate and inadequate pelvic fractures as well as their accompanying injuries and that a possible therapeutic relevance of this information gain could be obtained specially at the inadequate fractures showed.
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Affiliation(s)
| | - Charlotte Merz
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, Sports Traumatology, Ulm Army Hospital
| | - Hans-Georg Palm
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, Sports Traumatology, Ulm Army Hospital
| | - Benedikt Friemert
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, Sports Traumatology, Ulm Army Hospital
| | - Fabian Stuby
- Casualty Hospital, Occupational Accident Casualty Hospital, Murnau
| | - Patricia Lang
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Septic Surgery, Sports Traumatology, Ulm Army Hospital
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Lang P, Merz C, Hackenbroch C, Friemert B, Stuby F, Palm HG. Magnetic Resonance Imaging in Pelvic Fractures – Part 1: Which Criteria Lead Us to Supplementary MRI Diagnostics? ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:351-359. [DOI: 10.1055/a-0965-7589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Introduction Isolated pelvic fractures are relatively rare with an incidence of 3 – 6% of all fractures, but their incidence in polytraumatized individuals increases to 25%. The S3 guideline Polytrauma gives a clear recommendation for diagnostics by means of pelvic radiography (X-ray) and computed tomography (CT). A recommendation for the diagnosis by means of magnetic resonance tomography (MRI) especially in patients with low energetic/missing trauma does not currently exist. It is unclear on the basis of which criteria the MRI can be indicated in pelvic fractures. The aim of our study was therefore to retrospectively record indications for the indication of MRI in pelvic fractures – with adequate as well as inadequate trauma.
Material and Methods In a retrospective clinical study, a total of 140 patients (median 68 years, range 15 – 97, 75 female, and 66 male) with a pelvic fracture were included in the study over a period of three years. Overall, the trauma mechanism revealed 73 adequate and 67 inadequate fractures. 31/140 patients had undergone MRI of the pelvis in addition to a CT/X-ray scan. The two subgroups “with MRI” and “without MRI” were analyzed with regard to the parameters “sex”, “age”, “adequacy of the trauma”, “fracture localization”, “duration of admission to imaging”, “type of therapy” and “duration to surgery” compared.
Results It was shown that the MRI diagnosis was performed especially in female, elderly patients (81 years, range 19 – 94 years). Patients with inappropriate trauma have received MRI more frequently (74%) than patients with adequate trauma (26%). With regard to fracture localization no differences could be shown. The MRI was performed on a median 4 days after the CT examination. Regarding the decision “conservative” vs. “operationally” our two groups without and with MRT tended to differ not. Patients with MRI were operated on median 2 days later than patients who did not receive MRI.
Conclusions Pelvic fracture MRI should be performed primarily in elderly female patients without adequate trauma. In patients with adequate trauma, MRI is of low value, especially as MRI diagnostics are performed with delay, resulting in later surgery.
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Affiliation(s)
- Patricia Lang
- Klinik für Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm
| | - Charlotte Merz
- Klinik für Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm
| | | | - Benedikt Friemert
- Klinik für Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm
| | | | - Hans-Georg Palm
- Klinik für Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm
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Cement augmentation of sacroiliac screws in fragility fractures of the pelvic ring-A synopsis and systematic review of the current literature. Injury 2019; 50:1411-1417. [PMID: 31301810 DOI: 10.1016/j.injury.2019.06.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 05/29/2019] [Accepted: 06/24/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fragility fractures of the pelvis (FFP) show a notable rise in prevalence. Minimally invasive surgical fixation of FFP is increasingly advocated for its obvious advantages with reference to early mobilization and weight bearing. Concerns regarding the holding power of osteosynthetic materials in osteoporotic bone led to the development of cementing techniques. However, the role of cement augmentation in the surgical treatment of FFP has yet to be defined. Therefore, the aim of this study was to conduct a systematic review of the current literature concerning studies that are comparing the performance of cement augmented versus non-augmented sacroiliac (SI) screws. METHODS We conducted a systematic literature review from 01/01/2000 onwards. Inclusion criteria were randomized controlled studies, case series (n>3), biomechanical studies and reviews, comparing augmented and non-augmented SI screws. Only papers in German or English language were included. RESULTS Out of 1247 initial hits, eleven studies met the inclusion criteria. Out of those, six were biomechanical studies and five were clinical case series. Most biomechanical studies showed cement augmented screws to have a greater mechanical stability, both regarding pull-out force and resistance to cyclic loading. The five case studies reported on a total of 98 patients with 122 screw fixations. Three cases of cement leakage into neuroforamina occurred, however, none of these patients showed clinical symptoms. CONCLUSION In clinical case series, cement augmentation of SI screws appears to be a safe surgical technique without relevant complications and biomechanical studies demonstrate greater pull-out forces of augmented SI screws but no advantage in regard of cyclic loading. Hence, applicability of the mechanical testing results on the clinical situation are debatable. So far, there are neither retrospective nor randomized controlled studies comparing the performance of cemented and non-cemented SI screws in FFP. Therefore, the clinical benefit of SI screw cement augmentation is unclear and their use remains experimental.
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Booth A, Ingoe HMA, Northgraves M, Coleman E, Harden M, Kassam J, Kwok I, Hilton C, Bates P, McDaid C. Effectiveness of surgical fixation for lateral compression type one (LC-1) fragility fractures of the pelvis: a systematic review. BMJ Open 2019; 9:e024737. [PMID: 31110085 PMCID: PMC6530388 DOI: 10.1136/bmjopen-2018-024737] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To undertake a systematic review of the evidence base for the effectiveness of surgical fixation of lateral compression (LC-1) fragility fractures of the pelvis compared with non-surgical approaches. SEARCHES MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and two international trials registers were searched up to January 2017 (MEDLINE to February 2019) for studies of internal or external fixation of fragility fractures of the pelvis. PARTICIPANTS Patients with lateral compression pelvic fractures, sustained as the result of a low-energy mechanism, defined as a fall from standing height or less. INTERVENTIONS Surgery using either external or internal fixation devices. Conservative non-surgical treatment was the defined comparator. OUTCOME MEASURES Outcomes of interest were patient mobility and function, pain, quality of life, fracture union, mortality, hospital length of stay and complications (additional operative procedures, number and type of adverse events and serious adverse events). QUALITY ASSESSMENT AND SYNTHESIS The Joanna Briggs Institute Checklist for Case Series was used to assess the included studies. Results were presented in a narrative synthesis. RESULTS Of 3421 records identified, four retrospective case series met the inclusion criteria. Fixation types were not consistent between studies or within studies and most patients had more than one type of pelvic fixation. Where reported, mobility and function improved post-surgery, and a reduction in pain was recorded. Length of hospital stay ranged from 4 days to 54 days for surgical fixation of any type. Reported complications and adverse outcomes included: infections, implant loosening, pneumonia and thrombosis. Use of analgesia was not reported. CONCLUSIONS There is insufficient evidence to support guidance on the most effective treatment for patients who fail to mobilise after sustaining an LC-1 fragility fracture. TRIAL REGISTRATION NUMBER CRD42017055872.
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Affiliation(s)
- Alison Booth
- Department of Health Sciences, University of York, York, UK
| | - Helen Margaret Ann Ingoe
- Department of Health Sciences, University of York, York, UK
- Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough, UK
| | | | | | - Melissa Harden
- Centre for Reviews and Dissemination, University of York, York, UK
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Hoffmeyer P, Miozzari H, Holzer N. Non-hip/non-vertebral fractures - How to treat best? Best Pract Res Clin Rheumatol 2019; 33:236-263. [PMID: 31547981 DOI: 10.1016/j.berh.2019.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Fractures of the extremities in the elderly constitute more than two-thirds of all fragility fractures befalling frail, osteoporotic and sarcopenic patients. Although treatment controversies abound, consensus exists. Upper extremity fractures hinder activities of daily living and are debilitating. Open fractures or displaced fractures will need surgical intervention. Wrist fractures treated operatively allow early use of the hand. Most pelvic fractures are treated conservatively. In the lower extremities, fractures of the long bones, tibia and femur need surgical intervention. Non-displaced fractures around the foot may be treated with immobilisation and avoidance of full weight-bearing. As a rule, fractures take four months for consolidation. Individually tailored solutions are needed for frail patients with comorbidities. Maintaining joint mobility and muscle strength preserves mobility and autonomy. Caring for extremities trauma is team work, involving family and health care providers. Prevention efforts are mandatory.
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Affiliation(s)
- Pierre Hoffmeyer
- Swiss Foundation for Innovation and Training in Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1205, Switzerland.
| | - Hermes Miozzari
- Department of Orthopaedics, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1205, Switzerland.
| | - Nicolas Holzer
- Department of Orthopaedics, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1205, Switzerland.
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Höch A, Pieroh P, Henkelmann R, Josten C, Böhme J. In-screw polymethylmethacrylate-augmented sacroiliac screw for the treatment of fragility fractures of the pelvis: a prospective, observational study with 1-year follow-up. BMC Surg 2017; 17:132. [PMID: 29221479 PMCID: PMC5723042 DOI: 10.1186/s12893-017-0330-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 12/03/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The incidence of pelvic ring fractures in the elderly significantly increased. Because of persistent pain and immobilization associated with this injury, surgical treatment is recommended. To minimise comorbidities and surgical risk, percutaneous techniques are becoming more relevant. In-screw cement augmentation of sacroiliac screw fixation is a promising procedure; however, clinical follow-up data remain scarce. This study investigated the safety and possible complications of the procedure along with a 1-year follow-up. METHODS Thirty-four patients (treated with 43 screws) were prospectively included. Data on patients' age and sex, the mechanism of accident, fracture pattern, duration of hospital stay, surgery and adverse events were recorded. Data were obtained postoperatively on the reduction of pain and complications, such as infection, cement leakage and neurological deficits, and at 1-year follow-up on pain, quality of life according to the 12-Item Short Form Survey and mobility. Implant failure was defined as retraction or dislocation of screws and was also documented. RESULTS Screw-related complications occurred with 2 of 43 screws. None of these complications were related to cement augmentation. In-hospital adverse events occurred in 6 of 34 patients. Postoperative pain, measured by the visual analogue scale, was significantly reduced from 6.7 ± 1.4 preoperatively to 2.7 ± 1.0 postoperatively (p < 0.001). Although patients complained of pain at the 1-year follow-up, they reported a significant decline compared with pain at admission (3.4 ± 2.3; p < 0.001). Results on the quality of life were comparable with those for the age- and gender matched German population. All patients were mobile, and no implant failure was detected. CONCLUSIONS The results indicate that in-screw augmented sacroiliac screw fixation for fragility fractures of the pelvis is a safe technique. Pain was significantly reduced immediately after surgery compared to the preoperative state. Furthermore, significant pain reduction after one year compared to the preoperative state and quality of life was comparable to the age- and gender- matched German population. Thus, we recommend in-screw augmentation for screw fixation for sacral fragility fractures of the pelvis following failed conservative treatment.
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Affiliation(s)
- Andreas Höch
- Department of Orthopedics, Trauma and Plastic Surgery, Spine Center, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.
| | - Philipp Pieroh
- Department of Orthopedics, Trauma and Plastic Surgery, Spine Center, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.,Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Grosse Steinstrasse 52, 06097, Halle (Saale), Germany
| | - Ralf Henkelmann
- Department of Orthopedics, Trauma and Plastic Surgery, Spine Center, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma and Plastic Surgery, Spine Center, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
| | - Jörg Böhme
- Department of Orthopedics, Trauma and Plastic Surgery, Spine Center, University Hospital of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany.,Present address: Clinic of Trauma, Orthopedic and Septic Surgery, Hospital St.Georg GmbH, Delitzscher Str. 141, 04129, Leipzig, Germany
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