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Oda T, Kitada S, Hirase H, Takada Y, Iwasa K, Niikura T. Evaluation of a treatment protocol based on conservative therapy for fragility fractures of the pelvis. Eur J Trauma Emerg Surg 2024; 50:1173-1181. [PMID: 38393362 DOI: 10.1007/s00068-024-02469-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE In an aging society, fragility fractures of the pelvis (FFP) have increased significantly. However, there is no clear consensus on the timing and criteria for transitioning from conservative treatment to surgery for these fractures. Thus, we aimed to investigate the effects of our treatment protocol for FFP based on conservative treatment. METHODS We conducted a retrospective study including 74 patients with FFP at our institution between 2015 and 2021. All patients were treated conservatively for the first two weeks. During this period, only wheelchair transfer was allowed. If the patient could not walk after this period, surgery was performed. Fracture type (Rommens classification), walking ability, presence of complications after admission, presence of fracture union, and surgical treatment was investigated. Patients were divided into two groups: a stable group (type I/II) and an unstable group (type III/IV). RESULTS Fracture union was achieved in all patients. Thirteen patients developed complications after being admitted to our hospital; seven showed decreased walking ability, and six required surgeries. The stable and unstable groups comprised 47 and 27 patients, respectively. There were no statistically significant differences between the groups regarding the percentage of patients who developed complications or experienced decrease in walking ability. The percentage of patients who required surgery was significantly higher in the unstable group (p < 0.05). CONCLUSION Our FFP management protocol was effective regardless of fracture type. It is important to provide a period for careful assessment of instability, and to try to prevent fracture progression.
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Affiliation(s)
- Takahiro Oda
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Shimpei Kitada
- Orthopaedic Reconstruction Center, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan.
| | - Hitoshi Hirase
- Orthopaedic Reconstruction Center, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Yuma Takada
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Kenjiro Iwasa
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
- Orthopaedic Reconstruction Center, Hyogo Prefectural Nishinomiya Hospital, 13-9, Rokutanji, Nishinomiya, 662-0918, Japan
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Weitz M, Schwartz C, Scheinfeld MH. Radiologic blind spots in hip and pelvic radiographs. Emerg Radiol 2023; 30:569-575. [PMID: 37452984 DOI: 10.1007/s10140-023-02156-3] [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: 05/31/2023] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE The purpose of our study was to identify the locations at which hip and pelvic fractures are commonly missed on radiographs. METHODS A retrospective study was performed at four non-Level 1 trauma center emergency departments. IRB approval was obtained. All emergency department hip or pelvic radiographs with subsequent CT performed within 48 h were identified from 2017 to 2022. Reports for each radiograph and CT were scored for the presence or the absence of fracture in the following locations: ilium, sacrum, superior pubic ramus, inferior pubic ramus, pubis, acetabulum, subcapital femoral, femoral neck, greater trochanter, lesser trochanter, intertrochanteric, and subtrochanteric. The CT report was used as the gold standard. The false-negative radiography cases were reviewed on a PACS workstation to determine whether the case had an "unexpected miss" of a fracture, a subtle fracture, radiographically occult fracture, or exam was limited by artifact. The percentage of missed fractures at each location was calculated. RESULTS Nine hundred seventy-five radiography cases with subsequent CT were identified. One hundred forty-six cases did not meet entry criteria; therefore, 829 cases were analyzed further. Seventy-four percent of patients were female with age of 74 ± 16 (mean ± standard deviation) years (range 1-103). Three hundred fifty-two cases had at least one fracture, and many cases had multiple fractures. There were 68 false-negative cases. The most commonly missed fractures by percentage were pubis, ilium, and greater trochanter. The most common unexpectedly missed fractures were greater trochanter and femoral subcapital. CONCLUSION A careful systematic evaluation of hip and pelvic radiographs, with particular attention to the pubis, ilium, greater trochanter, and subcapital region, may improve radiographic fracture detection and decrease delays in diagnosis.
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Affiliation(s)
- Mordechai Weitz
- Department of Radiology, Montefiore Medical Center, 111 East 210 Street, Bronx, NY, 10467, USA
| | - Carly Schwartz
- Division of Emergency Radiology, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210 Street, Bronx, NY, 10467, USA
| | - Meir H Scheinfeld
- Division of Emergency Radiology, Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210 Street, Bronx, NY, 10467, USA.
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Janssens S, Deschodt M, Dejaeger M, Fagard K, Cerulus M, Cosyns H, Flamaing J, Herteleer M, Sermon A. From research to daily clinical practice: implementation of orthogeriatric co-management in the trauma ward. FRONTIERS IN HEALTH SERVICES 2023; 3:1249832. [PMID: 37711603 PMCID: PMC10498298 DOI: 10.3389/frhs.2023.1249832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/15/2023] [Indexed: 09/16/2023]
Abstract
Introduction Evidence strongly suggests that orthogeriatric co-management improves patient outcomes in frail older patients with a fracture, but evidence regarding how to implement this model of care in daily clinical practice is scarce. In this paper, we first describe the implementation process and selection of implementation strategies for an orthogeriatric co-management program in the traumatology ward of the University Hospitals Leuven in Belgium. Second, we report the results of a multi-method feasibility study. This study (1) measures the fidelity towards the program's core components, (2) quantifies the perceived feasibility and acceptability by the healthcare professionals, and (3) defines implementation determinants. Methods Implementation strategies were operationalized based on the Expert Recommendations for Implementing Change (ERIC) guidelines. In the feasibility study, fidelity towards the core components of the program was measured in a group of 15 patients aged 75 years and over by using electronic health records. Feasibility and acceptability as perceived by the involved healthcare professionals was measured using a 15-question survey with a 5-point Likert scale. Implementation determinants were mapped thematically based on seven focus group discussions and two semi-structured interviews by focusing on the healthcare professionals' experiences. Results We observed low fidelity towards completion of a screening questionnaire to map the premorbid situation (13%), but high fidelity towards the other program core components: multidimensional evaluation (100%), development of an individual care plan (100%), and systematic follow-up (80%). Of the 50 survey respondents, 94% accepted the program and 62% perceived it as feasible. Important implementation determinants were feasibility, awareness and familiarity, and improved communication between healthcare professionals that positively influenced program adherence. Conclusions Fidelity, acceptability, and feasibility of an orthogeriatric co-management program were high as a result of an iterative process of selecting implementation strategies with intensive stakeholder involvement from the beginning. Clinical trial registration [https://www.isrctn.com/ISRCTN20491828], International Standard Randomised Controlled Trial Number (ISRCTN) Registry: [ISRCTN20491828]. Registered on October 11, 2021.
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Affiliation(s)
- Sigrid Janssens
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Leuven, Belgium
| | - Mieke Deschodt
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Leuven, Belgium
- Competence Centre of Nursing, University Hospitals Leuven, Leuven, Belgium
| | - Marian Dejaeger
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Katleen Fagard
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Marie Cerulus
- Competence Centre of Nursing, University Hospitals Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Heidi Cosyns
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Johan Flamaing
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, Leuven, Belgium
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Michiel Herteleer
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Traumatology, University Hospitals Leuven, Leuven, Belgium
| | - An Sermon
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Traumatology, University Hospitals Leuven, Leuven, Belgium
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Effective treatment of highest instability in a subacute fragility fracture of the pelvis (FFP IV) using a cement augmented transsacral screw only. Trauma Case Rep 2023; 43:100771. [PMID: 36647437 PMCID: PMC9840177 DOI: 10.1016/j.tcr.2023.100771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2023] [Indexed: 01/10/2023] Open
Abstract
The highest instability in fragility fractures of the pelvis (FFP) is noted in presence of H-, U-type sacral fractures. Suggested surgical treatment options include uni- or bilateral sacroiliac or transsacral screw fixation at different levels or in combination, as well as lumbopelvic and bilateral triangular lumbopelvic stabilization. However, distinct treatment recommendations for this subset of injuries are scarce. We present a case sustaining rapid FFP crescendo instability following initial conservative treatment of a FFP type II injury resulting in a U-type spinopelvic dissociation. Fixation using one percutaneous cement augmented transsacral S1 screw resulted in perpetual clinical improvements in pain and mobility in presence of radiologic fracture consolidation.
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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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