Unstable minimally displaced lateral compression type 1 (LC1) pelvic ring injuries have a similar hospital course as intertrochanteric femur fractures

What outcomes do patients value after orthopaedic trauma: A best-worst scaling choice experiment

INTRODUCTION

Patient-centered treatment and research should focus on the outcomes that matter to patients. The primary aim of this study was to determine the outcome preferences of patients after musculoskeletal trauma. The secondary aim was to identify discrepancies between outcome preferences of surgeons and patients.

METHODS

A Best-worst scaling choice experiment survey was administered to patients with operative lower extremity injuries and orthopaedic surgeons who take trauma call. Participants completed 13 choice sets of 3 randomly-ordered outcomes, including: a full recovery (back to normal) without any problems; a problem that requires additional surgery or hospital stay versus medication or treatment in clinic/emergency department; minimal to moderate versus severe pain for 6 weeks; need for crutches/walker versus wheelchair for 6-12 weeks; being unable to work for 6-12 weeks; requiring 2-4 weeks in a facility; a perfect versus poor or worst-possible EuroQol 5 Dimension (EQ-5D) score at 1 year; and death. Within each set, participants ranked their "most-preferred" to "least-preferred" outcomes. Responses were aggregated to calculate the relative importance, or marginal utility, of each outcome stratified by respondent type.

RESULTS

Fifty-five patients and 65 surgeons participated. The most preferred outcome for patients and surgeons was a full recovery (back to normal) without any problems, followed by minimal to moderate pain for 6 weeks and a perfect EQ-5D score. The least preferred outcomes were death and the worst EQ-5D score, which had similar marginal utility, followed by a poor EQ-5D score and a problem that needs another surgery or stay at a hospital, which also had similar marginal utility. Surgeons, in comparison to patients, assigned a higher marginal utility to perfect EQ-5D scores at one year (3.55 vs. 2.03; p < 0.0001) and a 2-4 week stay in a facility (0.52 vs. -0.21; p = 0.001), and a lower marginal utility to severe pain for 6 weeks (-0.58 vs. -0.08; p = 0.04) and a poor EQ-5D score (-1.88 vs. -1.03; p = 0.02).

CONCLUSIONS

A full recovery (back to normal) without any problems was the most-preferred outcome for both patients and surgeons. Patient-centered care and research should focus on both patients' return to baseline and the avoidance of complications.

LEVEL OF EVIDENCE

N/A.

Patient Preferences for Operative Versus Nonoperative Treatment of LC1 Pelvis Fracture: A Discrete Choice Experiment

OBJECTIVES

To quantify how patients with lateral compression type 1 (LC1) pelvis fracture value attributes of operative versus nonoperative treatment.

METHODS

DESIGN

Discrete choice experiment.

SETTING

Three US Level 1 trauma centers.

PATIENT SELECTION CRITERIA

Adult survivors of an LC1 pelvis treated between June 2016 and March 2023 were identified from institutional registries. The choice experiment was administered as a survey from March through August 2023.

OUTCOME MEASURES AND COMPARISONS

Participants chose between 12 hypothetical comparisons of treatment attributes including operative or nonoperative care, risk of death, severity of pain, risk of secondary surgery, shorter hospital stay, discharge destination, and independence in ambulation within 1 month of injury. The marginal utility of each treatment attribute, for example, the strength of participants' aggregate preference for an attribute as indicated by their survey choices, was estimated by multinomial logit modeling with and without stratification by treatment received.

RESULTS

Four hundred forty-nine eligible patients were identified. The survey was distributed to 182 patients and collected from 72 patients (39%) at a median 2.3 years after injury. Respondents were 66% female with a median age of 59 years (IQR, 34-69 years). Before injury, 94% ambulated independently and 75% were working; 41% received operative treatment. Independence with ambulation provided the highest relative marginal utility (21%, P < 0.001), followed by discharge to home versus skilled nursing (20%, P < 0.001), moderate versus severe postdischarge pain (17%, P < 0.001), shorter hospital stay (16%, P < 0.001), secondary surgery (15%, P < 0.001), and mortality (10%, P = 0.02). Overall, no relative utility for operative versus nonoperative treatment was observed (2%, P = 0.54). However, respondents strongly preferred the treatment they received: operative patients valued operative treatment (utility, 0.37 vs. -0.37, P < 0.001); nonoperative patients valued nonoperative treatment (utility, 0.19 vs. -0.19, P < 0.001).

CONCLUSIONS

LC1 pelvis fracture patients valued independence with ambulation, shorter hospital stay, and avoiding secondary surgery and mortality in the month after their injury. Patients preferred the treatment they received rather than operative versus nonoperative care.

Fracture displacement of lateral compression type 1 (LC1) Pelvic Ring Injuries: Which measurement methods are reliable and does displacement correlate with adverse events?

PURPOSE

To determine the interobserver reliability of perceived displacement (PD) ≥ 1 cm of lateral compression type 1 (LC1) pelvic ring fractures and to determine if PD correlated with published methods of measuring fracture displacement and adverse events.

METHODS

The injury and follow-up radiographs of 10 patients with nonoperative minimally displaced LC1 injuries were reviewed by 27 orthopaedic trauma surgeons to determine if they perceived an interval fracture displacement ≥ 1 cm. Perceived displacement (PD) was compared to 11 measurements of displacement: the difference in heights of iliac crests (IC), sourcils, and ischial tuberosities on AP/outlet radiographs; the distance from femoral head (FH) to the sacral midline and the distance between the radiographic teardrops (TD) on the AP; the distance from the TD to sacral midline and the difference in distances between the SI joints and the contralateral TD on the inlet. The interobserver reliability and correlation of PD and measured displacement was calculated. The association between PD and adverse events was also evaluated.

RESULTS

PD had weak interobserver reliability (kappa = 0.46). Many of the measurements of displacement were poorly sensitive for PD. The magnification-corrected AP TD measurement had the highest sensitivity (100%) for PD and excellent interobserver reliability (Intraclass correlation 0.97), but had a low specificity (57.1%). All three patients with PD had adverse events while patients without PD had uneventful recoveries (p = 0.008).

CONCLUSIONS

The AP TD measurement detected all cases of PD and had excellent reliability. PD was associated with adverse events, suggesting that accurate and reliable measurements of displacement are warranted.

LEVEL OF EVIDENCE III

Diagnostic.

Early Outcomes of Operative Versus Nonoperative Management of Stress-Positive Minimally Displaced Lateral Compression Type 1 Pelvic Ring Injuries

OBJECTIVES

To compare the early outcomes of patients with stress-positive minimally displaced lateral compression type 1 (LC1b) pelvic ring injuries managed with or without operative fixation.

DESIGN

Retrospective comparison study.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

Forty-three patients with LC1b injuries.

INTERVENTION

Operative versus nonoperative.

MAIN OUTCOME MEASUREMENTS

Discharge to subacute rehabilitation (SAR); 2- and 6-week pain visual analog score, opioid use, assistive device use, percentage of normal single assessment numerical evaluation, SAR status; fracture displacement; and complications.

RESULTS

The operative group did not differ in age, gender, body mass index, high-energy mechanism, dynamic displacement stress radiographs, complete sacral fractures, Denis sacral fracture classification, Nakatani rami fracture classification, follow-up length, or American Society of Anesthesiologists classification. The operative group was less likely to be using an assistive device at 6 weeks [observed difference (OD) -53.9%, 95% confidence interval (CI) -74.3% to -20.6%, OD/CI 1.00, P = 0.0005], less likely to remain in an SAR at 2 weeks (OD -27.5%, CI, -50.0% to -2.7%, OD/CI 0.58, P = 0.02), and had less fracture displacement at follow-up radiographs (OD -5.0 mm, CI, -9.2 to -1.0 mm, OD/CI 0.61, P = 0.02). There were no other differences in outcomes between treatment groups. Complications occurred in 29.6% (n = 8/27) of the operative group compared with 25.0% (n = 4/16) of the nonoperative group resulting in 7 and 1 additional procedures, respectively.

CONCLUSIONS

Operative treatment was associated with early benefits over nonoperative management, including shorter time using assistive devices, less SAR use, and less fracture displacement at follow-up.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of the two surgery methods combined with accelerated rehabilitation in the treatment of lateral compression type 1 pelvic fractures in the elderly

BACKGROUND

Treating lateral compression type 1 (LC1) pelvic ring injuries in older patients is controversial. This study evaluated surgical treatments combined with ERAS for treating LC1 pelvic fractures in the elderly.

METHODS

In this retrospective study, patients who underwent surgery with INFIX (supra-acetabular spinal pedicle screws, and a subcutaneous connecting rod; the experimental group) or superior pubic ramus cannulated screw (the control group) fixation of LC1 pelvic fracture from January 2019 to January 2022 were reviewed. Injury radiography and computed tomography were performed to determine the Young-Burgess classification. All patients performed standardized early rehabilitation exercises after surgery and were followed up for > 12 months. After surgery, the Matta score and the visual analog scale (VAS) were evaluated, and the postoperative weight-bearing time and the length of stay (LOS) were recorded. The Barthel index and the Majeed score were evaluated at 4 months after surgery and at the last follow-up.

RESULTS

Fifty-three patients were included. Thirty-two patients included in the experimental group had a mean age of 75.0 ± 6.2 (range, 66-86) years, and the other 21 patients in the control group had a mean age of 74.6 ± 4.6 (range, 68-83) years. The mean follow-up time was 13.1 ± 1.6 (range, 12-18) months in the experimental group and 13.4 ± 1.3 (range, 12-16) months in the control group. There were no significant differences in follow-up time between the groups (P > 0.05). The mean VAS score, time to weight-bearing, and LOS were 2.0 ± 0.7 (range, 1-3), 1.1 ± 0.3 (range, 1-2) d, and 5.8 ± 0.9 (range, 4-7) d in the experimental group and 2.3 ± 1.2 (range, 1-5), 2.5 ± 1.6 (range, 1-7) d, and 6.1 ± 1.6 (range, 5-11) d in the control group, respectively. Between the two groups, there was a significant difference in the postoperative time to weight-bearing (P < 0.05), while there was no significant difference in the LOS (P > 0.05). No bedrest-related complications occurred in either group. The Matta score was 90.6% in the experimental group and 90.4% in the control group (P > 0.05). At the 4-months follow-up, the experimental group had a better Barthel index and Majeed score compared with the control group, which were 86.1 ± 6.2 (range, 70-95) vs. 81.2 ± 4.1 (range, 75-90) and 86.3 ± 3.3 (range, 78-91) vs. 80.3 ± 3.9 (range, 76-86), respectively. The experimental group had better early rehabilitation effect than the control group. There was no significant difference in Barthel index and Majeed score between the two groups at the last follow-up (P > 0.05).

CONCLUSION

Both INFIX and intramedullary superior pubic ramus cannulated screws can successfully treat LC1 pelvic fractures and reduce bed rest complications among older patients.

Nonoperative management of minimally displaced lateral compression type 1 (LC1) injuries with comminuted rami fractures is associated with late displacement

PURPOSE

Rami comminution has been found to be predictive of lateral compression type 1 (LC1) injury instability on examination under anesthesia (EUA) and lateral stress radiographs (LSR). The purpose of this study was to evaluate how rami comminution and subsequent operative vs. nonoperative management impact the late displacement of these injuries.

METHODS

Retrospective review of a prospectively collected LC1 database was performed to identify all patients with minimally displaced LC1 injuries (< 1 cm) and follow-up radiographs over a four-year period (n = 125). Groups were separated based on the presence of rami comminution and subsequent management, including rami comminution/operative (n = 49), rami comminution/nonoperative (n = 54), and no comminution/nonoperative (control group, n = 22). The primary outcome was late fracture displacement, analyzed as both a continuous variable and as late displacement ≥ 5 mm.

RESULTS

As a continuous variable, late fracture displacement was lower in the comminuted rami/operative group as compared to the comminuted rami/nonoperative group (PD: -3.0 mm, CI: -4.8 to -1.6 mm, p = 0.0002) and statistically non-different from control. Late displacement ≥ 5 mm was significantly more prevalent in the comminuted rami/nonoperative group than in the comminuted rami/operative and no comminution/nonoperative groups (control)(PD: -33.9%, CI: -49.0% to -16.1%, p = 0.0002 and PD: -30.0%, CI: -48.2% to -6.5%, p = 0.02, respectively).

CONCLUSION

Late fracture displacement was greatest in the group with rami comminution/nonoperative management. Rami comminution, which has been previously associated with dynamic displacement on EUA and LSR, is also associated with a higher incidence of late displacement when managed nonoperatively.

LEVEL OF EVIDENCE

Level III, prognostic retrospective cohort study.

Geriatric Patients Presenting With Isolated Pubic Rami Fractures and Inability to Mobilize May Have Occult Lateral Compression Pelvic Ring Injuries With Dynamic Instability

OBJECTIVES

To determine the incidence of patients with isolated pubic rami fractures on computed tomography scans who have dynamic instability secondary to occult lateral compression pelvic ring injuries.

DESIGN

Retrospective comparison study.

SETTING

Urban level 1 trauma center.

PATIENTS/PARTICIPANTS

This study included geriatric patients with isolated pubic rami fractures and inability to mobilize secondary to pain.

INTERVENTION

Lateral stress radiographs of pelvis to evaluate for ≥1 cm dynamic instability.

MAIN OUTCOME MEASUREMENTS

Physical therapy clearance, hospital length of stay, and discharge location.

RESULTS

A total of 19 patients were identified over 12 months. Patients were predominantly geriatric (median age: 75 years, interquartile range: 67 to 90), woman (11/19), with unilateral (17/19) comminuted distal rami fractures (12/19) sustained in ground-level falls (12/19). Dynamic instability was identified in 42% of patients (8/19). Magnetic resonance imaging, obtained in 6 of these patients, demonstrated occult posterior ring fractures in all cases. Patients with dynamic instability were more likely to have comminuted distal rami fractures (Nakatani type 1b) and a longer hospital length of stay. There was also a trend for these patients to be unable to clear physical therapy by discharge (63% (5/8) versus 36% (4/11)). The 90-day mortality rate of the cohort was 16% (3/19).

CONCLUSIONS

Patients presenting with seemingly isolated pubic rami fractures on radiographs and computed tomography scans who are unable to mobilize may have occult lateral compression injuries with dynamic instability.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Combined Anterior-Posterior versus Posterior-Only Fixation of Stress-Positive Minimally Displaced Lateral Compression Type 1 (LC1) Pelvic Ring Injuries

OBJECTIVES

To compare hospital outcomes and late displacement between stress-positive minimally displaced lateral compression type 1 (LC1) pelvic ring injuries treated with combined anterior-posterior versus posterior-only fixation.

DESIGN

Retrospective comparative cohort.

SETTING

Urban level-one trauma center.

PATIENTS/PARTICIPANTS

LC1 injuries managed operatively.

INTERVENTION

Anterior-posterior versus posterior-only fixation.

MAIN OUTCOME MEASUREMENTS

Physical therapy (PT) clearance, discharge location, hospital length of stay (LOS), inpatient morphine equivalent doses (MED), and fracture displacement at follow-up.

RESULTS

Groups were similar in demographic and injury characteristics (age, high energy mechanism, ASA score, stress displacement, and rami/sacral fracture classifications). Anterior-posterior fixation resulted in longer operative times (median difference (MD): 27.0 minutes, 95% confidence interval (CI): 17.0 to 40.0, P < 0.0001) and had a trend of increased estimated blood loss (MD: 10 mL, CI: 0 to 30, P = 0.07). Patients with anterior-posterior fixation required less inpatient MEDs (MD: -180.0, CI: -341.2 to -15.0, P = 0.02), were more likely to clear PT by discharge (100% vs. 70%, proportional difference (PD): 30%, CI: 2.0%-57.2%, P = 0.02), were less likely to discharge to rehabilitation facilities (0% vs. 30%, PD: 30%, CI: 2.0%-57.2%, P = 0.02), and had a trend of less days to clear PT after surgery (MD: -1, CI: -2 to 0, P = 0.09) and decreased LOS (MD: -1, CI: -4 to 1, P = 0.17). Late fracture displacement did not differ between groups.

CONCLUSION

Anterior-posterior fixation of LC1 injuries was associated with an improved early hospital course-specifically, reduced inpatient opioid use and an increased number of patients who could clear PT and discharge home.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rami Comminution Is Associated With Displacement of Minimally Displaced Lateral Compression Type 1 Injuries on Lateral Stress Radiographs

OBJECTIVES

To determine whether displacement on lateral stress radiographs (LSRs) in patients with minimally displaced lateral compression type 1 pelvic ring injuries is associated with any demographic and/or injury characteristics.

DESIGN

Retrospective comparative cohort.

SETTING

Urban level 1 trauma center.

PATIENTS/PARTICIPANTS

Ninety-three consecutive patients with minimally displaced lateral compression type 1 injuries.

INTERVENTION

Displacement of pelvic ring injury on LSR (≥10 mm vs. &lt;10 mm).

MAIN OUTCOME MEASUREMENTS

Demographic and injury characteristics (mechanism of injury, Nakatani rami classification, rami comminution, Denis zone, complete/incomplete sacral fracture, sacral comminution).

RESULTS

65.6% of patients (n = 61) had ≥10 mm of displacement on LSR. On univariate analysis, displacement was associated with increased age [median difference 11: confidence interval (CI), 2-23], female sex [proportional difference (PD): 25.1%, CI, 3.9%-44.4%], Nakatani classification (type I PD: 27.9%, type II PD: -19.5%), and rami comminution (PD: 55.6%, CI, 35.4%-71.3%). On multivariate analysis, displacement was only associated with rami comminution (odds ratio: 16.48, CI, 4.67-58.17). Displacement was not associated with energy of injury mechanism, sacral fracture Denis zone, complete sacral fracture, sacral comminution, or bilateral rami fractures.

CONCLUSIONS

Although rami comminution was the only variable found to be independently associated with displacement ≥10 mm on LSR, no single variable perfectly predicted displacement. Future studies are needed to determine whether displacement on stress radiographs should change the management of these injuries.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The lateral stress radiograph: an effective alternative to examination under anesthesia for identifying occult instability in minimally displaced lateral compression pelvic ring injuries

PURPOSE

The purpose of this study was to review the practice of utilizing lateral stress radiographs (LSRs) to identify occult instability (≥ 10 mm of dynamic displacement on LSRs) of minimally displaced lateral compression type 1 (LC1) pelvic ring injuries and to evaluate for associations between instability and patient demographics, injury characteristics, and hospital course.

METHODS

A retrospective review of a prospective registry from 2018 to 2022 identified 151 patients with LC1 injuries. LSRs were obtained in 86.8% (131/151) of patients. Three (2.2%) patients were excluded for malrotation of LSRs, leaving 128 patients for analysis.

RESULTS

The median maximum dynamic displacement on LSRs was 12.2 mm (IQR: 5.9 to 17.3). Occult instability was present in 62.5% (80/128) of patients and was associated with older age (Median difference 11.0 years, 95% CI 3.0 to 20.0), Nakatani type 1 rami fractures (73.7% vs. 47.9%, p = 0.001), and rami fracture comminution (Proportional difference 58.7%, 95% CI 42.8 to 71.3%), but not gender, high-energy mechanism, bilateral rami fractures, Denis classification, sacral fracture completeness, or sacral comminution. Patients with occult instability took longer to ambulate 15 feet and clear physical therapy (PT), were more likely to be unable to clear PT by hospital day 3 or by time of discharge, had longer hospital stays, and were more likely to require rehabilitation facilities.

CONCLUSION

LSRs were obtained in a majority of patients. Occult instability was frequently present and associated with older age, comminuted distal pubic rami fractures, longer hospital stays, longer times to mobilize and clear PT, and an increased need for rehabilitation facilities.

The effect of pelvic ring rotation and tilt on the radiographic teardrop distance: an important consideration in the assessment of dynamic displacement on stress radiographs

PURPOSE

The purpose of this study was to determine the effect of rotation and tilt on the radiographic teardrop distance (TD) on anteroposterior (AP) pelvis radiographs.

METHODS

Radiographic examination of a pelvis models was conducted utilizing increasing degrees of beam rotation and tilt on portable C-arm fluoroscopy. The TD, x-plane rotation (symphyseal-mid-sacrum distance (SMS)), and y-plane tilt (sacroiliac joint-symphysis distance (SIS)) were measured by four independent observers. Interobserver reliability was assessed using intraclass correlations.

RESULTS

TD was altered by less than 2 mm with up to 7.5° fluoroscopic rotation (SMS: 3 cm) and up to 30° of inlet and 15° of outlet (SIS: ± 3.3 cm). SMS distance effectively corresponded to the degree of rotation present (r = 1.00, CI: 0.97 to 1.00, p < 0.0001) and was strongly correlated to TD (r = -0.95, CI: -0.99 to -0.67, p = 0.001). SIS distance effectively corresponded to the degree of tilt present (r = -0.97, CI: -0.99 to -0.88, p < 0.0001) and was correlated to TD (r = 0.94, CI: 0.75 to 0.99, p = 0.0001). Linear regression models determined that, with every degree of rotation and tilt, TD was altered by 0.4 mm and 0.09 mm, respectively (p = 0.0004, r² = 0.93 and p < 0.0001, r² = 0.94, respectively). Interobserver reliability among observers was excellent (0.92).

CONCLUSION

The TD has excellent interobserver reliability and is minimally impacted by up to 7.5° of rotation, 30° inlet tilt, and 15° of outlet tilt. Utilization of these thresholds may ensure reliability of TD measurements when assessing pelvis stress radiographs.