High Incidence of Chronic Pain Following Surgery for Pelvic Fracture

Evaluation of cannulated compression headless screws as an alternative implant for superior pubic ramus fracture fixation: a biomechanical study

BACKGROUND/PURPOSE

Pubic ramus fractures account for the most common types of pelvic fractures. The standard surgical approach for superior pubic ramus fractures (SPRF) is a minimally invasive percutaneous screw fixation. However, percutaneous closed reduction and internal fixation of anterior pelvic ring injuries have high failure rates of up to 15%. The aim of this biomechanical study was to evaluate the stability of SPRF following stabilization with retrograde placed cannulated compression headless screw (CCHS) versus conventional fully and partially threaded screws in an artificial pelvic bone model.

METHODS

SPRF type II as described by Nakatani et al. was created by means of osteotomies in eighteen anatomical composite hemi-pelvises. Specimens were stratified into three groups of six specimens each (n = 6) for fixation with either a 7.3 mm partially threaded cannulated screw (group RST), a 7.3 mm fully threaded cannulated screw (group RSV), or a 7.5 mm partially threaded cannulated CCHS (group CCS). Each hemi-pelvic specimen was tested in an inverted upright standing position under progressively increasing cyclic axial loading. The peak load, starting at 200 N, was monotonically increased at a rate of 0.1 N/cycle until 10 mm actuator displacement.

RESULTS

Total and torsional displacement were associated with higher values for RST versus CCS and RSV, with significant differences between RST and CCS for both these parameters (p ≤ 0.033). The differences between RST and RSV were significant for total displacement (p = 0.020), and a trend toward significance for torsional displacement (p = 0.061) was observed. For both failure criteria 2 mm total displacement and 5° torsional displacement, CCS was associated with significantly higher number of cycles compared to RST (p ≤ 0.040).

CONCLUSION

CCHS fixation presented predominantly superior stability to the standard surgical treatment and could therefore be a possible alternative implant for retrograde SPRF screw fixation, whereas partially threaded screws in group RST were associated with inferior biomechanical stability.

Does iliosacral screw removal reduce postoperative pain in unstable pelvic fracture patients? A matched prospective cohort study

BACKGROUND

To compare pain and function in patients with unstable posterior pelvic fractures stabilized with posterior fixation who undergo iliosacral screw removal versus those who retain their iliosacral screws.

METHODS

A prospective observational cohort study identified 59 patients who reported pain at least 4 months after iliosacral screw fixation of an unstable posterior pelvic ring fracture from 2015-2019. The primary intervention was iliosacral screw removal versus a matched iliosacral screw retention control group. Patient-reported pain was measured with the 10-point Brief Pain Inventory, and patient-reported function was measured with the Majeed Pelvic Outcome Score. Both measured within 6 months of the intervention.

RESULTS

Before iliosacral screw removal, the mean pain was 4.7 (SD, 3.0) compared with 4.7 (SD, 3.0) in the matched control group. Following iliosacral screw removal, the average pain in the screw removal group was 3.7 (SD, 2.7) and 3.3 (SD, 2.5) in the matched control group. We found no evidence that iliosacral screw removal reduced pain in this population (mean difference, 0.2 points; 95% CI, -1.0 to 1.5; p = 0.71). In addition, the improvement in function after iliosacral screw removal was not statistically indistinguishable from zero (mean difference, 3.1 points; 95% CI, -4.6 to 10.9; p = 0.42).

CONCLUSIONS

The results suggest that iliosacral screw removal offers no significant pelvic pain or function benefit when compared with a matched control group. Surgeons should consider these data when managing patients with pelvic pain who are candidates for iliosacral screw removal.

Estimating Risk of Chronic Pain and Disability Following Musculoskeletal Trauma in the United Kingdom

IMPORTANCE

Serious traumatic injury is a leading cause of death and disability globally, with most survivors known to develop chronic pain.

OBJECTIVE

To describe early variables associated with poor long-term outcome for posttrauma pain and create a clinical screening tool for this purpose.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective cohort study at a major trauma center hospital in England. Recruitment commenced in December 2018 and ceased in March 2020. Participants were followed up for 12 months. Patients aged 16 years or older who were hospitalized because of acute musculoskeletal trauma within the preceding 14 days were included. Data were analyzed from March to December 2021.

EXPOSURE

Acute musculoskeletal trauma requiring admittance to a major trauma center hospital.

MAIN OUTCOMES AND MEASURES

A poor outcome was defined as Chronic Pain Grade II or higher and measured at both 6 months (primary time point) and 12 months. A broad range of candidate variables potentially associated with outcomes were used, including surrogates for pain mechanisms, quantitative sensory testing, and psychosocial factors. Univariable models were used to identify the variables most likely to be associated with poor outcome, which were entered into multivariable models. A clinical screening tool (nomogram) was derived from 6-month results.

RESULTS

In total, 1590 consecutive patients were assessed for eligibility, of whom 772 were deemed eligible and 124 (80 male [64.5%]; mean [SD] age, 48.9 [18.8] years) were recruited. At 6 months, 19 of 82 respondents (23.2%) reported a good outcome, whereas at 12 months 27 of 44 respondents (61.4%) reported a good outcome. At 6 months on univariable analysis, an increase in total posttraumatic stress symptoms (odds ratio [OR], 2.09; 95% CI, 1.33-3.28), pain intensity average (OR, 2.87; 95% CI, 1.37-6.00), number of fractures (OR, 2.79; 95% CI, 1.02-7.64), and pain extent (OR, 4.67; 95% CI, 1.57-13.87) were associated with worse outcomes. A multivariable model including those variables had a sensitivity of 0.93, a specificity of 0.54, and C-index of 0.92.

CONCLUSIONS AND RELEVANCE

A poor long-term pain outcome from musculoskeletal traumatic injuries may be estimated by measures recorded within days of injury. These findings suggest that posttraumatic stress symptoms, pain spatial distribution, perceived average pain intensity, and number of fractures are good candidates for a sensitive multivariable model and derived clinical screening tool.

Three-year functional outcome after open pelvic fracture treatment: a retrospective case series from a level I trauma center

PURPOSE

Open pelvic fractures have high mortality rates, and survivors may have ongoing functional deficits from severe trauma and invasive life-saving procedures. However, there are limited reports regarding the functional status evaluation following open pelvic fractures. We aimed to report the treatment experiences and short-term functional outcomes of patients with open pelvic fractures.

METHODS

We retrospectively reviewed the data of 19 consecutive patients with pelvic fractures who underwent treatment at a single institute between January 2014 and June 2018. The resuscitation protocol, osteosynthesis strategy, reduction quality of the pelvic ring, and functional outcomes were analyzed.

RESULTS

The incidence and mortality rates in patients with open pelvic fractures were 4.9 and 21.6%, respectively. Ten, one, and seven of the open wounds related to the pelvic fractures were located in Faringer zones I, II, and III, respectively. Fractures of four patients were categorized as classes 1 and 2, and those of 11 patients as class 3, according to the Jones-Powell classification. Eleven of 19 (57.9%) and 9 of 19 (47.5%) revealed excellent reduction quality by Matta/Torenetta and Lefaivre criteria, respectively. The Merle d'Aubigné score improved at each evaluation but stagnated after 24 months. The Majeed hip score also improved at the 12-month evaluation but the improvement stopped thereafter. At a 3-year follow-up, the patients with excellent reduction of the pelvic ring showed the highest functional performances.

CONCLUSION

Improvements in functional status of patients with open pelvic fractures can be anticipated based on the reduction quality of the pelvis ring.

Risk of Mortality and Readmission among Patients with Pelvic Fracture and Urinary Tract Infection: A Population-Based Cohort Study

Patients with pelvic fractures could encounter various complications during or after treatments. This cohort study investigated the risk of mortality and readmissions in patients with pelvic fractures, with or without urinary tract infections (UTIs), within 30 days following the pelvic fractures. This retrospective cohort study examined claim records from the Longitudinal Health Insurance Database 2000 (LHID2000). We selected patients hospitalized with pelvic fractures between 1997 and 2013 for study. Patients who had index data before 2000 or after 2010 (n = 963), who died before the index date (n = 64), who were aged <18 years (n = 94), or who had a pelvic injury (n = 31) were excluded. In total, the study cohort comprised 1623 adult patients; 115 had UTIs, and 1508 patients without UTIs were used as a comparison cohort. Multivariate analysis with a multiple Cox regression model and Kaplan-Meier survival analysis were performed to analyze the data. Our results showed that the 1-year mortality rate (adjusted hazard ratio [HR]: 2.32; 95% CI: 1.25-4.29) and readmission rate (adjusted HR: 1.72; 95% CI: 1.26-3.34) of the UTI group were significantly higher than those of the non-UTI group. Moreover, the Kaplan-Meier curve for the 1-year follow-up indicated that the UTI group had a higher cumulative risk of both mortality and hospital readmission compared with the non-UTI group. In conclusion, among patients with pelvic fracture, patients with UTI were associated with increased risks of mortality and readmission. Physicians must pay more attention to such patients to prevent UTIs among patients with pelvic fractures during hospitalization and conduct a follow-up after discharge within at least 1 year.

Feline Neuropathic Pain

Neuropathic pain represents the extreme in maladaptive pain processing. In itself, it is a disease in which pain has become exaggerated in some combination of scope, severity, character, field, duration, and spontaneity. It is almost certainly an underappreciated, underdiagnosed cause of possible significant patient morbidity in cats. This article explores the basic mechanisms, recognition, known and suspect syndromes, and prospective treatment of feline maladaptive and neuropathic pain.

Psychological morbidity and functional impairment following traumatic pelvic injury

Pelvic injuries often result from high-energy trauma and lead to significant functional impairment. While the physical outcomes of these injuries have been widely studied, the psychological consequences remain largely unexplored. The purpose of this study was to examine psychosocial and functional outcomes of patients with pelvic trauma in the year after injury. The sample (N = 32) consisted of adult patients with traumatic pelvic injures, as defined by ICD-9 codes, who were admitted to a Level I Trauma Center for at least 24 h. Participants were primarily female (53%) with a mean age of 48.7 years (SD = 17.9). Demographic, injury-related, and psychosocial data (e.g., posttraumatic stress disorder (PTSD), depression, alcohol use, quality of life, pain, return to work) were gathered at the time of hospitalization as well as at 3-, 6-, and 12 month follow-ups. Mixed regression models were used to examine the outcome variables over time. There were significant decreases in pain and alcohol use at each follow-up compared to baseline. However, despite the decrease, the levels of pain and alcohol use remained high. Physical and mental health also decreased significantly, indicating worsened functioning and lowered quality of life. Neither PTSD nor depression changed significantly over time, indicating that participants' symptoms were not likely to improve. These data suggest that sustaining a traumatic pelvic injury increases the risk of diminished quality of life, both mentally and physically. Even one-year post-injury, participants experienced moderate physical pain and higher levels of PTSD, depression, and problematic alcohol use than would be expected in the general population. These findings highlight the need for an interdisciplinary approach to treating patients with pelvic injuries, including psychological screening and intervention in acute care and throughout recovery.

Fractures as a suicidal behavior risk factor: A nationwide population-based cohort study

This study aimed to evaluate the association between fracture history and sequential risk of suicidal behavior.A total of 82,804 patients with fractures and 82,804 control subjects without fractures were matched. The influence of fractures on the risk of suicidal behavior-related hospital visit was analyzed using a Cox proportional hazards model.The overall adjusted hazard ratio (aHR) of suicidal behavior-related hospital visit was 2.21 in fracture cohort. The aHR declined from 2.90 at the 1-year follow-up to 2.00 after 5 years or more. In fracture patients, the risk of suicidal behavior-related hospital visit was higher at age <35 years, with comorbidities of stroke and sleep disorder. Patients with multiple fractures had a 1.69-fold risk.Fractures are an independent risk factor for suicidal behavior. Individuals aged younger than 35 years, with comorbidities of stroke and sleep disorder, and those who have suffered multiple fractures have elevated risk of suicidal behavior among subjects in the fracture group. Furthermore, this increased risk remained even after 5 years had passed since the fracture incident.

Assessment of the Breakaway Torque at the Posterior Pelvic Ring in Human Cadavers

Purpose: To enhance the diminished screw purchase in cancellous, osteoporotic bone following the fixation of posterior pelvic ring injuries by iliosacral screws an increased bone-implant contact area using modificated screws, techniques or bone cement may become necessary. The aim of the study was to identify sites within the pathway of iliosacral screws requiring modifications of the local bone or the design of instrumentations placed at this site. Materials and Methods: The breakaway torque was measured mechanically at the iliosacral joint (“ISJ”), the sacral lateral mass (“SLM”) and the center of the S1 (“CS1”), at a superior and an inferior site under fluoroscopic control on five human cadaveric specimens (3 female; mean age 87 years, range: 76–99) using the DensiProbe™Spine device. Results: The measured median (range) breakaway torque was 0.63 Nm (0.31–2.52) at the “iliosacral joint”, 0.14 Nm (0.05–1.22) at the “sacral lateral mass”, 0.57 Nm (0.05–1.42) at the “S1 center.” The “sacral lateral mass” breakaway torque was lower than compared to that at the “iliosacral joint” (p < .001) or “S1 center” (p < .001). The median (range) breakaway torque measured at all superior measurement points was 0.52 Nm (0.10–2.52), and 0.48 Nm (0.05–1.18) at all inferior sites. The observed difference was statistically significant (p < .05). Conclusions: The lateral mass of the sacrum provides the lowest bone quality for implant anchorage. Iliosacral screws should be placed as superior as safely possible, should bridge the iliosacral joint and may allow for cement application at the lateral mass of the sacrum through perforations.

Comparison of operant escape and reflex tests of nociceptive sensitivity

Testing of reflexes such as flexion/withdrawal or licking/guarding is well established as the standard for evaluating nociceptive sensitivity and its modulation in preclinical investigations of laboratory animals. Concerns about this approach have been dismissed for practical reasons - reflex testing requires no training of the animals; it is simple to instrument; and responses are characterized by observers as latencies or thresholds for evocation. In order to evaluate this method, the present review summarizes a series of experiments in which reflex and operant escape responding are compared in normal animals and following surgical models of neuropathic pain or pharmacological intervention for pain. Particular attention is paid to relationships between reflex and escape responding and information on the pain sensitivity of normal human subjects or patients with pain. Numerous disparities between results for reflex and operant escape measures are described, but the results of operant testing are consistent with evidence from humans. Objective reasons are given for experimenters to choose between these and other methods of evaluating the nociceptive sensitivity of laboratory animals.

Fracture as an independent risk factor of dementia: a nationwide population-based cohort study

Dementia is among various diseases affecting the elderly, who is also at a high risk for fractures. This study aimed to evaluate the association between fracture history and sequential risk of dementia in Taiwan.A retrospective cohort study was designed using the claims data of the entire insured residents covered by Taiwan's universal health insurance from 1998 to 2010. A total of 66,797 patients with fractures and 133,594 control subjects without fractures were matched in terms of age (±5 years), sex, and index year and then recruited. Fractures and dementia were defined in accordance with the International Classification of Diseases, 9th Revision, Clinical Modification. The influence of fractures on the risk of dementia was analyzed using a Cox proportional hazards model.After a 12-year follow-up period, 2775 and 3991 incident cases of dementia were reported in exposed and unexposed cohorts, respectively. The overall incidence rate of dementia in individuals with fractures was 41% higher than that in individuals without fractures (6.05 vs 4.30 per 1000 person-years) at an adjusted hazard ratio of 1.38 (95% confidence interval 1.32-1.45) after age, sex, urbanization, and individual disorders or comorbidities were adjusted. Considering fracture location, we found that patients with hip fractures were at a slightly high risk for dementia. The occurrence of multiple fractures at a single visit was also significantly associated with an increased risk of dementia.Fracture history is regarded as an independent risk factor of dementia in individuals aged ≥65 years, particularly those who suffered from multiple fractures and/or fractures located in the hip. Further studies are needed to support an independent role of fracture in dementia considering the clinical information and other comorbidities.

Quality of life and sexual function after traumatic pelvic fracture

OBJECTIVES

To provide evidence on the midterm sexual-function- and health-related quality-of-life outcome of patients with a traumatic pelvic fracture, as recorded at least 12 months after their surgery.

DESIGN

Prospective noncomparative study.

SETTING

Tertiary referral centre for pelvic-and-acetabular reconstruction.

PATIENTS AND PARTICIPANTS

Cohort of patients attending a dedicated pelvic-and-acetabular reconstruction clinic because of blunt pelvic trauma, at a minimum of a year after their injury.

INTERVENTION

Operatively treated pelvic fractures and concomitant surgical interventions for associated injuries, if any, sustained by the patients after blunt trauma.

MAIN OUTCOME MEASURES

Sexual function questionnaires: IIEF (international index of erectile function) and FSFI (female sexual function index). Quality of life was assessed with the EuroQol-5D questionnaire.

RESULTS

Of a cohort of 110 patients, 80 patients (48 males and 32 females) consented to participate with a median age of 46 years (range, 19-65 years). Of the above cohort, 62.5% were a result of road traffic accidents and 52.5% were classified as lateral compression type fractures. Assessment occurred at a median period of 36 months after injury (range, 12-96). Overall, significant decrease of their quality of life (P < 0.0001) and sexual function were recorded (males, P < 0.00014; females, P < 0.001). Sexual dysfunction was identified in 43.8% of the female and 52.1% of the male patients, as per the validated gender-specific sexual function scores (female sexual function index and international index of erectile function, respectively). Regression analysis identified the presence of urinary tract injury (P < 0.049) and open surgical treatment (P < 0.047) as independent risk factors for sexual dysfunction. A near significant association with injury severity score (P = 0.05) was seen. Male gender (P < 0.006), abdominal injury (P < 0.0001), pelvic fracture severity (P < 0.049), pain (P < 0.0001), and sexual dysfunction (P < 0.034) were identified as significant independent risk factors for decreased quality of life.

CONCLUSIONS

All domains of female and male sexual function were significantly decreased at a minimum of a year after pelvic fracture. Quality of life was also significantly decreased in this group with sexual dysfunction shown to be an independent risk factor for decreased quality of life after injury. Further pivotal clinical studies should follow based on the provided evidence. High clinical suspicion and prompt engagement of appropriate multidisciplinary pathways, including urological, gynecological, and psychiatric consultations, is recommended.

LEVEL OF EVIDENCE

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

Urogenital disorders after pelvic ring injuries

Introduction

The close anatomical relationship between the skeletal and connective systems of the pelvis, neurological, and vascular structures and pelvic organs are predisposing factors for structural and functional damages of the urogenital system.

Materials and methods

We performed PUBMED and MEDLINE search using terms “pelvic ring trauma/disruption, bladder injury, urethral injury, sexual dysfunction”.

Results

The probability of damage of the pelvic organs increases along with the degree of disturbance of integrity of the pelvic ring. The most important risk factor of urogenital injuries is the rupture of the symphyseal joint. Patients with lesions of the urogenital system have a higher risk of mortality compared with patients without lesions of the urogenital system. Sexual dysfunctions along with urinary incontinence are a common consequence of the pelvic fracture in men and women.

Conclusions

Injuries of the urogenital organs during pelvic ring fractures have an important negative prognostic value in terms of morbidity and quality of life. A prerequisite for a successful therapeutic outcome in case of pelvic fractures with disturbance of pelvic ring integrity is cooperation of orthopedists and urologists, with possible early diagnosis and treatment of injuries of the urogenital organs.

Symptom Burden, Medication Detriment, and Support for the Use of the 15D Health-Related Quality of Life Instrument in a Chronic Pain Clinic Population

Chronic noncancer pain is a prevalent problem associated with poor quality of life. While symptom burden is frequently mentioned in the literature and clinical settings, this research highlights the considerable negative impact of chronic pain on the individual. The 15D, a measure of health-related quality of life (HRQOL), is a user-friendly tool with good psychometric properties. Using a modified edmonton symptom assessment scale (ESAS), we examined whether demographics, medical history, and symptom burden reports from the ESAS would be related statistically to HRQOL measured with the 15D. Symptom burden, medication detriment scores, and number of medical comorbidities were significant negative predictors of 15D scores with ESAS symptom burden being the strongest predictor. Our findings highlight the tremendous symptom burden experienced in our sample. Our data suggest that heavier prescription medication treatment for chronic pain has the potential to negatively impact HRQOL. Much remains unknown regarding how to assess and improve HRQOL in this relatively heterogeneous clinical population.

Saddle-horn injury of the pelvis. The injury, its outcomes, and associated male sexual dysfunction

BACKGROUND

A saddle-horn injury of the pelvis occurs when a horse rider is thrown into the air and then falls back, with the perineum coming into contact with the saddle or saddle horn. The purpose of this study was to evaluate the characteristics and clinical outcomes, including sexual dysfunction, of this injury.

METHODS

We conducted a retrospective review of a consecutive series of male patients who had a saddle-horn injury of the pelvis after being bucked from a horse. Clinical and radiographic results were assessed more than eighteen months after the injury. Functional outcome measures were evaluated at the time of the latest follow-up with use of visual analog pain scales, a questionnaire addressing occupational and recreational function, the International Index of Erectile Function instrument, the Iowa pelvic score, and the Short Form-36.

RESULTS

Twenty patients were assessed at an average of thirty-three months after the injury. Seventeen patients had returned to riding horses, and ten felt that they had returned to their previous level of recreation, which had been "heavy" in nine cases and "moderate" in one. Eighteen patients had returned to their previous employment. Eighteen patients were found to have sexual dysfunction at the time of the latest follow-up. The mean Iowa pelvic score was 84 points (range, 56 to 99 points). The Short Form-36 outcomes scores were diminished in two subsections, role physical and role emotional, compared with population norms.

CONCLUSIONS

Mild pain can be expected after saddle-horn injury despite successful surgical treatment, and the injury does not preclude a return to previous employment or riding horses. A high proportion of men experience erectile dysfunction, which is unlikely to respond well to pharmacologic therapy.

Neuropathic pain in dogs and cats: if only they could tell us if they hurt

Neuropathic pain is difficult to diagnose in veterinary patients because they are unable to verbalize their pain. By assuming that neuropathic pain may exist based on the history of events that each patient has experienced, a focused client history and neurologic examination may identify a lesion resulting in persistent or spontaneous pain. Once neuropathic pain is diagnosed, a trial analgesic or acupuncture session(s) should be prescribed with instructions for owners to observe behavior. Dosing of the analgesic can be titrated to the patient's needs while avoiding adverse effects. When a particular analgesic may be ineffectual, an alternate class should be tried. As research into the neurobiologic mechanisms of neuropathic pain continues, specific therapies for its management should eventually appear in the human clinical setting and subsequently be investigated for veterinary clinical use.