1
|
Swenson RA, Paull TZ, Yates RA, Foster JA, Griffin JT, Southall WGS, Aneja A, Nguyen MP. Comparison of Operative and Nonoperative Management of Elderly Fragility Pelvic Ring Fractures. J Orthop Trauma 2024; 38:472-476. [PMID: 39016440 DOI: 10.1097/bot.0000000000002863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVES To compare outcomes of nonoperative and percutaneous fixation of geriatric fragility lateral compression 1 (LC1) pelvic ring fractures. METHODS DESIGN Retrospective. SETTING Two level 1 trauma centers. PATIENT SELECTION CRITERIA Included were patients who were 60 years or older with an isolated LC1 pelvic ring fracture managed nonoperatively or those who failed mobilization and were managed operatively with percutaneous sacral fixation. Patients with high-energy mechanisms of injury or polytrauma were excluded. OUTCOME MEASURES AND COMPARISONS The primary outcome was pain as measured by using the visual analog scale (VAS) after treatment. Secondary outcomes included length of stay, discharge disposition, mortality, readmission rates, and complications. RESULTS In total, 231 patients were included with a mean age of 79.5 years (range 60-100). One hundred eighty-five (80.0%) patients were female. Sixty-two (26.8%) patients received percutaneous sacral fixation after failed mobilization, and 169 (73.2%) were managed nonoperatively. In the operative group, the median time to surgery was hospital day 4. Nonoperative patients were older (81.5 ± 10.0 years vs. 74.2 ± 9.4 years, P < 0.01) and had a shorter hospital length of stay (4.8 ± 6.2 days) than the operative group (10.6 ± 9.5 days, P < 0.01). Patients in the operative group had more pain (VAS 7.9 ± 3.0) than those in the nonoperative group (VAS 6.6 ± 3.0) ( P = 0.01) on admission but had similar pain control postoperatively (VAS 4.4 ± 3.0) compared with the nonoperative group (VAS 4.5 ± 3.6) on the equivalent hospital day ( P = 0.91). Thus, patients in the operative group experienced more improvement in pain (VAS 3.3 ± 2.7) compared with the nonoperative group (VAS 1.9 ± 3.9) after treatment ( P = 0.02). Ninety-day mortality ( P = 0.21) and readmission rates ( P = 0.27) were similar for both groups. Two patients in the operative cohort sustained nerve injuries, whereas 1 patient in the nonoperative group had a nonunion and underwent surgery. CONCLUSIONS Patients who undergo percutaneous surgical fixation for low-energy LC1 injuries have similar discharge disposition, mortality, complication rates, and readmission rates compared with patients treated nonoperatively. Percutaneous surgical fixation may provide significant pain relief for patients who failed conservative management. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Riley A Swenson
- Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN; and
| | - Thomas Z Paull
- Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN; and
| | - Rob A Yates
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Jeffrey A Foster
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Jarod T Griffin
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Wyatt G S Southall
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Arun Aneja
- Department of Orthopaedic Surgery & Sports Medicine, University of Kentucky, Lexington, KY
| | - Mai P Nguyen
- Department of Orthopaedic Surgery, Regions Hospital, Saint Paul, MN
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN; and
| |
Collapse
|
2
|
Lee AK, Marecek GS, Collinge CA. Standardization and Reproducibility of Dynamic Stress Testing for Occult Pelvic Ring Instability. J Am Acad Orthop Surg 2024:00124635-990000000-01048. [PMID: 39018575 DOI: 10.5435/jaaos-d-23-00165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 05/16/2024] [Indexed: 07/19/2024] Open
Abstract
INTRODUCTION Examination under anesthesia (EUA) (stress fluoroscopy) is commonly done after pelvic ring injury to identify occult instability because unstable disruptions may displace causing morbidity. The force applied during EUA for these injuries has not been standardized. The purpose of this study was to examine the forces used during the EUA by experienced orthopaedic trauma pelvic surgeons. METHODS Orthopaedic traumatologists performed simulated EUA on a cadaver at two North American pelvis and acetabular courses using internal rotation (IR), external rotation, and push-pull maneuvers while wearing a handheld dynamometer to measure force. All surgeons used a comparable method, and each performed EUA multiple times. Maximum forces were measured in Newton (N). RESULTS Eighteen surgeons participated. Four had been practicing for <5 years, six for 5 to 10 years, six for 11 to 20 years, and two for >20 years. Surgeons applied a force ranging from 40.4 to 374.9 N during IR, 72.9 to 338.4 N during external rotation, and 25 to 323 N during push-pull, with notable variability seen between surgeons. Three surgeons (18%) had >50-N variability on serial trials of a single EUA maneuver (IR). DISCUSSION This is the first study evaluating the forces applied during pelvic EUA used to assess ring stability. Notable variability existed among surgeons performing EUA and in serial examinations by the same surgeon. Additional study is needed to standardize the displacement measured and threshold for instability that guides management.
Collapse
Affiliation(s)
- Adam Keith Lee
- From the University of Chicago Medical Center, Chicago, IL (Lee), Cedars Sinai Medical Center, Los Angeles, CA (Marecek), and Texas Health Harris Methodist Hospital Fort Worth, Fort Worth, TX (Collinge)
| | | | | |
Collapse
|
3
|
Livesey MG, Salmons HI, Butler BA, Edmond TJ, Slobogean GP, O'Toole RV. Does Fracture Pattern Really Predict Displacement of LC1 Sacral Fractures? J Bone Joint Surg Am 2024; 106:138-144. [PMID: 37967162 DOI: 10.2106/jbjs.23.00614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
BACKGROUND Operative management of minimally displaced lateral compression type-1 (LC1) pelvic ring injuries remains controversial. We aimed to assess the proportion of LC1 pelvic fractures that displaced following nonoperative management as a function of specific ring fracture patterns, and we quantified the magnitude of this displacement. METHODS A retrospective review of the billing registry of a level-I trauma center was performed. Two hundred and seventy-three patients with a high-energy LC1 pelvic ring fracture and <5 mm of sacral displacement were included. The fracture pattern was characterized with use of computed tomography (CT) scans and radiographs. Absolute and interval pelvic ring displacement were quantified with use of previously described methodology. RESULTS Thirty-five pelvic ring injuries (13%) were displaced. The rate of displacement was 31% (15 of 49) for LC1 injuries involving a complete sacral fracture and bilateral ramus fractures, 12% (7 of 58) for injuries involving a complete sacral fracture and a unilateral ramus fracture, and 10% (5 of 52) for injuries involving an incomplete sacral fracture and bilateral ramus fractures. In displaced injuries, the average interval displacement was 4.2 mm (95% confidence interval [CI], 1.8 to 6.8) and the final displacement was 9.9 mm ± 4.2 mm. CONCLUSIONS Our study suggests that fracture characteristics can be used to predict the likelihood of displacement of LC1 fractures that are treated without surgery. To our knowledge, the present study is the first to describe the magnitude of displacement that may occur in association with LC1 pelvic ring injuries that are treated nonoperatively; however, further studies are needed to determine the clinical impact of this displacement. LEVEL OF EVIDENCE Diagnostic Level IV . See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Michael G Livesey
- R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Harold I Salmons
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Bennet A Butler
- R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Tyler J Edmond
- R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gerard P Slobogean
- R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
4
|
Brostowitz NJ, Heimke IM, Furdock RJ, Vallier HA. Postmobilization Plain Radiography After Lateral Compression Type 1 Pelvic Ring Injury Does Not Affect Treatment. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202311000-00005. [PMID: 37947428 PMCID: PMC10635594 DOI: 10.5435/jaaosglobal-d-23-00182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/15/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION The purpose of this study was to describe the practice of postmobilization radiography after lateral compression type 1 pelvis ring injury. We hypothesized that postmobilization radiographs would be more frequent over time and would not influence treatment. METHODS Displacement of pelvis ring injury on initial and final plain radiographs was measured. Frequency of postmobilization radiography was determined, and the impact on treatment and final radiographical outcome were assessed. RESULTS Of the 156 patients reviewed, 98 (62.8%) were women and mean age was 60.1 years. Thirty-three of 156 patients (21.2%) had a postmobilization radiograph. Over 5 years, radiographs increased to 67% of presenting patients. None of the patients who received postmobilization plain radiographs (n = 33) had any change in clinical plan afterward; all continued with nonsurgical care. Initial fracture characteristics and alignment were no different for patients with postmobilization radiographs. Final alignment was unchanged in nearly 70%. Overall, 74% of all nonsurgical patients experienced no change in alignment, with similar rates among the patients with postmobilization radiographs. DISCUSSION Patients with an lateral compression type 1 fracture demonstrated no changes in care after receiving postmobilization radiographs. However, the frequency of postmobilization radiographs increased over time, denoting opportunities to reduce costs and to improve efficiency and safety.
Collapse
|
5
|
Klingebiel FKL, Hasegawa M, Parry J, Balogh ZJ, Sen RK, Kalbas Y, Teuben M, Halvachizadeh S, Pape HC, Pfeifer R. Standard practice in the treatment of unstable pelvic ring injuries: an international survey. INTERNATIONAL ORTHOPAEDICS 2023; 47:2301-2318. [PMID: 37328569 PMCID: PMC10439026 DOI: 10.1007/s00264-023-05859-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 05/27/2023] [Indexed: 06/18/2023]
Abstract
PURPOSE Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe. METHODS A standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents). RESULTS The Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization). CONCLUSION The Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences' impact on outcomes needs to be further explored.
Collapse
Affiliation(s)
- Felix Karl-Ludwig Klingebiel
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Morgan Hasegawa
- Division of Orthopaedic Surgery, John A. Burns School of Medicine, University of Hawai’i, Honolulu, HI USA
| | - Joshua Parry
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO USA
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital, Hunter Medical Research Institute and University of Newcastle, Newcastle, NSW Australia
| | | | - Yannik Kalbas
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Michel Teuben
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
- Department of Surgical Research, Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Zurich University Hospital, Zurich, Switzerland
| |
Collapse
|
6
|
Tucker NJ, Scott BL, Heare A, Stacey SC, Mauffrey C, Parry JA. Nonoperative management of minimally displaced lateral compression type 1 (LC1) injuries with comminuted rami fractures is associated with late displacement. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03646-3. [PMID: 37542555 DOI: 10.1007/s00590-023-03646-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/11/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE Rami comminution has been found to be predictive of lateral compression type 1 (LC1) injury instability on examination under anesthesia (EUA) and lateral stress radiographs (LSR). The purpose of this study was to evaluate how rami comminution and subsequent operative vs. nonoperative management impact the late displacement of these injuries. METHODS Retrospective review of a prospectively collected LC1 database was performed to identify all patients with minimally displaced LC1 injuries (< 1 cm) and follow-up radiographs over a four-year period (n = 125). Groups were separated based on the presence of rami comminution and subsequent management, including rami comminution/operative (n = 49), rami comminution/nonoperative (n = 54), and no comminution/nonoperative (control group, n = 22). The primary outcome was late fracture displacement, analyzed as both a continuous variable and as late displacement ≥ 5 mm. RESULTS As a continuous variable, late fracture displacement was lower in the comminuted rami/operative group as compared to the comminuted rami/nonoperative group (PD: -3.0 mm, CI: -4.8 to -1.6 mm, p = 0.0002) and statistically non-different from control. Late displacement ≥ 5 mm was significantly more prevalent in the comminuted rami/nonoperative group than in the comminuted rami/operative and no comminution/nonoperative groups (control)(PD: -33.9%, CI: -49.0% to -16.1%, p = 0.0002 and PD: -30.0%, CI: -48.2% to -6.5%, p = 0.02, respectively). CONCLUSION Late fracture displacement was greatest in the group with rami comminution/nonoperative management. Rami comminution, which has been previously associated with dynamic displacement on EUA and LSR, is also associated with a higher incidence of late displacement when managed nonoperatively. LEVEL OF EVIDENCE Level III, prognostic retrospective cohort study.
Collapse
Affiliation(s)
- Nicholas J Tucker
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Bryan L Scott
- Department of Orthopedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Austin Heare
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stephen C Stacey
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cyril Mauffrey
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua A Parry
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO, 80204, USA.
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.
| |
Collapse
|
7
|
Shawky MA, Abdelazeem AH, Abdel-Kader KF, Mohammad MM, Azzam AH. Does sequential examination under anaesthesia provide a reliable method to determine a management plan for unstable lateral compression pelvic ring injuries? a prospective study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03625-8. [PMID: 37407719 DOI: 10.1007/s00590-023-03625-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/17/2023] [Indexed: 07/07/2023]
Abstract
PURPOSE To assess the reliability of sequential examination under anaesthesia (EUA) to determine pelvic instability and to evaluate radiological and functional outcomes in unstable lateral compression (LC) injuries. METHODS A prospective case series study was conducted from 2020 to 2022 at a university hospital on 43 cases with LC injuries that met the inclusion criteria. Sequential EUA was carried out in three steps. Posterior-only fixation or anterior-posterior fixation was done according to the algorithm. Each patient was followed up for at least 12 months, both radiologically and functionally. RESULTS Forty cases proved unstable and were fixed. None showed secondary displacement in the anterior-posterior fixation group. However, five cases (19.2%) of the posterior-only fixation group showed secondary displacement with a mean of 5.9 mm. Four cases of them had tetra-ramic injuries. There is a high tendency for secondary displacement at 14.5 mm or more preoperative displacement of the rami. Patients with secondary displacement showed comparable functional outcome scores to patients without secondary displacement. Posterior-only fixation showed shorter operative time, lesser radiological exposure, blood loss and iatrogenic nerve injury than anterior-posterior fixation. CONCLUSION EUA is a reliable method to determine pelvic instability and management plan for LC fractures with unilateral anterior ring injury. Anterior-posterior fixation is needed if there is a tetra-ramic fracture or initial anterior ring displacement of 14.5 mm or more, irrespective of EUA.
Collapse
Affiliation(s)
- Mostafa Ahmed Shawky
- Pelvic Trauma and Arthroplasty Unit, Department of Orthopaedics and Traumatology, Kasr-AlAiny Hospital, Cairo University, 12 Al-Saraya Street, El Manial, Cairo, Egypt.
| | - Ahmed Hazem Abdelazeem
- Pelvic Trauma and Arthroplasty Unit, Department of Orthopaedics and Traumatology, Kasr-AlAiny Hospital, Cairo University, 12 Al-Saraya Street, El Manial, Cairo, Egypt
| | - Khaled Fawzy Abdel-Kader
- Pelvic Trauma and Arthroplasty Unit, Department of Orthopaedics and Traumatology, Kasr-AlAiny Hospital, Cairo University, 12 Al-Saraya Street, El Manial, Cairo, Egypt
| | - Molham Mahmood Mohammad
- Pelvic Trauma and Arthroplasty Unit, Department of Orthopaedics and Traumatology, Kasr-AlAiny Hospital, Cairo University, 12 Al-Saraya Street, El Manial, Cairo, Egypt
| | - Ahmad Hamdi Azzam
- Pelvic Trauma and Arthroplasty Unit, Department of Orthopaedics and Traumatology, Kasr-AlAiny Hospital, Cairo University, 12 Al-Saraya Street, El Manial, Cairo, Egypt
| |
Collapse
|
8
|
Dai J, He J, Ying Y, Huang D, Feng L. Clinical and epidemiological characteristics of 369 patients with pelvic fractures in Eastern Zhejiang Province of China: a retrospective study. BMC Musculoskelet Disord 2023; 24:495. [PMID: 37328894 DOI: 10.1186/s12891-023-06632-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 06/13/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Data on the epidemiological characteristics and prognostic factors of patients with pelvic fractures are lacking, particularly in China. This study aimed to summarise the clinical and epidemiological characteristics of patients with pelvic fractures in eastern Zhejiang Province, China, and to identify risk factors for poor prognosis. METHODS The clinical data of 369 patients with pelvic fractures admitted to the Ningbo No. 6 Hospital between September 2020 and September 2021 were retrospectively analysed. Data on the demographic characteristics; fracture classification; injury time, cause, and site; treatment plan; and prognosis were collected using the Picture Archiving and Communication System and the Hospital Information System. Differences in constituent proportions were analysed using the chi-square test. Logistic regression analysis was used to identify factors affecting patient prognosis. Statistical significance was set at p ≤ 0.05. RESULTS Among the 369 patients, there were 206 men and 163 women, at a ratio of 1.26:1, and the average age was 53.64 ± 0.78 years. More than 50% of patients were aged 41-65 years. The average length of hospital stay was 18.88 ± 1.78 days. The three most common causes of pelvic fractures were traffic accidents (51.2%), falls from height (31.44%), and flat-ground falls (14.09%). There were significant differences in the distribution of the three causes of injury depending on age (p < 0.001), sex (p < 0.001), and occupation (p < 0.0001). Most patients were manual workers (48.8%). Furthermore, most patients (n = 262, 71.0%) underwent surgical treatment for pelvic fractures. Postoperative complications occurred in 26 patients (7.05%), and infection was the main complication (73.08%). Age (p = 0.013), occupation (p = 0.034), cause of injury (p = 0.022), treatment options (p = 0.001), and complications (p < 0.0001) were independent factors affecting the prognosis of patients with pelvic fractures. One death (0.027%) occurred, which was due to severe blood loss. CONCLUSIONS Age, occupation, cause of injury, treatment options and complications were factors affecting patient prognosis. In addition, changes in blood flow and prevention of infection warrant attention.
Collapse
Affiliation(s)
- Jiao Dai
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Junhong He
- Department of Pharmacy, Ningbo No. 6 Hospital, Ningbo, China
| | - Ying Ying
- Department of Nursing, Ningbo No. 6 Hospital, Ningbo, China
| | - Dichao Huang
- Department of Traumatic Orthopedics, Ningbo No. 6 Hospital, Ningbo, China
| | - Leling Feng
- Department of Nursing, Ningbo No. 6 Hospital, Ningbo, China.
| |
Collapse
|
9
|
de Ridder VA, Whiting PS, Balogh ZJ, Mir HR, Schultz BJ, Routt M“C. Pelvic ring injuries: recent advances in diagnosis and treatment. OTA Int 2023; 6:e261. [PMID: 37533441 PMCID: PMC10392441 DOI: 10.1097/oi9.0000000000000261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/30/2022] [Indexed: 08/04/2023]
Abstract
Pelvic ring injuries typically occur from high-energy trauma and are often associated with multisystem injuries. Prompt diagnosis of pelvic ring injuries is essential, and timely initial management is critical in the early resuscitation of polytraumatized patients. Definitive management of pelvic ring injuries continues to be a topic of much debate in the trauma community. Recent studies continue to inform our understanding of static and dynamic pelvic ring stability. Furthermore, literature investigating radiographic and clinical outcomes after nonoperative and operative management will help guide trauma surgeons select the most appropriate treatment of patients with these injuries.
Collapse
Affiliation(s)
| | - Paul S. Whiting
- Department of Orthopedics and Rehabilitation, University of Wisconsin Hospital and Clinics, Madison, WI
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales, Australia
| | - Hassan R. Mir
- Director of Orthopedic Trauma Research, Florida Orthopedic Institute, Tampa FL; and
| | - Blake J. Schultz
- University of Texas Health Science Center at Houston, Houston TX
| | | |
Collapse
|
10
|
Tucker NJ, Scott BL, Heare A, Stacey SC, Mauffrey C, Parry JA. Combined Anterior-Posterior versus Posterior-Only Fixation of Stress-Positive Minimally Displaced Lateral Compression Type 1 (LC1) Pelvic Ring Injuries. J Orthop Trauma 2023; 37:189-194. [PMID: 36395075 DOI: 10.1097/bot.0000000000002519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To compare hospital outcomes and late displacement between stress-positive minimally displaced lateral compression type 1 (LC1) pelvic ring injuries treated with combined anterior-posterior versus posterior-only fixation. DESIGN Retrospective comparative cohort. SETTING Urban level-one trauma center. PATIENTS/PARTICIPANTS LC1 injuries managed operatively. INTERVENTION Anterior-posterior versus posterior-only fixation. MAIN OUTCOME MEASUREMENTS Physical therapy (PT) clearance, discharge location, hospital length of stay (LOS), inpatient morphine equivalent doses (MED), and fracture displacement at follow-up. RESULTS Groups were similar in demographic and injury characteristics (age, high energy mechanism, ASA score, stress displacement, and rami/sacral fracture classifications). Anterior-posterior fixation resulted in longer operative times (median difference (MD): 27.0 minutes, 95% confidence interval (CI): 17.0 to 40.0, P < 0.0001) and had a trend of increased estimated blood loss (MD: 10 mL, CI: 0 to 30, P = 0.07). Patients with anterior-posterior fixation required less inpatient MEDs (MD: -180.0, CI: -341.2 to -15.0, P = 0.02), were more likely to clear PT by discharge (100% vs. 70%, proportional difference (PD): 30%, CI: 2.0%-57.2%, P = 0.02), were less likely to discharge to rehabilitation facilities (0% vs. 30%, PD: 30%, CI: 2.0%-57.2%, P = 0.02), and had a trend of less days to clear PT after surgery (MD: -1, CI: -2 to 0, P = 0.09) and decreased LOS (MD: -1, CI: -4 to 1, P = 0.17). Late fracture displacement did not differ between groups. CONCLUSION Anterior-posterior fixation of LC1 injuries was associated with an improved early hospital course-specifically, reduced inpatient opioid use and an increased number of patients who could clear PT and discharge home. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Nicholas J Tucker
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Bryan L Scott
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
| | - Austin Heare
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Stephen C Stacey
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Cyril Mauffrey
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| | - Joshua A Parry
- Department of Orthopedics, Denver Health Medical Center, Denver, CO
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO
| |
Collapse
|
11
|
Comparing Emergency Department Stress of Lateral Compression Type 1 Pelvis Fractures With a Validated Instability Scoring System. J Am Acad Orthop Surg 2023; 31:e451-e458. [PMID: 36727708 DOI: 10.5435/jaaos-d-22-00160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 12/12/2022] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Lateral compression type 1 (LC1) pelvic ring injuries represent a heterogeneous group of fractures with controversial surgical indications. Recently, multiple institutions have suggested the safety and reliability of an emergency department (ED) stress to evaluate for occult instability. The purpose of this study was to correlate ED stress examination of LC1 pelvis fractures against a validated fracture instability scoring system. METHODS This was a retrospective review of a consecutive series of 70 patients presenting with minimally displaced LC1 fractures at a level 1 academic trauma center. All patients were stressed in the ED radiology suite, and displacement was measured by comparing calibrated stress radiographs with static radiographs (>10 mm displacement defined positivity). ED stress results were compared with radiographic scores assigned according to the validated Beckmann scoring system (score <7: stable-nonsurgical recommendation; score 7 to 9: indeterminant recommendation; and score >9: unstable-surgical recommendation). RESULTS Thirteen patients had a positive ED stress examination, and 57 patients stressed negative. The mean displacement was significantly different between the three groups (Beckmann 5 to 6: 3.31 mm, SD = 2.4; Beckmann 7 to 9: 4.23 mm, SD = 3.2; Beckmann 10+: 12.1 mm, SD = 8.6; P < 0.001). Zero of 18 patients in the stable group stressed positive, and only 3 of 38 patients in the indeterminant group stressed positive (7.9%). Finally, 10 of 14 patients in the unstable group stressed positive (71.4%; P < 0.001). Sacral displacement (P = 0.001), superior ramus location (P < 0.02), and sacral columns (P < 0.001) significantly predicted ED stress positivity in multivariate analysis. CONCLUSIONS Comparison of a validated instability scoring system with ED stress examination of minimally displaced LC1 fractures in awake and hemodynamically stable patients showed excellent correlation. This suggests that the ED stress examination is a useful diagnostic adjunct. LC1 fracture characteristics should be analyzed to determine which pelvic fracture characteristics determine occult instability before stress examination. LEVEL OF EVIDENCE Level III diagnostic.
Collapse
|
12
|
Anterior Pelvic Ring Fracture Pattern Predicts Subsequent Displacement in Lateral Compression Sacral Fractures. J Orthop Trauma 2022; 36:550-556. [PMID: 35583370 DOI: 10.1097/bot.0000000000002407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine if anterior pelvic fracture pattern in lateral compression (LC) sacral fractures correlates with subsequent displacement on examination under anesthesia (EUA) or follow-up in both nonoperative and operative cases. DESIGN Retrospective cohort study. SETTING Level 1 trauma center. PATIENTS Two hundred twenty-seven skeletally mature patients with traumatic LC (OTA/AO 61B1.1, 61B2.1-2, and 61B3.1-2) pelvic ring injuries treated nonoperatively, with EUA, or with pelvic fixation were included. INTERVENTION The study intervention included retrospective review of patients' charts and radiographs. MAIN OUTCOME MEASUREMENT Displacement on EUA or follow-up radiographs (both operative and nonoperative) correlated with anterior pelvic ring fracture pattern. RESULTS Independent of sacral fracture pattern (complete or incomplete), risk of subsequent displacement on EUA or at follow-up after both nonoperative and operative treatments correlated strongly with ipsilateral superior and inferior pubic rami fractures that were either comminuted (95.6%, P < 0.001) or oblique (100%, P < 0.001). Patients with transverse or lack of inferior pubic ramus fracture did not displace (0%, P < 0.001). Out of 21 LC injuries treated with posterior-only fixation, displacement at follow-up occurred in all 11 patients (100%) with comminuted and/or oblique superior and inferior pubic rami fractures. Nakatani zone I and II rami fractures correlated most with risk of subsequent displacement. CONCLUSIONS Unstable anterior fracture patterns are characterized as comminuted and/or oblique fractures of ipsilateral superior and inferior pubic rami. EUA should be strongly considered in these patients to disclose occult instability, for both complete and incomplete sacral fracture patterns. Additionally, these unstable anterior fracture patterns are poor candidates for posterior-only fixation and supplemental anterior fixation should be considered. Irrespective of sacral fracture pattern (complete or incomplete), nonoperative management is successful in patients with transverse or lack of inferior pubic ramus fractures. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
13
|
Prospective Characterization of Pain and Function in Patients With Unstable Pelvic Fractures Treated With Posterior Screw Fixation. J Orthop Trauma 2022; 36:557-563. [PMID: 35605147 DOI: 10.1097/bot.0000000000002416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Describe patient-reported pain and function within 24 months of a pelvic fracture treated with posterior screw fixation and identify factors associated with increased pain. DESIGN Prospective case series. SETTING Academic trauma center. PATIENTS/INTERVENTION Eighty-eight patients with adult pelvic fracture treated with sacroiliac or transiliac screws. MAIN OUTCOME MEASURES Average pain measured with the Brief Pain Inventory (BPI); function measured with the Majeed Pelvic Outcome Score from 6 to 24 months postinjury. RESULTS The mean pain from 6 to 24 months postinjury was 2.22 on the 10-point BPI scale (95% CI, 0.64-3.81). Sixty-nine patients (78.4%) reported mild to no pain at 6 months; 12 (13.6%) patients had severe pain. Two years after injury, 71 patients (80.6%) exhibited mild to no pain. Within 24 months of injury, the mean pelvic function was 71 on the 100-point Majeed scale (95% CI, 60-82). Half of the sample (n = 44) had good to excellent pelvis function by 6 months postinjury; 55 patients (62.5%) attained this level of function by 24 months. A history of chronic pain (1.31; 95% CI, 0.26-2.37; P = 0.02), initial fracture displacement (≥5 mm) (0.99; 95% CI, 0.23-1.69; P = 0.01), and socioeconomic deprivation (0.28; 95% CI, 0.11-0.44; P < 0.01) were significantly associated with increased pain. CONCLUSION Our findings suggest that most patients with unstable pelvic ring fractures treated with posterior screw fixation achieve minimal to no pelvis pain and good to excellent pelvic function 6-24 months after injury. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
14
|
Varma JR, Foxall-Smith M, Donovan R, Whitehouse MR, Rogers C, Acharya M. Surgical Versus Non-surgical Treatment of Unstable Lateral Compression Type I (LC1) Injuries of the Pelvis With Complete Sacral Fractures in Non-fragility Fracture Patients: A Systematic Review. Cureus 2022; 14:e29239. [PMID: 36262937 PMCID: PMC9573782 DOI: 10.7759/cureus.29239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 11/05/2022] Open
|
15
|
Tucker NJ, Heare A, Stacey SC, Mauffrey C, Parry JA. The lateral stress radiograph: an effective alternative to examination under anesthesia for identifying occult instability in minimally displaced lateral compression pelvic ring injuries. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03373-1. [PMID: 36056970 DOI: 10.1007/s00590-022-03373-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE The purpose of this study was to review the practice of utilizing lateral stress radiographs (LSRs) to identify occult instability (≥ 10 mm of dynamic displacement on LSRs) of minimally displaced lateral compression type 1 (LC1) pelvic ring injuries and to evaluate for associations between instability and patient demographics, injury characteristics, and hospital course. METHODS A retrospective review of a prospective registry from 2018 to 2022 identified 151 patients with LC1 injuries. LSRs were obtained in 86.8% (131/151) of patients. Three (2.2%) patients were excluded for malrotation of LSRs, leaving 128 patients for analysis. RESULTS The median maximum dynamic displacement on LSRs was 12.2 mm (IQR: 5.9 to 17.3). Occult instability was present in 62.5% (80/128) of patients and was associated with older age (Median difference 11.0 years, 95% CI 3.0 to 20.0), Nakatani type 1 rami fractures (73.7% vs. 47.9%, p = 0.001), and rami fracture comminution (Proportional difference 58.7%, 95% CI 42.8 to 71.3%), but not gender, high-energy mechanism, bilateral rami fractures, Denis classification, sacral fracture completeness, or sacral comminution. Patients with occult instability took longer to ambulate 15 feet and clear physical therapy (PT), were more likely to be unable to clear PT by hospital day 3 or by time of discharge, had longer hospital stays, and were more likely to require rehabilitation facilities. CONCLUSION LSRs were obtained in a majority of patients. Occult instability was frequently present and associated with older age, comminuted distal pubic rami fractures, longer hospital stays, longer times to mobilize and clear PT, and an increased need for rehabilitation facilities.
Collapse
Affiliation(s)
- Nicholas J Tucker
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, Denver, CO, MC 0188, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Austin Heare
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, Denver, CO, MC 0188, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stephen C Stacey
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, Denver, CO, MC 0188, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cyril Mauffrey
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, Denver, CO, MC 0188, USA
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua A Parry
- Department of Orthopedics, Denver Health Medical Center, 777 Bannock St, Denver, CO, MC 0188, USA.
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.
| |
Collapse
|
16
|
Nonoperative Management of Minimally Displaced Lateral Compression Type 1 Pelvic Ring Injuries With and Without Occult Instability. J Orthop Trauma 2022; 36:287-291. [PMID: 34690326 DOI: 10.1097/bot.0000000000002300] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the association of pelvic fracture displacement on lateral stress radiographs (LSRs) with the hospital course of patients with minimally displaced lateral compression type 1 (LC1) pelvic injuries. DESIGN Retrospective review. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Twenty-eight adult patients with minimally displaced (<1 cm) LC1 injuries. INTERVENTION Nonoperative management. MAIN OUTCOME MEASUREMENTS Delayed operative fixation, days to clear physical therapy, mobilization, hospital length of stay, and total hospital opioid morphine equivalent dose. RESULTS LSR displacement was correlated with delayed operative fixation [r = 0.23, 95% confidence interval (CI) 0.05-1.11; P = 0.01], days to clear PT (r = 0.13, CI 0.01-0.28; P = 0.02), length of stay (r = 0.13, CI 0.006-0.26; P = 0.02), and opioid morphine equivalent dose (r = 19.4, CI 1.5-38.1; P = 0.03). A receiver operating characteristic curve for delayed operative fixation over LSR displacement had an area under the curve of 0.87. The LSR displacement threshold that maximized sensitivity and specificity for detecting patients who required delayed fixation was 10 mm (100% sensitivity and 78% specificity). Ten of the 15 patients with ≥10 mm of displacement on LSRs underwent delayed operative fixation for pain with mobilization at a median of 6 days (interquartile range 3.7-7.5). Patients with ≥10 mm of displacement on LSRs took longer to clear PT, took longer to walk 15 feet, had longer hospital stays, and used more opioids. CONCLUSIONS LC1 fracture displacement on LSRs is associated with delayed operative fixation, difficulty mobilizing secondary to pain, longer hospital stays, and opioid use. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
17
|
Unilateral Sacral Fractures Demonstrate Slow Recovery of Patient-Reported Outcomes Irrespective of Treatment. J Orthop Trauma 2022; 36:179-183. [PMID: 34483321 DOI: 10.1097/bot.0000000000002260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To report functional outcomes of unilateral sacral fractures treated both operatively and nonoperatively. DESIGN Prospective, multicenter, observational study. SETTING Sixteen Level 1 trauma centers. PATIENTS/PARTICIPANTS Skeletally mature patients with unilateral zone 1 or 2 sacral fractures categorized as displaced nonoperative (DN), displaced operative (DO), nondisplaced nonoperative (NN), and nondisplaced operative (NO). MAIN OUTCOME MEASUREMENTS Pelvic displacement was documented on injury plain radiographs. Short Musculoskeletal Function Assessment (SMFA) scores were obtained at baseline and at 3, 6, 12, and 24 months after injury. Displacement was defined as greater than 5 mm in any plane at the time of injury. RESULTS Two hundred eighty-six patients with unilateral sacral fractures were initially enrolled, with a mean age of 40 years and mean injury severity score of 16. One hundred twenty-three patients completed the 2-year follow-up as follows: 29 DN, 30 DO, 47 NN, and 17 NO with 56% loss to follow-up at 2 years. Highest dysfunction was seen at 3 months for all groups with mean SMFA dysfunction scores: 25 DN, 28 DO, 27 NN, and 31 NO. The mean SMFA scores at 2 years for all groups were 13 DN, 12 DO, 17 NN, and 17 NO. CONCLUSIONS All groups (operative/nonoperative and displaced/nondisplaced) reported worst function 3 months after injury, and all but (DN) continued to recover for 2 years after injury, with peak recovery for DN seen at 1 year. No functional benefit was seen with operative intervention for either displaced or nondisplaced injuries at any time point. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
18
|
DeKeyser GJ, Kellam PJ, Haller JM, Higgins TF, Marchand LS, Rothberg DL. Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable. J Bone Joint Surg Am 2022; 104:336-344. [PMID: 34921551 DOI: 10.2106/jbjs.21.00737] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Occult instability of lateral compression type-1 (LC1) pelvic ring injuries may be determined with a fluoroscopic stress examination under anesthesia (EUA) performed in the operating room. We hypothesized that LC1 injuries, similar to some fractures of the extremities, could be radiographically stressed for stability in the emergency department (ED). Our primary objective was to determine if stress examination of LC1 fractures could be safely and accurately performed in the ED and could be tolerated by patients. METHODS A prospective, consecutive series of 70 patients with minimally displaced LC1 pelvic injuries (<10-mm displacement on presentation) underwent stress examinations performed by the on-call orthopaedic resident in the ED radiology suite. The stress examination series included static 40° inlet, internal rotation stress inlet, and external rotation stress inlet views. Pelvic fractures that had positive stress results (≥10 mm of overlap of the rami) were indicated for a surgical procedure. These fractures also underwent EUA in order for the 2 techniques to be compared. RESULTS All patients tolerated the ED stress examination without general anesthetic or hemodynamic instability. Fifty-seven patients (81%) had negative stress results and were allowed to bear weight. All patients with negative stress results who had 3-month follow-up went on to radiographic union without substantial displacement. For the patients with a positive stress result in the ED, the mean displacement was 15.15 mm (95% confidence interval [CI], 10.8 to 19.4 mm) for the ED stress test and 15.60 mm (95% CI, 11.7 to 19.4 mm) for the EUA (p = 0.86). Two patients with a negative ED stress test did not mobilize during their hospitalization and underwent EUA and conversion to a surgical procedure. Thus, a total of 11 patients underwent both stress testing in the ED and EUA; no patient had a positive result on one test but a negative result on the other. CONCLUSIONS ED stress examination of LC1 injuries is a safe and reliable method to determine pelvic ring stability. The displacement measured in the ED stress examination is similar to the displacement measured under general anesthesia. Furthermore, a negative ED stress examination predicts successful nonoperative treatment. Given the results of this study, we encourage the use of stress examination in the ED for LC1-type injuries involving complete sacral fractures only. Widescale adoption of this streamlined protocol may substantially diminish cost, anesthetic risk, and potential operations for patients. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Graham J DeKeyser
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | | | | | | | | | | |
Collapse
|
19
|
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.
Collapse
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
| |
Collapse
|
20
|
Tucker NJ, Mauffrey C, Parry JA. Unstable minimally displaced lateral compression type 1 (LC1) pelvic ring injuries have a similar hospital course as intertrochanteric femur fractures. Injury 2022; 53:481-487. [PMID: 34911634 DOI: 10.1016/j.injury.2021.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 12/03/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to evaluate how the hospital course of minimally displaced LC1 fractures, with and without occult instability, compares with that of intertrochanteric femur fractures. PATIENTS AND METHODS Retrospective comparative cohort analysis at an urban level one trauma center of 40 consecutive patients with an isolated LC1 pelvic ring injury and 40 age/sex matched patients with an isolated intertrochanteric femur fracture was performed. Medical records and radiographs were reviewed for patient and injury characteristics, including demographics, displacement, time to surgery, ambulation, physical therapy (PT) clearance, hospital length of stay (LOS), and inpatient morphine milligram equivalents (MME). RESULTS The LC1 pelvic ring injury group included 26 (65%) patients with ≥ 10 mm of displacement on lateral stress radiographs. The unstable LC1 group, compared to the stable LC1 group, had a greater LOS (median difference (MD): 2 days, 95% confidence interval (CI): 1 to 4, p = 0.0004), longer time to ambulate 15 feet (MD: 1 day, CI: 1 to 2, p = 0.0002), longer time to clear PT (MD: 2 days, CI: 1 to 3, p = 0.0003), and more inpatient MMEs (MD: 386 MME, CI: 225.8 to 546.7, p = 0.0002). The unstable LC1 and intertrochanteric fracture groups had no detectable differences in LOS (p = 0.24), days to ambulate 15 feet (p = 0.46), days to clear PT (p = 0.95), and inpatient MMEs (p = 0.06). CONCLUSION Patients with minimally displaced unstable LC1 injuries had worse hospital courses than stable LC1 injuries and similar hospital courses as intertrochanteric femur fractures. These findings emphasize the associated morbidity of unstable LC1 injuries. LEVEL OF EVIDENCE Level III, Retrospective cohort study.
Collapse
Affiliation(s)
- Nicholas J Tucker
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO 80204, United States
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO 80204, United States; Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Joshua A Parry
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, MC 0188, Denver, CO 80204, United States; Department of Orthopaedics, University of Colorado School of Medicine, Aurora, CO, United States.
| |
Collapse
|
21
|
Wang P, Ali SH, Fei C, Zhang B, Wei X, Wang H, Cong Y, Deng H, Fu Y, Zhang K, Zhuang Y. Management of LC Type I (LC-1) Pelvic Injuries with Complete Sacral Fracture: Comparison of Solitary Anterior Fixation with Combined Anterior-Posterior Fixation. BIOMED RESEARCH INTERNATIONAL 2022; 2022:3918794. [PMID: 35087907 PMCID: PMC8789421 DOI: 10.1155/2022/3918794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/08/2021] [Accepted: 12/16/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Management of LC-1 type pelvic injuries, particularly in patients with complete sacral fracture (LC-1 PICSF, OTA type 61-B2.1), remains controversial. Specific indications for solitary fixation remain unclear, and there is a paucity of outcomes data in comparison to combined fixation. We undertook a retrospective study in patients with LC-1 PICSFs to compare outcomes between solitary anterior fixation and combined anterior-posterior fixation. METHODS A retrospective cohort study was conducted with enrollment from 2016 to 2018 at a single tertiary-referral center in China. Adults with operatively managed LC-1 PICSFs were enrolled. Patients with sacral displacement < 1 cm as assessed by axial CT received solitary anterior ring fixation (group A); patients with displacement ≥ 1 cm received combined fixation of both the anterior and posterior rings (group B). Reduction was confirmed by manipulation under anesthesia. Patients followed up for at least 24 months postoperatively. Primary outcome was function (Majeed score). Secondary outcomes included intraoperative characteristics, pain (VAS score), quality of fracture reduction (Tornetta and Matta radiographic grading), rate of nonunion, early weight-bearing status, and complication rate. RESULTS 68 (89%) of 76 enrolled patients completed follow-up. Patients in group A exhibited improved operative times, less time under fluoroscopy, and less blood loss as compared to group B. There were no significant differences between groups A and B regarding quality of fracture reduction, rate of union, functional outcomes, or rate of complications. Notably, group B patients were more likely to achieve full early weight-bearing. CONCLUSION LC-1 PFCSFs can get benefits from ORIF; the treatment algorithm should be differently made following the degree of the sacral fractures displacement. Less than 1 cm sacral fracture displacement may get good functional outcomes from solitary anterior fixation. However, for the sacral fractures displacement greater or equal to 1 cm, both the anterior and posterior pelvic rings should be surgical stabilization.
Collapse
Affiliation(s)
- Pengfei Wang
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Syed Haider Ali
- Institute for Global Orthopaedics & Traumatology, University of California, 2550 23rd St., Bldg.9, 2nd Floor San Francisco, CA, 94110 San Francisco, USA
| | - Chen Fei
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Binfei Zhang
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Xing Wei
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Hu Wang
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Yuxuan Cong
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Hongli Deng
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Yahui Fu
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Kun Zhang
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| | - Yan Zhuang
- Department of Orthopedics and Traumatology, Xi'an Honghui Hospital, Xi'an Jiao Tong University Health Science Center, Xi'an, No. 555, East Friendship Road, 710054 Xi'an City, Shaanxi Province, China
| |
Collapse
|
22
|
Sacral Fracture Completeness in Lateral Compression Type 1 Pelvic Ring Injuries Has Weak Interobserver Reliability. J Orthop Trauma 2021; 35:650-653. [PMID: 33878067 DOI: 10.1097/bot.0000000000002125] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine the agreement between fellowship-trained orthopaedic trauma surgeons in evaluating sacral fracture completeness in the setting of minimally displaced lateral compression type 1 pelvic ring injuries. DESIGN Survey study. SETTING Urban Level 1 trauma center. PATIENTS/PARTICIPANTS This study included 10 fellowship-trained orthopaedic trauma surgeons reviewing 10 cases of minimally displaced lateral compression type 1 injuries with proven occult instability (≥10 mm of fracture displacement on lateral stress radiographs). Sacral fractures were considered complete (n = 5; fracture line exiting posterior cortex of sacrum) or incomplete (n = 5). INTERVENTION Participants reviewed videos of all axial computed tomography images of the sacrum and were asked if the sacral fracture was complete or incomplete. MAIN OUTCOME MEASUREMENTS Interobserver reliability of completeness of sacral fracture. RESULTS Interobserver reliability among surgeons for completeness of sacral fractures was considered to be weak (k = 0.46) with a 95% confidence interval that ranged from minimal (k = 0.37) to weak (k = 0.55). None of the 5 unstable sacral fractures that were considered to be complete garnered 100% agreement among surgeons. Agreement for each of these cases ranged from 40% to 90%. In contrast, 4 of the 5 unstable sacral fractures considered to be incomplete had 100% agreement. CONCLUSIONS Completeness of sacral fractures had weak interobserver reliability among fellowship-trained orthopaedic trauma surgeons. Sacral fractures that were considered incomplete by all surgeons did have occult instability. These results highlight the large potential for error created by using sacral fracture completeness as a criterion to rule out occult instability. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
23
|
Zhang BF, Wang J, Zhang YM, Cheng HG, Cheng QY, Cao WW. The morphological mapping of lateral compression type 1 pelvic fracture and pelvic ring stability classification: a finite element analysis. J Orthop Surg Res 2021; 16:675. [PMID: 34789299 PMCID: PMC8597293 DOI: 10.1186/s13018-021-02818-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/01/2021] [Indexed: 11/14/2022] Open
Abstract
Purpose This finite element analysis assessed lateral compression (LC-1) fracture stability using machine learning for morphological mapping and classification of pelvic ring stability. Methods Computed tomography (CT) files of LC-1 pelvic fractures were collected. After morphological mapping and producing matrix data, we used K-means clustering in unsupervised machine learning to classify the fractures. Based on these subtypes, we manually added fracture lines in ANSYS software. Finally, we performed a finite element analysis of a normal pelvis and eight fracture subtypes based on von Mises stress and total deformation changes. Results A total of 218 consecutive cases were analyzed. According to the three main factors—zone of sacral injury and completion, pubic ramus injury side, and the sagittal rotation of the injured hemipelvis—the LC-1 injuries were classified into eight subtypes (I–VIII). No significant differences in stress or deformation were observed between unilateral and bilateral public ramus fractures. Subtypes VI and VIII showed the maximum stress while subtypes V–VIII showed the maximum deformation in the total pelvis and sacrum. The subtypes did not differ in superior public ramus deformation. Conclusions Complete fracture of sacrum zones 2/3 may be a feature of unstable LC-1 fractures. Surgeons should give surgical strategies for subtypes V–VIII.
Collapse
Affiliation(s)
- Bin-Fei Zhang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China.
| | - Jun Wang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China
| | - Yu-Min Zhang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China
| | - Hui-Guang Cheng
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China
| | - Qian-Yue Cheng
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China
| | - Wen-Wen Cao
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, Shaanxi Province, 710054, The People's Republic of China
| |
Collapse
|
24
|
Parry JA, Funk A, Heare A, Stacey S, Mauffrey C, Starr A, Crist B, Krettek C, Jones CB, Kleweno CP, Firoozabadi R, Sagi HC, Archdeacon M, Eastman J, Langford J, Oransky M, Martin M, Cole P, Giannoudis P, Byun SE, Morgan SJ, Smith W, Giordano V, Trikha V. An international survey of pelvic trauma surgeons on the management of pelvic ring injuries. Injury 2021; 52:2685-2692. [PMID: 32943214 DOI: 10.1016/j.injury.2020.07.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION There exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive survey on the management of pelvic ring injuries among an international group of pelvic trauma surgeons to determine areas of agreement and disagreement. METHODS A 45-item questionnaire was developed using an online survey platform and distributed to 30 international pelvic trauma surgeons. The survey consisted of general questions on the acute management of pelvic ring injuries and questions regarding 5 cases: Lateral compression (LC) type 1 injury, LC-3, Anterior-posterior compression (APC) type 3 injury, a combined vertical shear (VS) injury through the sacrum, and VS injury through sacroiliac joint. Respondents were shown blinded anteroposterior pelvis radiographs and axial computed tomography (CT) images for each case and asked if the injury needed fixation, the type of fixation, the order of fixation, and postoperative weight-bearing status. The Kappa statistic was calculated to assess agreement between respondents for each question. RESULTS Nineteen out of 30 pelvic trauma surgeons completed the survey. Respondents practiced in Brazil (n = 1), Germany (n = 1), India (n = 1), Italy (n = 1) United Kingdom (n = 1), and the United States (n = 14). Of the 45 questions in this survey, 38 (84%) had minimal to no agreement among the respondents. There was moderate agreement, for performing lumbopelvic fixation when indicated, for anterior and posterior fixation of the LC-3 injury, and on forgoing EUA or stress X-rays for the APC-3 injury. There was strong agreement for open reduction and internal fixation of the anterior pelvic ring in the APC-3 injury and the VS injury through the SI joint. In contrast, LC-1 injury and combined VS pelvic ring injury through the sacrum had no areas of moderate to strong agreement. DISCUSSION This study identified specific areas of pelvic ring injury management with minimal to no agreement among pelvic trauma surgeons. Future research should target these areas with a lack of agreement to decrease practice variability and improve patient outcomes.
Collapse
Affiliation(s)
- Joshua A Parry
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
| | - August Funk
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
| | - Austin Heare
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
| | - Stephen Stacey
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
| | - Cyril Mauffrey
- Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO.
| | - Adam Starr
- Department of Orthopaedic Surgery, University of Texas at Southwestern, Dallas, Texas
| | - Brett Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Christian Krettek
- Department of Orthopaedic Surgery, University of Munich at Hannover Medical School, Hannover, Germany
| | - Clifford B Jones
- Department of Orthopaedic Surgery, Dignity Health Medical Group, Phoenix, Arizona
| | - Conor P Kleweno
- Department of Orthopaedic Surgery, Harboview Medical Center, University of Washington, Seattle, Washington
| | - Reza Firoozabadi
- Department of Orthopaedic Surgery, Harboview Medical Center, University of Washington, Seattle, Washington
| | - Henry Claude Sagi
- Department of Orthopaedic Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Mike Archdeacon
- Department of Orthopaedic Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Jonathan Eastman
- Department of Orthopaedic Surgery, University of California Davis, Sacramento, California
| | - Joshua Langford
- Department of Orthopaedic Surgery, Orlando Regional Medical Center, Orlando, Florida
| | - Michel Oransky
- Department of Orthopaedic Surgery, Aurelia Hospital, Roma, Italy
| | - Murphy Martin
- Department of Orthopaedic Surgery, Tulane University, New Orleans, Louisiana
| | - Peter Cole
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, Minnesota
| | - Peter Giannoudis
- Department of Orthopaedic Surgery, University of Leeds, Leeds, United Kingdom
| | - Seong-Eun Byun
- Department of Orthopaedic Surgery, CHA Bundang Medical Center, CHA University, Seongnam, SC Korea
| | - Steven J Morgan
- Department of Orthopaedic Surgery, Swedish Medical Center, Englewood, Colorado
| | - Wade Smith
- Department of Orthopaedic Surgery, Swedish Medical Center, Englewood, Colorado
| | - Vincenzo Giordano
- Department of Orthopaedic Surgery, Hospital Municipal Miguel Couto, Rio de Janeiro, Brazil
| | - Vivek Trikha
- Department of Orthopaedic Surgery, All India Institute of Medical Sciences, South Delhi, India
| |
Collapse
|
25
|
Tucker D, Carney J, Nguyen A, Alluri RK, Lee A, Marecek G. Examination Under Anesthesia Improves Agreement on Mechanical Stability: A Survey of Experienced Pelvic Surgeons. J Orthop Trauma 2021; 35:e241-e246. [PMID: 33252448 DOI: 10.1097/bot.0000000000001996] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/28/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess agreement among experts in pelvic fracture management regarding stability and need for operative repair of lateral compression-type pelvic fractures with static radiographs compared to static radiographs and examination under anesthesia (EUA). SETTING Online survey. PATIENTS/PARTICIPANTS Ten patients who presented to our level-1 trauma center with a pelvic ring injury were selected. Vignettes were distributed to 11 experienced pelvic surgeons. INTERVENTION Examination under anesthesia. MAIN OUTCOME MEASUREMENTS Agreement regarding pelvic fracture stability and need for surgical fixation. RESULTS Agreement on stability was achieved in 4 (40%) cases without EUA compared to 8 (80%) cases with EUA. Interreviewer reliability was poor without EUA and moderate with EUA (0.207 vs. 0.592). Agreement on need to perform surgery was achieved in 5 (50%) cases compared to 6 (60%) cases with EUA. Interreviewer reliability was poor without EUA and moderate with EUA (0.250 vs. 0.432). For reference cases with agreement, surgeons were able to predict stability or instability using standard imaging in 57 of a possible 88 reviewer choices (64.8%) compared to 82 of 88 choices (93.2%) with the addition of EUA (P < 0.0001). CONCLUSIONS EUA increased agreement among experienced pelvic surgeons regarding the assessment of pelvic ring stability and the need for operative intervention. Further research is necessary to define specific indications for which patients may benefit from EUA.
Collapse
Affiliation(s)
- Douglass Tucker
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - John Carney
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Aileen Nguyen
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Ram K Alluri
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Adam Lee
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Geoffrey Marecek
- Department of Orthopaedic Surgery, Cedar-Sinai Medical Center, Los Angeles, CA
| |
Collapse
|
26
|
Short-Term Functional Outcomes and Quality of Life after B2.1 Type Pelvic Fractures for Surgically and Non-Surgically Treated Young Patients. ACTA ACUST UNITED AC 2021; 57:medicina57060513. [PMID: 34063870 PMCID: PMC8224058 DOI: 10.3390/medicina57060513] [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] [Received: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
Background and Objectives: Lateral compression injuries of the pelvic ring are most common among young and elderly patients. Of all pelvic ring fracture injuries, the B2.1 type—involving lateral compression of the pelvic ring—is the most common. Despite this, we still have no high-level evidence to consult when choosing between the surgical and non-operative approaches. The purpose of this research was to compare the short-term functional and quality of life outcomes between operatively and non-operatively treated young patients after a B2.1 type pelvic fracture. Materials and Methods: Patients aged 18 to 65 years with pelvic B2.1 type fractures—according to AO/Tile classification—that were hospitalized in a single trauma center between 2016 November and 2019 September were included in the research. Patients were retrospectively divided into two groups regarding their treatment: non-operative and operative. Functional outcomes were evaluated using Majeed score, and SF-36 was used for the evaluation of quality of life. Patients completed these questionnaires twice: first during hospitalization, regarding their pre-traumatic condition (timepoint I); and again 10 weeks after the injury, regarding their current condition (timepoint II). Results: A total of 55 patients (70.6% of whom were female) with type B2.1 pelvic fractures were included in the analysis, with an average age of 37.24 ± 13.78 years. There were 21 (38.18%) patients with high injury severity, and 37 (67.3%) patients were treated operatively versus 18 (32.7%) non-operatively. Between the two timepoints, Majeed score reduced by 34.08 ± 18.95 for operatively and 31.44 ± 14.41 for non-operatively treated patients. For operatively and non-operatively treated patients, the physical component summary (PCS) of the SF-36 questionnaire reduced by 19.45 ± 9.95 and 19.36 ± 7.88, respectively, while the mental component summary (MCS) reduced by 6.38 ± 11.04 and 7.23 ± 10.86, respectively. Conclusions: We observed that operative treatment of B2.1 type pelvic fractures for young patients is not superior to non-operative in the short-term, because the functional outcomes and quality of life are similar in both groups.
Collapse
|
27
|
Kuršumović K, Hadeed M, Bassett J, Parry JA, Bates P, Acharya MR. Lateral compression type 1 (LC1) pelvic ring injuries: a spectrum of fracture types and treatment algorithms. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:841-854. [PMID: 33860399 DOI: 10.1007/s00590-021-02935-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
Lateral compression type 1 (LC1) fractures are the commonest pelvic ring injury. However, they represent a heterogenous spectrum of injury mechanisms and fracture patterns, resulting in a lack of strong evidence for a universally agreed treatment algorithm. Although consensus exists that LC1 fractures have a preserved posterior ligamentous complex and are vertically stable, controversy persists around defining internal rotational instability. As such, treatment strategies extend from routine non-operative management through to dynamic imaging such as examination under anaesthetic (EUA) or stress radiographs to guide fixation algorithm. Multiple protocols sit between these two, all with slightly different thresholds for advocating surgery or otherwise, exemplifying a broad lack of consensus that is not seen for other, more severe, grades of pelvic ring injury. In the following review we discuss the evolving concepts of pelvic ring instability and management, starting from a historical perspective, through to current trends and controversies in LC1 fracture treatment. Emerging directions for research and emerging pharmacological and surgical treatments/technologies are also considered and expert commentary from 3 leading centres provided. The distinction is made between LC1 fracture arising from high-energy trauma and those following low-energy falls from standing height (so-called fragility fractures of the pelvis-FFP), since these two patient groups have different functional requirements and medical vulnerabilities. Issues pertaining to FFP are considered separately.
Collapse
Affiliation(s)
- Kenan Kuršumović
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Michael Hadeed
- Department of Orthopaedic Surgery, Denver Health Medical Centre, University of Colorado School of Medicine, Denver, CO, USA
| | - James Bassett
- Department of Trauma and Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Joshua A Parry
- Department of Orthopaedic Surgery, Denver Health Medical Centre, University of Colorado School of Medicine, Denver, CO, USA
| | - Peter Bates
- Department of Trauma and Orthopaedics, Barts Health NHS Trust, The Royal London Hospital, London, UK.
| | - Mehool R Acharya
- Department of Trauma and Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| |
Collapse
|
28
|
Huang H, Zhang BF, Liu P, Deng HL, Wang PF, Wang H, Li BF, Cong YX, Zhuang Y. The traditional experience strategy (TES) and combined ultrasonography examination (CUE) for the treatment of lateral compression type 1 pelvic fractures: a historical control study. BMC Musculoskelet Disord 2021; 22:110. [PMID: 33494747 PMCID: PMC7836564 DOI: 10.1186/s12891-021-03993-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 01/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is difficult to judge the stability of lateral compression type-1 (LC-1) pelvic fracture, as it is often based on static images of the pelvis. Compared with the traditional experience strategy, ultrasonography examination may be able to distinguish operative and conservative patients before definitive treatment. However, in previous studies, we have not compared the outcomes between traditional experience strategy (TES group) and combined ultrasonography examination (CUE group). Thus, the aim of the study is comparing the differences between TES and CUE strategy, to identify the value of ultrasonography examination. METHODS Medical records system for patients with LC-1 pelvic fractures who were treated with TES and CUE strategy were included. Patients' baseline characteristics, treatment strategy, and function were recorded at follow-up. Functional outcomes were evaluated using the Majeed grading system. RESULTS In total, 77 patients with LC-1 pelvic fractures were included in the study. There were 42 and 35 patients in TES and CUE group, respectively. Compared to TES group (69 %), there were less proportion patients chosen the operative treatment in CUE group (43 %, P = 0.021). The volume of intraoperative blood loss in CUE operative group was more than TES operative group (P = 0.037). There were more patients with complete sacral fracture in CUE operative group than TES operative group (P = 0.002). The Majeed scores in CUE conservative group was higher than TES conservative group (P = 0.008). The overall Majeed scores in CUE group was higher than that in TES group (P = 0.039). CONCLUSIONS The ultrasonography examination could relatively accurately identify the unstable LC-1 pelvis than the traditional experience strategy, the operative rate could be reduced and the overall function of LC-1 patients could be improved under the ultrasonography examination. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Hai Huang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Bin-Fei Zhang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Ping Liu
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Hong-Li Deng
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Peng-Fei Wang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Hu Wang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Bao-Feng Li
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China
| | - Yu-Xuan Cong
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China.
| | - Yan Zhuang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, Beilin District, No. 555 Youyi East Road, Shaanxi Province, 710054, Xi'an, Republic of China.
| |
Collapse
|
29
|
Parry JA, Salameh M, Funk A, Heare A, Stacey SC, Mauffrey C. Mobilization versus displacement on lateral stress radiographs for determining operative fixation of minimally displaced lateral compression type I (LC1) pelvic ring injuries. INTERNATIONAL ORTHOPAEDICS 2021; 45:1625-1631. [PMID: 33452886 DOI: 10.1007/s00264-020-04912-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Operative fixation of minimally displaced lateral compression type I (LC1) pelvic ring injuries is considered by some if the patient is unable to mobilize or displacement is seen on stress radiographs. The purpose of this study was to compare these methods of determining operative fixation. METHODS A retrospective study of a prospectively gathered registry of LC1 injuries was performed before and after the adoption of a mobilization protocol. Fixation was considered if the patient was unable to mobilize 15 feet on the second day of admission. Prior to this protocol, all patients with displacement of ≥ 10 mm on stress radiographs were offered fixation. All patients received lateral stress radiographs (LSR), an anteroposterior pelvis radiograph in the lateral decubitus positions without sedation, to assess stability. RESULTS There were 21 and 18 patients treated under the stress radiograph and mobilization protocols. Displacement ≥ 10 mm was present in 12 (57%) and six (33%) patients in the LSR and mobilization groups. Under the mobilization protocol, patients with ≥ 10 mm of displacement on LSR all had incomplete sacral fractures and were less likely to mobilize (2 (33%) vs. 11 (92%); 95% confidence interval of the difference (CID) - 86 to - 9%). The mobilization protocol did not identify all cases of occult instability and resulted in an increased time to surgery compared to the LSR protocol (5 vs. 2 days, 95% CID 1 to 5). CONCLUSION Under the mobilization protocol, unstable LC1 injuries were less likely to mobilize and the time to surgery was increased.
Collapse
Affiliation(s)
- Joshua A Parry
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA.
| | - Motasem Salameh
- Department of Orthopaedic Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - August Funk
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Austin Heare
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Stephen C Stacey
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO, USA
| |
Collapse
|
30
|
The Lateral Stress Radiograph Identifies Occult Instability of Lateral Compression Pelvic Ring Injuries Without Sedation. J Orthop Trauma 2020; 34:567-571. [PMID: 33065655 DOI: 10.1097/bot.0000000000001805] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine if pelvic ring displacement on the lateral stress radiograph (LSR) correlated with displacement on examination under anesthesia (EUA). DESIGN Retrospective cohort study. SETTING Urban Level I trauma center. PATIENTS/PARTICIPANTS Twenty consecutive patients with unilateral minimally displaced LC1 injuries with complete sacral fractures. INTERVENTION An anteroposterior pelvis radiograph taken in the lateral decubitus position (LSR) was performed on awake patients before EUA in the operating room. MAIN OUTCOME MEASUREMENTS Correlation between ≥1 cm of pelvic ring displacement on the LSR and EUA. RESULTS The LSR demonstrated ≥1 cm of displacement in 11 of the 20 patients (55%). All of these patients had ≥1 cm of displacement on EUA and underwent surgical fixation. The remaining 9 patients with <1 cm of displacement on the LSR also had <1 cm of displacement on EUA and were managed nonoperatively. CONCLUSIONS The LSR reliably identified occult instability in LC1 pelvic ring injuries and demonstrated 100% correlation with EUA. In contrast to EUA, the LSR does not require sedation and normalizes the amount of force applied to determine instability. LEVEL OF EVIDENCE Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
31
|
A Survey to Assess Agreement Between Pelvic Surgeons on the Outcome of Examination Under Anesthesia for Lateral Compression Pelvic Fractures. J Orthop Trauma 2020; 34:e304-e308. [PMID: 32815841 DOI: 10.1097/bot.0000000000001759] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To assess agreement among pelvic surgeons regarding the interpretation of examination under anesthesia (EUA), the methodology by which EUA should be performed, and the definition of a positive examination. DESIGN Survey. PATIENTS/PARTICIPANTS Ten patients who presented to our Level 1 trauma center with a pelvic ring injury were selected as clinical vignettes. Vignettes were distributed to 15 experienced pelvic surgeons. INTERVENTION Examination under anesthesia. MAIN OUTCOME MEASUREMENTS Agreement regarding pelvic fracture stability (defined as >80% similar responses), need for surgical fixation, definition of an unstable EUA, and method of performing EUA. RESULTS There was agreement that a pelvic fracture was stable or unstable in 8 (80%) of 10 cases. There was agreement that fixation was required or not required in 6 (60.0%) of 10 cases. Seven (46.7%) surgeons endorsed performing a full 15-part EUA, whereas the other 8 (53.3%) used an abbreviated or alternative method. Eight (53.3%) surgeons provided a definition of what constitutes a positive EUA, whereas the remaining 7 did not endorse adhering to a strict definition. CONCLUSIONS Pelvic surgeons generally agree on what constitutes a positive or negative EUA but not necessarily the implications of a positive or negative examination. There is no clear consensus among surgeons regarding the method of performing EUA nor regarding the definition of a positive EUA. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
32
|
Shang K, Ke C, Fu YH, Han S, Wang PF, Zhang BF, Zhuang Y, Zhang K. Feasibility of anterior pelvic ring fixation alone for treating lateral compression type 1 pelvic fractures with nondisplaced complete sacral fractures: a retrospective study. PeerJ 2020; 8:e8743. [PMID: 32211233 PMCID: PMC7081779 DOI: 10.7717/peerj.8743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/13/2020] [Indexed: 12/04/2022] Open
Abstract
Purpose The aim of this study was to evaluate the feasibility of anterior pelvic ring fixation alone for treating lateral compression type 1 (LC-1) fractures with nondisplaced complete sacral fractures. Methods Patients with LC-1 type pelvic fractures with nondisplaced complete sacral fractures in the Xi’an Honghui Hospital were screened. Those who underwent surgical treatment for the anterior pelvic ring fractures and conservative treatment for the sacral factures were included in the analysis. The Majeed and Short Form-12 (SF-12) functional scores were used to evaluate these patients. Results Of the 123 patients enrolled, 108 (88%) responded to our enquiries regarding the outcome. The mean follow-up period was 18.37 months for the 108 patients who responded. The mean SF-12 functional score was 48.22 ± 9.68. The mean Majeed score was 83.47 ± 9.23, including 52 with excellent, 47 with good, seven with fair, two with poor outcomes. The SF-12 functional and Majeed scores were significantly higher in those aged <45 years or without lower limb injury than in those aged ≥45 years or with lower limb injury (P < 0.05). Conclusion Acceptable functional outcomes can be obtained for LC-1 pelvic fractures with nondisplaced complete sacral fractures by using anterior pelvic ring fixation alone.
Collapse
Affiliation(s)
- Kun Shang
- Department of Orthopedic trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Chao Ke
- Department of Orthopedic trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Ya-Hui Fu
- Department of Orthopedic trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Shuang Han
- Department of Orthopedic trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Peng-Fei Wang
- Department of Orthopedic trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bin-Fei Zhang
- Department of Orthopedic trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yan Zhuang
- Department of Orthopedic trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Kun Zhang
- Department of Orthopedic trauma, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| |
Collapse
|
33
|
Abstract
Lateral compression type 1 pelvic fractures comprise a spectrum of injuries of varying stability. The clinician should be cognizant of signs and symptoms of instability including complete sacral fractures, bilateral ramus fractures, displacement greater than 1 cm, high-energy mechanism, and inability to bear weight. Management of these injuries is controversial, but the clinician should consider examination under anesthesia and potentially surgical stabilization.
Collapse
|
34
|
Barnfield S, Ingram J, Halliday R, Griffin X, Greenwood R, Kandiyali R, Thompson J, Glynn J, Beasant L, McArthur J, Bates P, Acharya M. TULIP: a randomised controlled trial of surgical versus non-surgical treatment of lateral compression injuries of the pelvis with complete sacral fractures (LC1) in the non-fragility fracture patient-a feasibility study protocol. BMJ Open 2020; 10:e036588. [PMID: 32047021 PMCID: PMC7044852 DOI: 10.1136/bmjopen-2019-036588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Lateral compression type 1 (LC1) pelvic fractures are the most common type of pelvic fracture. The majority of LC1 fractures are considered stable. Fractures where a complete sacral fracture is present increases the degree of potential instability and have the potential to displace over time. Non-operative management of these unstable fractures may involve restricted weight bearing and significant rehabilitation. Frequent monitoring with X-rays is also necessary for displacement of the fracture. Operative stabilisation of these fractures may be appropriate to prevent displacement of the fracture. This may allow patients to mobilise pain-free, quicker. METHODS AND ANALYSIS The study is a feasibility study to inform the design of a full definitive randomised controlled trial to guide the most appropriate management of these injuries. Participants will be recruited from major trauma centres and randomly allocated to either operative or non-operative management of their injuries. A variety of outcome instruments, measuring health-related quality of life, functional outcome and pain, will be completed at several time points up to 12 months post injury. Qualitative interviews will be undertaken with participants to explore their views of the treatments under investigation and trial processes.Eligibility and recruitment to the study will be analysed to inform the feasibility of a definitive trial. Completion rates of the measurement instruments will be assessed, as well as their sensitivity to change and the presence of floor or ceiling effects in this population, to inform the choice of the primary outcome for a definitive trial. ETHICS AND DISSEMINATION Ethical approval for the study was given by the South West-Central Bristol NHS Research Ethics Committee on 2nd July 2018 (Ref; 18/SW/0135). The study will be reported in relevant specialist journals and through presentation at specialist conferences. TRIAL REGISTRATION NUMBER ISRCTN10649958.
Collapse
Affiliation(s)
- Steven Barnfield
- Department of Trauma & Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Jenny Ingram
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Ruth Halliday
- Department of Trauma & Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Xavier Griffin
- Nuffield Dept of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), Kadoorie Centre, John Radcliffe Hospital, Oxford, Oxfordshire, UK
| | - Rosemary Greenwood
- University Hospitals Bristol NHS Foundation Trust, Level 3 Education Centre, Bristol, UK
| | | | - Julian Thompson
- Department of Anaesthetics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Joel Glynn
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Lucy Beasant
- Bristol Medical School, University of Bristol, Bristol, UK
| | - John McArthur
- Department of Orthopaedics, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Peter Bates
- Department of Orthopaedics, Barts Health NHS Trust, London, UK
| | - Mehool Acharya
- Department of Trauma & Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| |
Collapse
|
35
|
Abstract
OBJECTIVES To develop a radiographic fracture scoring system for lateral compression type 1 (LC-1) pelvic fractures based on OTA/AO survey data and to preliminarily evaluate this system within an LC-1 pelvis fracture cohort. DESIGN Survey study with validation patient cohort. SETTING Two Level 1 academic trauma centers. PATIENTS/PARTICIPANTS Attendings (n=111) at the 2013 OTA/AO national meeting reviewed imaging from 27 LC-1 fractures and indicated surgical recommendations ("yes/no"). A separate LC-1 fracture cohort (33 patients) was used to evaluate the scoring system. INTERVENTION The LC-1 scoring system (range: 5-14) based on radiographic morphology of sacral, superior ramus (SR), and inferior ramus (IR) fracture components. MAIN OUTCOME MEASUREMENT Numeric scores were compared against (1) OTA/AO attendees' operative recommendations and (2) LC-1 cohort treatment and outcomes. RESULTS Operative tendency of OTA/AO survey respondents-defined as the percent of "yes" responses to recommend surgical stabilization-was highly correlated with radiographic findings: sacral displacement {odds ratio (OR) = 18.9 [95% confidence interval (CI): 11.7-30.6]}; sacral column 2-3 versus 1 [OR = 5.7 (95% CI: 3.9-8.3)]; Denis classification [OR = 10 (95% CI: 6.7-14.9); IR displacement OR = 3.4 (95% CI: 2.3-4.8)]; and SR fracture [OR = 1.9 (95% CI: 1.3-2.8)]. Total scores <7 were 81% accurate in predicting nonoperative treatment. Total scores >9 were 89% accurate in predicting an operative recommendation. In the LC-1 cohort, scoring accuracy was 100% (95% CI: 85%-100%). CONCLUSIONS Based on survey results and patient cohort data, scores <7 predict nonoperative treatment recommendation, scores >9 indicate surgical recommendations, and scores 7-9 indicate indeterminate stability that should be further evaluated.
Collapse
|
36
|
Assessment of instability in type B pelvic ring fractures. J Clin Orthop Trauma 2020; 11:1009-1015. [PMID: 33192003 PMCID: PMC7656487 DOI: 10.1016/j.jcot.2020.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 09/28/2020] [Accepted: 10/02/2020] [Indexed: 11/22/2022] Open
Abstract
Pelvic ring fractures have increased in incidence and operative fixation over the past several decades. These are dynamic injuries but decisions on operative management are still often made on the basis of static imaging. Expert opinion varies greatly on which injuries require fixation and how much fixation. Examination under anaesthesia has been shown to guide management of pelvic injuries by more accurately assessing levels of instability.
Collapse
|
37
|
Becker CA, Kussmaul AC, Suero EM, Regauer M, Woiczinski M, Braun C, Flatz W, Pieske O, Kammerlander C, Boecker W, Greiner A. Tape suture for stabilization of incomplete posterior pelvic ring fractures-biomechanical analysis of a new minimally invasive treatment for incomplete lateral compression pelvic ring fractures. J Orthop Surg Res 2019; 14:465. [PMID: 31881914 PMCID: PMC6935107 DOI: 10.1186/s13018-019-1509-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 12/05/2019] [Indexed: 12/13/2022] Open
Abstract
Background Incomplete lateral compression fractures (including AO Type B2.1) are among the most common pelvic ring injuries. Although the treatment of choice remains controversial, sacroiliac (SI) screws are commonly used for the operative treatment of incomplete lateral compression fractures of the pelvic ring. However, the disadvantages of SI screws include the risk of nerve root or blood vessel injury. Recently, tape sutures have been found useful as stabilizing material for the treatment of injuries of the syndesmosis, the rotator cuff and knee ligaments. In this current study, we aimed to test the biomechanical feasibility of tape sutures to stabilize the pelvis in the setting of AO Type B2.1 injury. Methods Six human cadaveric pelvises underwent cyclic loading to compare the biomechanical stability of different osteosynthesis methods in a B2.1 fracture model. The methods tested in this experiment were a FiberTape® suture and the currently established SI screw. A 3D ultrasound tracking system was used to measure fracture fragment motion. Linear regression was used to model displacement and stiffness at the posterior and anterior pelvic ring. Results At the posterior fracture site, the FiberTape® demonstrated similar displacement (2.2 ± 0.8 mm) and stiffness (52.2 ± 18.0 N/mm) compared to the sacroiliac screw (displacement 2.1 ± 0.6 mm, P > 0.999; stiffness 50.8 ± 13.0 N/mm, P > 0.999). Considering the anterior fracture site, the FiberTape® again demonstrated similar displacement (3.8 ± 1.3 mm) and stiffness (29.5 ± 9.0 N/mm) compared to the sacroiliac screw (displacement 2.9 ± 0.8 mm, P = 0.2196; stiffness 37.5 ± 11.5 N/mm, P = 0.0711). Conclusion The newly presented osteosynthesis, the FiberTape®, shows promising results for the stabilization of the posterior pelvic ring in AO Type B2.1 lateral compression fractures compared to a sacroiliac screw osteosynthesis based on its minimal-invasiveness and the statistically similar biomechanical properties.
Collapse
Affiliation(s)
| | - Adrian Cavalcanti Kussmaul
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Eduardo Manuel Suero
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Markus Regauer
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Matthias Woiczinski
- Department of Orthopedic Surgery, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Munich, Germany
| | - Christian Braun
- Department of Legal and Forensic Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Wilhelm Flatz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Pieske
- Department of Trauma Surgery, Evangelic Hospital Oldenburg, Oldenburg, Germany
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Boecker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Axel Greiner
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany.
| |
Collapse
|
38
|
Affiliation(s)
- Heather A Vallier
- Department of Orthopaedic Surgery, The Metro Health System, Affiliated with Case Western Reserve University, Cleveland, OH
| | - Paul Tornetta
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA
| |
Collapse
|
39
|
Does Operative Intervention Provide Early Pain Relief for Patients With Unilateral Sacral Fractures and Minimal or No Displacement? J Orthop Trauma 2019; 33:614-618. [PMID: 31403559 DOI: 10.1097/bot.0000000000001578] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare pain after operative versus nonoperative pelvic ring injuries with unilateral sacral fractures. DESIGN Prospective, multicenter, observational. SETTING Sixteen trauma centers. PATIENTS/PARTICIPANTS Skeletally mature patients with pelvic ring injury and minimally displaced unilateral zone 1 or 2 sacral fractures and without anteroposterior compression injuries. MAIN OUTCOME MEASUREMENTS Pelvic displacement was documented on injury plain radiographs and computed tomography scans; a 10 point Visual Analog Scale (VAS) was used to evaluate pain was obtained in the anterior and posterior pelvic ring during the time of union (12 weeks). RESULTS One hundred ninety-four patients with unilateral sacral fractures displaced less than 5 mm, mean age of 38.7, and mean Injury Severity Score of 14.5 were included. Ninety-nine percent had lateral compression injuries, and 62% were in zone 1. Seventy-four percent were treated nonoperatively. Nonoperative patients had more zone 1 fractures (71%, P = 0.004). Nonoperative patients reported mean VAS 2.7 points higher in the posterior pelvis (P = 0.01) and 1.9 points higher anteriorly (P = 0.11) 24 hours after injury compared with patients treated operatively. After 3 months, nonoperative patients reported higher VAS scores than operative patients: 4.0 versus 2.9 posteriorly (P = 0.019) and 3.2 versus 2.3 anteriorly (P = 0.035). CONCLUSIONS For sacrum fractures with minimal or no displacement, slight differences in the VAS were noted within 24 hours after injury or surgery, but limited differences were seen at 3 months for either operatively treated minimally or undisplaced sacrum fractures. It is unknown whether this represents clinical relevance. These differences were below the minimally important clinical difference for VAS scores for other orthopaedic conditions. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
40
|
Abstract
OBJECTIVES To evaluate unilateral sacral fractures and compare those treated operatively versus nonoperatively to determine indications for surgery. DESIGN Prospective, multicenter, observational study. SETTING Sixteen trauma centers. PATIENTS/PARTICIPANTS Skeletally mature patients with pelvic ring injury and unilateral zone 1 or 2 sacral fractures and without anteroposterior compression injuries. MAIN OUTCOME MEASUREMENTS Injury plain anteroposterior, inlet, and outlet radiographs and computed tomography scans of the pelvis were evaluated for fracture displacement. RESULTS Three hundred thirty-three patients with unilateral sacral fractures and a mean age of 41 years with a mean Injury Severity Score of 15 were included. Ninety-two percent sustained lateral compression injuries, and 63% of all fractures were in zone 1. Thirty-three percent of patients were treated operatively, including all without lateral compression patterns. Operative patients were more likely to have zone 2 fractures (54%) and to have posterior cortical displacement (29% vs. 6.2%), both with P < 0.001. Over 60% of all patients had no posterior displacement. Mean rotational displacements comparing the injured side versus the intact side were no different for patients treated operatively compared with those treated nonoperatively. CONCLUSIONS Most unilateral sacral fractures are minimally or nondisplaced. Many patients with radiographically similar fractures were treated operatively and nonoperatively by different surgeons. This suggests an opportunity to develop consistent indications for treatment. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
Collapse
|
41
|
Pieroh P, Höch A, Hohmann T, Gras F, Märdian S, Pflug A, Wittenberg S, Ihle C, Blankenburg N, Dallacker-Losensky K, Schröder T, Herath SC, Wagner D, Palm HG, Josten C, Stuby FM. Fragility Fractures of the Pelvis Classification: A Multicenter Assessment of the Intra-Rater and Inter-Rater Reliabilities and Percentage of Agreement. J Bone Joint Surg Am 2019; 101:987-994. [PMID: 31169575 DOI: 10.2106/jbjs.18.00930] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The fragility fractures of the pelvis (FFP) classification was established to address the specific fracture morphology and dynamic instability in the elderly. Although this system is frequently used, data on the intra-rater and inter-rater reliabilities are lacking. METHODS Six experienced and 6 inexperienced surgeons and 1 surgeon trained by the originator of the FFP classification ("gold standard") each used the FFP classification 3 times to grade the computed tomography (CT) scans of 60 patients from 6 hospitals. We assessed intra-rater and inter-rater reliabilities using Fleiss kappa statistics and the percentage of agreement using the "gold standard," the submitting hospital, and the majority vote as references. RESULTS The intra-rater reliability for the FFP classification was mainly moderate, with a mean Fleiss kappa coefficient (and 95% confidence interval) of 0.46 (0.40 to 0.50) for the complete classification (i.e., both the main-group FFP ratings [I through III] and the subgroup ratings [a, b, and c]) and 0.60 (0.53 to 0.65) for the main group only. The inter-rater reliability was substantial for the main group classification (0.61 [0.54 to 0.66]) and moderate for the complete classification (0.53 [0.48 to 0.58]). The percentage of agreement was 68% to 80%. The lowest agreement was found for FFP II and III. CONCLUSIONS The FFP classification displayed moderate and substantial intra-rater and inter-rater reliabilities. CLINICAL RELEVANCE With moderate to substantial intra-rater and inter-rater reliabilities, the FFP classification forms a solid basis for future clinical investigations. The differentiation of FFP II from FFP III should be evaluated thoroughly, as the initial treatment changes from nonoperative for II to operative for III.
Collapse
Affiliation(s)
- Philipp Pieroh
- Department of Orthopedics, Trauma, and Plastic Surgery, University of Leipzig, Leipzig, Germany.,Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,German Pelvic Injury Register of the German Society of Traumatology (Deutsche Gesellschaft für Unfallchirurgie [DGU]) and the German Section of the AO Foundation, Berlin, Germany
| | - Andreas Höch
- Department of Orthopedics, Trauma, and Plastic Surgery, University of Leipzig, Leipzig, Germany.,German Pelvic Injury Register of the German Society of Traumatology (Deutsche Gesellschaft für Unfallchirurgie [DGU]) and the German Section of the AO Foundation, Berlin, Germany
| | - Tim Hohmann
- Department of Anatomy and Cell Biology, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Florian Gras
- German Pelvic Injury Register of the German Society of Traumatology (Deutsche Gesellschaft für Unfallchirurgie [DGU]) and the German Section of the AO Foundation, Berlin, Germany.,Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Jena, Jena, Germany
| | - Sven Märdian
- German Pelvic Injury Register of the German Society of Traumatology (Deutsche Gesellschaft für Unfallchirurgie [DGU]) and the German Section of the AO Foundation, Berlin, Germany.,Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Berlin, Germany
| | - Alexander Pflug
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Jena, Jena, Germany
| | - Silvan Wittenberg
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Berlin, Germany
| | - Christoph Ihle
- BG Trauma Center, Eberhard Karls University, Tübingen, Germany
| | - Notker Blankenburg
- Department of Orthopedics, Trauma, and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Kevin Dallacker-Losensky
- Trauma Research Group, Department of Trauma Surgery and Orthopedics, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Tanja Schröder
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Steven C Herath
- German Pelvic Injury Register of the German Society of Traumatology (Deutsche Gesellschaft für Unfallchirurgie [DGU]) and the German Section of the AO Foundation, Berlin, Germany.,Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Daniel Wagner
- German Pelvic Injury Register of the German Society of Traumatology (Deutsche Gesellschaft für Unfallchirurgie [DGU]) and the German Section of the AO Foundation, Berlin, Germany.,Department of Orthopedics and Traumatology, University Medical Center Mainz, Mainz, Germany
| | - Hans-Georg Palm
- German Pelvic Injury Register of the German Society of Traumatology (Deutsche Gesellschaft für Unfallchirurgie [DGU]) and the German Section of the AO Foundation, Berlin, Germany.,Trauma Research Group, Department of Trauma Surgery and Orthopedics, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Christoph Josten
- Department of Orthopedics, Trauma, and Plastic Surgery, University of Leipzig, Leipzig, Germany.,German Pelvic Injury Register of the German Society of Traumatology (Deutsche Gesellschaft für Unfallchirurgie [DGU]) and the German Section of the AO Foundation, Berlin, Germany
| | - Fabian M Stuby
- German Pelvic Injury Register of the German Society of Traumatology (Deutsche Gesellschaft für Unfallchirurgie [DGU]) and the German Section of the AO Foundation, Berlin, Germany.,BG Trauma Center, Eberhard Karls University, Tübingen, Germany
| |
Collapse
|
42
|
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.
Collapse
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
| | | | | | | | | | | |
Collapse
|
43
|
Zwingmann J, Eberbach H, Strohm PC, Südkamp NP, Lauritsen J, Schmal H. Decision-making, therapy, and outcome in lateral compression fractures of the pelvis - analysis of a single center treatment. BMC Musculoskelet Disord 2019; 20:217. [PMID: 31092220 PMCID: PMC6521455 DOI: 10.1186/s12891-019-2583-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 04/23/2019] [Indexed: 02/16/2023] Open
Abstract
Background Pelvic lateral compression fractures are the most stable of the unstable fractures. Therefore, decision making regarding operative or non-operative therapy is still a matter of debate. Methods Factors, influencing decision making for therapy, were explored based on prospectively collected register data of a single Level-1 trauma center. The analysis included epidemiological records such as age and gender, and injury characterizing parameters such as degree of displacement and the Injury Severity Score (ISS). In-hospital mortality and complications served as short-term outcome variables. After matching for relevant confounders, long-term results were compared between operatively and non-operatively treated patients, evaluating the Merle d’Aubigne and the EQ. 5D-3 L scores. Results Over an 11-year period (2004–14), 134 patients suffered from lateral compression fractures out of 567 pelvic fractures (33%). After excluding patients with clear indications for operation (complex pelvic fractures and pubic symphysis ruptures) and pediatric fractures, 114 patients could be included in the analysis. Sixty-one patients were treated conservatively (54%), 53 with an operation (46%). The operated patients were younger (43.7 vs 58.3 years), had higher ISS (19.9 vs 15.5 points) and fracture displacements (2.3 vs 4.9 mm) (p < 0.001 for all). The length of hospital stay was shorter in the conservatively treated group (12.7 vs 17.3 days, p < 0.02). Although the types of complications were different, the incidence was not. The mortality was less in the operated group (1.9% vs. 6.6%), however, a logistic regression analysis showed that only the ISS was an independent risk factor, but not the type of therapy. Merle d’Aubigne and EQ. 5D-3 L scores were not different in the matched cohorts. Conclusion Decision-making for operative therapy was favored in severely injured young patients with high displacement. However, short- and long-term outcomes showed no difference between operatively and non-operatively treated patients. Trial registration DRKS, no. 00000488. Registered 14th July 2010 - Retrospectively registered
Collapse
Affiliation(s)
- J Zwingmann
- Department of Orthopaedics and Trauma Surgery; Faculty of Medicine, Medical Center - Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - H Eberbach
- Department of Orthopaedics and Trauma Surgery; Faculty of Medicine, Medical Center - Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - P C Strohm
- Department of Orthopaedics and Trauma Surgery; Faculty of Medicine, Medical Center - Albert-Ludwigs-University of Freiburg, Freiburg, Germany.,Department of Orthopaedics and Traumatology, Sozialstiftung Bamberg, Klinikum am Bruderwald, Bamberg, Germany
| | - N P Südkamp
- Department of Orthopaedics and Trauma Surgery; Faculty of Medicine, Medical Center - Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - J Lauritsen
- Department of Orthopaedics and Traumatology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Sdr. Boulevard 29, 5000, Odense C, Denmark
| | - H Schmal
- Department of Orthopaedics and Trauma Surgery; Faculty of Medicine, Medical Center - Albert-Ludwigs-University of Freiburg, Freiburg, Germany. .,Department of Orthopaedics and Traumatology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Sdr. Boulevard 29, 5000, Odense C, Denmark.
| |
Collapse
|
44
|
Zhang BF, Lei JL, Zhang H, Wang PF, Wang H, Cong YX, Huang H, Zhuang Y. Use of ultrasonography for evaluation of stability of lateral compression type 1 (LC-1) pelvic fractures to assist determination of treatment strategy. J Orthop Surg Res 2019; 14:7. [PMID: 30616655 PMCID: PMC6323740 DOI: 10.1186/s13018-018-1047-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 12/21/2018] [Indexed: 11/10/2022] Open
Abstract
Background Lateral compression type1 (LC-1) pelvic fractures represent a wide spectrum of heterogeneous injuries. These include both stable and unstable patterns; however, determining whether a LC-1 fracture is stable or unstable is a challenge, and the method used to evaluate fracture stability is complicated. Methods We prospectively collected and analyzed data from 22 patients with LC-1 pelvic fractures, who underwent ultrasonography and a pelvic compression and separation test, in order to evaluate the role of ultrasonography in determining fracture stability and assist decision-making for treatment strategy. Results Twenty-two patients (15 men and 7 women) were included in the study. Following an ultrasound examination, 10 patients were classified into the stable group and 12 into the unstable group. In total, 13 patients received conservative treatment and 9 underwent surgery. At follow-up, there were no differences in fracture healing times or fracture-related complications between the two groups. The Majeed score was comparable between the two groups and most patients recovered well. There was a moderate degree of consistency in Kappa values (Kappa = 0.571, P = 0.01) between the classification of stability and the final treatment received. In addition, the sensitivity of ultrasonography was 66.67% and the specificity was 76.92%. Conclusions In conclusion, ultrasonography is a useful tool for diagnosing the stability of LC-1 pelvic fractures and assists the determination of treatment strategy. Left-right mobility ≥ 0.3 cm may be used as the criterion for determining instability. Trial registration ChiCTR-DDD-16008722.
Collapse
Affiliation(s)
- Bin-Fei Zhang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Jin-Lai Lei
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Hong Zhang
- Department of Ultrasound Medicine, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Peng-Fei Wang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Hu Wang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Yu-Xuan Cong
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Hai Huang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China
| | - Yan Zhuang
- Department of Orthopedic Trauma, Honghui Hospital, Xi'an Jiaotong University, 555 Youyi East Road, Beilin District, Xi'an, Shaanxi, China.
| |
Collapse
|
45
|
Avilucea FR, Archdeacon MT, Collinge CA, Sciadini M, Sagi HC, Mir HR. Fixation Strategy Using Sequential Intraoperative Examination Under Anesthesia for Unstable Lateral Compression Pelvic Ring Injuries Reliably Predicts Union with Minimal Displacement. J Bone Joint Surg Am 2018; 100:1503-1508. [PMID: 30180059 DOI: 10.2106/jbjs.17.01650] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Examination under anesthesia (EUA) has been used to identify pelvic instability. Surgeons may utilize percutaneous methods for posterior and anterior pelvic ring stabilization. We developed an intraoperative strategy whereby posterior fixation is performed, with reassessment using sequential EUA to determine the need for anterior fixation. Our aim in the current study was to evaluate whether this strategy reliably results in union with minimal displacement. METHODS This was a multicenter retrospective study involving adult patients with closed lateral compression (LC) pelvic ring injuries treated during the period of 2013 to 2016. Included were patients who underwent percutaneous pelvic fixation based on sequential EUA. Data points included patient demographics, injury and fixation details, and displacement as observed on follow-up radiographs. RESULTS Complete documentation was available for 74 patients (mean age, 41 years). The mean duration of follow was 11 months. Fifty-three of the patients had LC-1 injuries, 19 had LC-2 injuries, and 2 had LC-3 injuries. Twenty-five (47.2%) of the 53 patients with LC-1 and 11 (57.9%) of the 19 patients with LC-2 injuries did not undergo anterior fixation on the basis of the algorithm. The 36 LC-1 or LC-2 patients who underwent combined anterior and posterior fixation had no measurable displacement at union. Of the 36 LC-1 or LC-2 patients with no anterior fixation, 27 with unilateral rami fractures had no measurable displacement at union. The remaining 9 LC-1 or LC-2 cases with no anterior fixation had bilateral superior and inferior rami fractures; each of these patients demonstrated displacement (mean, 7.5 mm; range, 5 to 12 mm) within 6 weeks of fixation that remained until union. All patients had protected weight-bearing for 12 weeks. CONCLUSIONS A fixation strategy based on sequential intraoperative EUA reliably results in union with minimal displacement for unstable LC pelvic ring injuries. Injuries requiring combined anterior and posterior fixation healed with no displacement. Those without anterior fixation and a unilateral ramus fracture healed with no displacement. In the presence of bilateral rami fractures, even with a negative finding on sequential EUA, the pelvis healed with 7.5 mm average displacement. Surgeons may consider anterior fixation to prevent this displacement. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
| | | | | | - Marcus Sciadini
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - H Claude Sagi
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Hassan R Mir
- University of South Florida/Florida Orthopaedic Institute, Tampa, Florida
| |
Collapse
|
46
|
Thamyongkit S, Bachabi M, Thompson JM, Shafiq B, Hasenboehler EA. Use of reprocessed external fixators in orthopaedic surgery: a survey of 243 orthopaedic trauma surgeons. Patient Saf Surg 2018; 12:10. [PMID: 29930708 PMCID: PMC5991444 DOI: 10.1186/s13037-018-0156-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/26/2018] [Indexed: 11/10/2022] Open
Abstract
Background The increasing financial burden of orthopaedic implants on our health care system has prompted cost-control measures, such as implant reprocessing. The purpose of this study was to describe the current usage by orthopaedic trauma surgeons of reprocessed external fixators (EFs) for treatment of complex fractures. Methods A 16-question survey about use and perceptions of reprocessed EFs was distributed to 894 Orthopaedic Trauma Association members between August 2016 and June 2017 using a web-based survey system. Results The authors received 243 responses (27%). Thirty-seven percent of respondents reported using reprocessed EFs. Nonprofit hospitals used reprocessed EFs more commonly than did for-profit hospitals (41% vs 15%, P = .0004). Eighty-seven percent of respondents believed reprocessing could be cost-effective. The most common reason (32%) for not using reprocessed EFs was coordination/logistics of reprocessing. Concern about litigation was also reported as a main reason for not using (20%) or having recently stopped using (21%) reprocessed EFs. Conclusions Many orthopaedic traumatologists are interested in the reprocessing of EF components but few have reprocessing systems in place at their institutions. A major barrier to implementation is concern about litigation, which is likely unwarranted on the basis of Food and Drug Administration approval and a lack of previous litigation. Reprocessing by the original device manufacturers has yielded substantial savings at our institution and is an example of the cost savings that can be expected when implementing an EF reprocessing system.
Collapse
Affiliation(s)
- Sorawut Thamyongkit
- 1Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224 USA.,2Chakri Naruebodindra Medical Institute, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewi, Bangkok, 10400 Thailand
| | - Malick Bachabi
- 1Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224 USA
| | - John M Thompson
- 1Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224 USA
| | - Babar Shafiq
- 1Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224 USA
| | - Erik A Hasenboehler
- 1Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, MD 21224 USA
| |
Collapse
|
47
|
Nguyen MP, Como JJ, Golob JF, Reich MS, Vallier HA. Variation in treatment of low energy gunshot injuries - A survey of OTA members. Injury 2018; 49:570-574. [PMID: 29396308 DOI: 10.1016/j.injury.2018.01.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 11/10/2017] [Accepted: 01/17/2018] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to determine current practice patterns in the treatment of low energy gunshot wounds involving bones and joints. One hundred seventy-three Orthopaedic Trauma Association (OTA) members completed a web-based survey. The survey included practices for antibiotic therapy and operative treatment for different types of low-energy gunshot injuries. Six different scenarios of soft tissue injury, intra-articular injury, and fractures were described. Several permutations of antibiotic therapy and operative or non-operative management options were given as choices on the survey. Survey responses had a high degree of heterogeneity with only two treatment options receiving more than 50% agreement among responders: 54% agreed on joint exploration with perioperative antibiotics for gunshot wounds (GSWs) traversing a joint and 55% agreed on treating operative tibial shaft fractures from GSWs with fixation, along with debridement and irrigation of the GSW tract, and perioperative antibiotics. The majority of participants (69%) were either not aware of or not sure of an established protocol for treatment of GSW to bones and joints at their institution. Moreover, there is still wide variation in treatments among 31% of the participants who reported a protocol in place at their institutions. We conclude there is wide variation among orthopaedic surgeons in the antimicrobial prophylaxis and treatment of GSWs. Opportunity exists to develop standardized practices to minimize related infections, other complications, and costs.
Collapse
Affiliation(s)
- Mai P Nguyen
- Case Western Reserve University, Cleveland, OH, USA
| | - John J Como
- Case Western Reserve University, Cleveland, OH, USA
| | | | | | | |
Collapse
|
48
|
Dahill M, McArthur J, Roberts GL, Acharya MR, Ward AJ, Chesser TJS. The use of an anterior pelvic internal fixator to treat disruptions of the anterior pelvic ring: a report of technique, indications and complications. Bone Joint J 2017; 99-B:1232-1236. [PMID: 28860405 DOI: 10.1302/0301-620x.99b9.bjj-2016-1025.r2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 04/02/2017] [Indexed: 11/05/2022]
Abstract
AIMS The anterior pelvic internal fixator is increasingly used for the treatment of unstable, or displaced, injuries of the anterior pelvic ring. The evidence for its use, however, is limited. The aim of this paper is to describe the indications for its use, how it is applied and its complications. PATIENTS AND METHODS We reviewed the case notes and radiographs of 50 patients treated with an anterior pelvic internal fixator between April 2010 and December 2015 at a major trauma centre in the United Kingdom. The median follow-up time was 38 months (interquartile range 24 to 51). RESULTS Three patients were excluded from the analysis leaving 47 patients with complete follow-up data. Of the 47 patients, 46 achieved radiological union and one progressed to an asymptomatic nonunion. Of the remaining patients, 45 required supplementary posterior fixation with percutaneous iliosacral screws, 2 of which required sacral plating. The incidence of injury to the lateral femoral cutaneous nerve (LFCN) was 34%. The rate of infection was 2%. There were no other significant complications. Without this treatment, 44 patients (94%) would have needed unilateral or bilateral open reduction and plate fixation extending laterally to the hip joint. CONCLUSION The anterior pelvic internal fixator reduces the need for extensive open surgery and is a useful addition to the armamentarium for the treatment of anterior pelvic injuries. It is associated with injury to the LFCN in a third of patients. Cite this article: Bone Joint J 2017;99-B.1232-6.
Collapse
Affiliation(s)
- M Dahill
- Severn Deanery, Vantage Office Park, Old Gloucester Road, Bristol, BS16 1GW, UK
| | - J McArthur
- University Hospital Coventry, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - G L Roberts
- Cardiff University School of Medicine, Cardiff, UK
| | | | - A J Ward
- North Bristol NHS Trust, Bristol, UK
| | | |
Collapse
|
49
|
Zhang BF, Zhang H, Wang PF, Wang H, Lei JL, Fu YH, Cong YX, Huang H, Huo XM, Zhuang Y, Zhang K. The role of ultrasonography in examination of the stability of Tile-B2 pelvic fractures: 7 case reports and a literature review. Medicine (Baltimore) 2017; 96:e8100. [PMID: 28930856 PMCID: PMC5617723 DOI: 10.1097/md.0000000000008100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Determining whether a Tile-B2 pelvic fracture is stable is very challenging. We sought to identify the role of ultrasonography in determining the stability of Tile-B2 pelvic fractures. METHODS We collected the clinical data of patients with Tile-B2 pelvic fractures who presented at Xi'an Hong-Hui Hospital between June 1, 2016, and August 5, 2016. The treatment strategy of each patient was determined by a team of senior surgeons in the department. A single sinologist observed the movement of the fracture sites in patients during rest, under compression, and during separation to determine fracture stability. According to the pelvic fracture stability assessment, an appropriate treatment strategy was redetermined. Overall, 7 patients, including 5 women and 2 men, with Tile-B2 pelvic fractures were included in this case series. RESULTS During the initial examination, senior surgeons recommended that 2 patients should undergo internal fixation and 4 patients, conservative treatment; treatment was undecided for 1 patient. After ultrasonography examination, 4 patients underwent surgery via the Stoppa (n = 2) or ilioinguinal approach (n = 1) or cannulated screw fixation (n = 1). The rest of the patients (n = 3) received conventional treatment. Follow-up ranged from 6 to 10 months. Most of the patients showed excellent functions based on their last Majeed grading scores. There were no complications during the follow-up. Using ultrasonography examination, the preoperative treatment plan in 1 patient was changed, and the uncertain preoperative plan in 1 patient was identified. CONCLUSION Preoperative assessment of stability using ultrasonography may assist surgeons in making appropriate treatment choices for patients with Tile-B2 pelvic fractures.
Collapse
Affiliation(s)
| | - Hong Zhang
- Department of Ultrasound Medicine, Hong-Hui Hospital, Xi’an Jiao Tong University College of Medicine, Xi’an, Shaanxi Province, China
| | | | - Hu Wang
- Department of Orthopedic Trauma
| | | | | | | | | | - Xiao-Ming Huo
- Department of Ultrasound Medicine, Hong-Hui Hospital, Xi’an Jiao Tong University College of Medicine, Xi’an, Shaanxi Province, China
| | | | | |
Collapse
|
50
|
Biomechanical study of different fixation techniques for the treatment of sacroiliac joint injuries using finite element analyses and biomechanical tests. Comput Biol Med 2017; 87:250-257. [PMID: 28618337 DOI: 10.1016/j.compbiomed.2017.06.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/03/2017] [Accepted: 06/05/2017] [Indexed: 11/23/2022]
Abstract
The pelvis is one of the most stressed areas of the human musculoskeletal system due to the transfer of truncal loads to the lower extremities. Sacroiliac joint injury may lead to abnormal joint mechanics and an unstable pelvis. Various fixation techniques have been evaluated and discussed. However, it may be difficult to investigate each technique due to variations in bone quality, bone anatomy, fracture pattern, and fixation location. Additionally, the finite element method is one useful technology that avoids these variations. Unfortunately, most previous studies neglected the effects of the lumbar spine and femurs when they investigated the biomechanics of pelvises. Thus, the aim of this study was to investigate the biomechanical performance of intact, injured, and treated pelvises using numerical and experimental approaches. Three-dimensional finite element models of the spine-pelvis-femur complex with and without muscles and ligaments were developed. The intact pelvis, the pelvis with sacroiliac joint injury, and three types of pelvic fixation techniques were analyzed. Concurrently, biomechanical tests were conducted to validate the numerical outcomes using artificial pelvises. Posterior iliosacral screw fixation showed relatively better fixation stability and lower risks of implant failure and pelvic breakage than sacral bar fixation and a locking compression plate fixation. The present study can help surgeons and engineers understand the biomechanics of intact, injured, and treated pelvises. Both the simulation technique and the experimental setup can be applied to investigate different pelvic injuries.
Collapse
|