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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.
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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)
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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.
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Hempen EC, Wheatley BM, Schimoler PJ, Kharlamov A, Melvin PR, Miller MC, Altman GT, Altman DT, Westrick ER. A biomechanical comparison of superior ramus plating versus intramedullary screw fixation for unstable lateral compression pelvic ring injuries ,,. Injury 2022; 53:3899-3903. [PMID: 36182593 DOI: 10.1016/j.injury.2022.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 09/10/2022] [Accepted: 09/17/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Management of the anterior component of unstable lateral compression (LC) pelvic ring injuries remains controversial. Common internal fixation options include plating and superior pubic ramus screws. These constructs have been evaluated in anterior-posterior compression (APC) fracture patterns, but no study has compared the two for unstable LC patterns, which is the purpose of this study. METHODS A rotationally unstable LC pelvic ring injury was modeled in 10 fresh frozen cadaver specimens by creating a complete sacral fracture, disruption of posterior ligaments, and ipsilateral superior and inferior rami osteotomies. All specimens were repaired posteriorly with two fully threaded 7 mm cannulated transiliac-transsacral screws through the S1 and S2 corridors. The superior ramus was repaired with either a 3.5 mm pelvic reconstruction plate (n = 5) or a bicortical 5.5 mm cannulated retrograde superior ramus screw (n = 5). Specimens were loaded axially in single leg support for 1000 cycles at 400 N followed by an additional 3 cycles at 800 N. Displacement and angulation of the superior and inferior rami osteotomies were measured with a three-dimensional (3D) motion tracker. The two fixation methods were then compared with Mann-Whitney U-Tests. RESULTS Retrograde superior ramus screw fixation had lower average displacement and angulation than plate fixation in all categories, with the motion at the inferior ramus at 800 N of loading showing a statistically significant difference in angulation. CONCLUSION Although management of the anterior ring in unstable LC injuries remains controversial, indications for fixation are becoming more defined over time. In this study, the 5.5 mm cannulated retrograde superior ramus screw significantly outperformed the 3.5 mm reconstruction plate in angulation of the inferior ramus fracture at 800 N. No other significance was found, however the ramus screw demonstrated lower average displacements and angulations in all categories for both the inferior and superior ramus fractures.
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Affiliation(s)
- Eric C Hempen
- Department of Orthopedic Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Benjamin M Wheatley
- Department of Orthopedic Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Patrick J Schimoler
- Department of Orthopedic Surgery, Allegheny Health Network, Pittsburgh, PA, USA; Departments of Mechanical Engineering and Materials Science and Bioenginering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexander Kharlamov
- Department of Orthopedic Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Patricia R Melvin
- Department of Orthopedic Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Mark Carl Miller
- Departments of Mechanical Engineering and Materials Science and Bioenginering, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Gregory T Altman
- Department of Orthopedic Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Daniel T Altman
- Department of Orthopedic Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Edward R Westrick
- Department of Orthopedic Surgery, Allegheny Health Network, Pittsburgh, PA, USA
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Chan ACK, Chui KH, Lee KB, Li W. Three-dimensional navigation-guided percutaneous trans-symphyseal screw for mechanically unstable pubic symphysis diastasis. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2022. [DOI: 10.1177/22104917221133562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Minimally invasive trans-symphyseal screw (TSS) for pubic symphysis diastasis was recently advocated, and its feasibility and reproducibility under 3D-navigation guidance are explored. Fifteen cases between 2016 and 2021 with a background of pubic symphysis diastasis are reviewed in this case series. Twenty-two TSS were inserted with an average Injury Severity Score of 35.3. Sixty percent received a one-stage procedure including fracture reduction, intra-operative 3D imaging, and planning followed by execution. The mean operative time and blood loss were 132 minutes and 160 ml, respectively. Average fracture healing was 5.8 months with two delayed unions at 9 months. The pubic symphysis distance was maintained in all cases at 6 months post-op. The average Marjeed score, Multicenter Study Group Pelvic Outcome Score, and Numeric pain rating scale were 60.2, 6.5, and 2.7, respectively. We conclude that 3D-navigation-guided percutaneous TSS restores pelvic stability and provides satisfactory pain control, and thus a safe and effective alternative to open reduction internal fixation.
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Affiliation(s)
| | - King Him Chui
- Orthopedics and Traumatology, Queen Elizabeth Hospital, Hong Kong
| | - KB Lee
- Orthopedics and Traumatology, Queen Elizabeth Hospital, Hong Kong
| | - Wilson Li
- Orthopedics and Traumatology, Queen Elizabeth Hospital, Hong Kong
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Stine S, Washington A, Sen RK, Nasr K, Vaidya R. Pelvic Malunion: A Systematic Review, Dichotomy of Definitions and Treatment. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081098. [PMID: 36013565 PMCID: PMC9415997 DOI: 10.3390/medicina58081098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/04/2022] [Accepted: 08/11/2022] [Indexed: 11/24/2022]
Abstract
Background and Objectives: Pelvic nonunion and malunion have been documented as rare complications in pelvic fractures and literature describing these topics is severely limited. Articles dedicated solely to pelvic malunion are nearly nonexistent. We conducted a literature search with the goal of providing a summary of the definition, causes, treatment strategies, and outcomes of pelvic malunion correction. Materials and Methods: An initial review of the literature was performed using the PubMed, ScienceDirect, and Cochrane Database of Systematic Reviews databases. Search terms used were “malunion” AND “pelvic” OR “pelvis”. Duplicate articles, non-English language articles without translations available and non-human subject studies were excluded. Results: Eleven original publications were found describing experiences with pelvic malunion. Seven of the articles were exclusively dedicated to the topic of pelvic fracture malunion, and only two reported on a series of patients treated for malunion with variably staged procedures. Most reports define pelvic pain as the main indication for surgical correction, along with gait disturbance, standing or sitting imbalance, and urinary or sexual dysfunction. Radiographically, vertical displacement of one to two centimeters and rotation of the hemipelvis of fifteen degrees or more have been described in defining malunion. No treatment algorithms exist, and each patient is treated with a unique work-up and operative plan due to the complexity of the problem. Only one series reported a patient satisfaction rate of 75% following malunion treatment. Conclusions: Pelvic malunion is a rare complication of pelvic ring injury and is seldom discussed in the literature. We found two small case series reporting exclusively on malunion treatment and complications. While some of the combination studies made the distinction in the diagnosis of malunion and nonunion, they rarely differentiated the treatment outcomes between the two categories. This paper describes pelvic malunion and highlights the need for more research into surgical outcomes of treatment specifically regarding functionality, patient satisfaction, and recurrence of preoperative symptoms.
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Affiliation(s)
- Sasha Stine
- Detroit Medical Center; 3990 John R Street, Harper 7-Brush, Detroit, MI 48201, USA
- Correspondence: ; Tel.: +1-218-591-5301
| | - Austen Washington
- Detroit Medical Center; 3990 John R Street, Harper 7-Brush, Detroit, MI 48201, USA
| | - Ramesh Kumar Sen
- Max Hospital Mohali, Phase 6 Mohali (PB), Chandigarh 160055, India
| | - Kerellos Nasr
- Detroit Medical Center; 3990 John R Street, Harper 7-Brush, Detroit, MI 48201, USA
| | - Rahul Vaidya
- Detroit Medical Center; 3990 John R Street, Harper 7-Brush, Detroit, MI 48201, USA
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Herteleer M, Boudissa M, Hofmann A, Wagner D, Rommens PM. Plate fixation of the anterior pelvic ring in patients with fragility fractures of the pelvis. Eur J Trauma Emerg Surg 2021; 48:3711-3719. [PMID: 33693977 PMCID: PMC9532279 DOI: 10.1007/s00068-021-01625-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 02/16/2021] [Indexed: 11/24/2022]
Abstract
Introduction In fragility fractures of the pelvis (FFP), fractures of the posterior pelvic ring are nearly always combined with fractures of the anterior pelvic ring. When a surgical stabilization of the posterior pelvis is performed, a stabilization of the anterior pelvis is recommended as well. In this study, we aim at finding out whether conventional plate osteosynthesis is a valid option in patients with osteoporotic bone. Materials and methods We retrospectively reviewed medical charts and radiographs of all patients with a FFP, who underwent a plate osteosynthesis of the anterior pelvic ring between 2009 and 2019. Patient demographics, fracture characteristics, properties of the osteosynthesis, complications and revision surgeries were documented. Single plate osteosynthesis (SPO) at the pelvic brim was compared with double plate osteosynthesis (DPO) with one plate at the pelvic brim and one plate anteriorly. We hypothesized that the number and severity of screw loosening (SL) or plate breakage in DPO are lower than in SPO. Results 48 patients with a mean age of 76.8 years were reviewed. In 37 cases, SPO was performed, in 11 cases DPO. Eight out of 11 DPO were performed in patients with FFP type III or FFP type IV. We performed significantly more DPO when the instability was located at the level of the pubic symphysis (p = 0.025). More patients with a chronic FFP (surgery more than one month after diagnosis) were treated with DPO (p = 0.07). Infra-acetabular screws were more often inserted in DPO (p = 0.056). Screw loosening (SL) was seen in the superior plate in 45% of patients. There was no SL in the anterior plate. There was SL in 19 of 37 patients with SPO and in 3 of 11 patients with DPO (p = 0.16). SL was localized near to the pubic symphysis in 19 of 22 patients after SPO and in all three patients after DPO. There was no SL in DPO within the first month postoperatively. We performed revision osteosynthesis in six patients (6/48), all belonged to the SPO group (6/37). The presence of a bone defect, unilateral or bilateral anterior pelvic ring fracture, post-operative weight-bearing restrictions, osteosynthesis of the posterior pelvic ring, and the presence of infra- or supra-acetabular screws did not significantly influence screw loosening in SPO or DPO. Conclusion There is a high rate of SL in plate fixation of the anterior pelvic ring in FFP. In the vast majority, SL is located near to the pubic symphysis. DPO is associated with a lower rate of SL, less severe SL and a later onset of SL. Revision surgery is less likely in DPO. In FFP, we recommend DPO instead of SPO for fixation of fractures of the anterior pelvic ring, which are located in or near to the pubic symphysis.
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Affiliation(s)
- Michiel Herteleer
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Mainz, Germany.
| | - Mehdi Boudissa
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Mainz, Germany
| | - Alexander Hofmann
- Department of Traumatology and Orthopaedics, Westpfalz-Clinics Kaiserslautern, Kaiserslautern, Germany
| | - Daniel Wagner
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Mainz, Germany
| | - Pol Maria Rommens
- Department of Orthopaedics and Traumatology, University Medical Center Mainz, Mainz, Germany
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