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Kumaran P, Wier J, Hasegawa I, Patterson JT, Gary JL. Stability before and after percutaneous anterior medullary fixation of lateral compression 1 and 2 pelvic ring disruptions: Should surgeons prioritize the anterior ring? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-04037-y. [PMID: 38965132 DOI: 10.1007/s00590-024-04037-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Accepted: 06/24/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE Surgical intervention for lateral compression (LC) 1 and 2 pelvic ring fractures is controversial. Posterior ring stabilization remains the most common mode of initial fixation. However, greater mechanical instability is observed in the anterior component of LC pelvic fractures. This study tested whether reduction and percutaneous superior ramus fixation will decrease the instability of LC pelvic fractures on intraoperative fluoroscopic imaging. METHODS All adult patients (≥ 18 years) presenting with either a Young-Burgess LC1 or LC2 pelvic ring disruption treated operatively with percutaneous anterior followed by posterior fixation by a single surgeon from July 2021 to June 2023 were retrospectively reviewed. Displacement of the anterior ring to intraoperative manual internal rotation stress examination under fluoroscopy was compared before and after anterior pelvic ring reduction and fixation and prior to posterior pelvic ring fixation. Pre- and post-operative visual analog scores (VAS) for pain were also compared. RESULTS Twenty-one patients with a mean age of 48.7 years were included. Fifteen patients (71.4%) presented with an LC1, and six (28.6%) with an LC2 injury patterns. Anterior pelvic fixation alone provided 7.5mm reduction in mean displacement of the anterior pelvic ring (pre-operative = 9.2 mm vs. post-operative = 1.6 mm, p < 0.001). VAS significantly decreased from 7.2 one-day pre-operatively to 2.2 twenty-four h post-operatively (p < 0.001). CONCLUSIONS Reduction and fixation of the anterior pelvic ring prior to posterior fixation for LC1 and LC2 pelvic ring disruptions substantially improves mechanical stability on intraoperative stress examination. Combination of percutaneous anterior and posterior fixation significantly decreased VAS above the MCID 24 h after stabilization.
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Affiliation(s)
- Pranit Kumaran
- Department of Orthopedic Surgery, Keck School of Medicine of USC, 1520 San Pablo St, Ste 2000, Los Angeles, CA, 90033, USA.
| | - Julian Wier
- Department of Orthopedic Surgery, Keck School of Medicine of USC, 1520 San Pablo St, Ste 2000, Los Angeles, CA, 90033, USA
| | - Ian Hasegawa
- Department of Orthopedic Surgery, Keck School of Medicine of USC, 1520 San Pablo St, Ste 2000, Los Angeles, CA, 90033, USA
| | - Joseph T Patterson
- Department of Orthopedic Surgery, Keck School of Medicine of USC, 1520 San Pablo St, Ste 2000, Los Angeles, CA, 90033, USA
| | - Joshua L Gary
- Department of Orthopedic Surgery, Keck School of Medicine of USC, 1520 San Pablo St, Ste 2000, Los Angeles, CA, 90033, USA
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Patterson JT, Parry JA, Working ZM, McKibben NA, Baca J, Duong A, Senior J, Kim A, Marchand LS, O'Hara N. Patient Preferences for Operative Versus Nonoperative Treatment of LC1 Pelvis Fracture: A Discrete Choice Experiment. J Orthop Trauma 2024; 38:291-298. [PMID: 38442188 DOI: 10.1097/bot.0000000000002794] [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: 02/28/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVES To quantify how patients with lateral compression type 1 (LC1) pelvis fracture value attributes of operative versus nonoperative treatment. METHODS DESIGN Discrete choice experiment. SETTING Three US Level 1 trauma centers. PATIENT SELECTION CRITERIA Adult survivors of an LC1 pelvis treated between June 2016 and March 2023 were identified from institutional registries. The choice experiment was administered as a survey from March through August 2023. OUTCOME MEASURES AND COMPARISONS Participants chose between 12 hypothetical comparisons of treatment attributes including operative or nonoperative care, risk of death, severity of pain, risk of secondary surgery, shorter hospital stay, discharge destination, and independence in ambulation within 1 month of injury. The marginal utility of each treatment attribute, for example, the strength of participants' aggregate preference for an attribute as indicated by their survey choices, was estimated by multinomial logit modeling with and without stratification by treatment received. RESULTS Four hundred forty-nine eligible patients were identified. The survey was distributed to 182 patients and collected from 72 patients (39%) at a median 2.3 years after injury. Respondents were 66% female with a median age of 59 years (IQR, 34-69 years). Before injury, 94% ambulated independently and 75% were working; 41% received operative treatment. Independence with ambulation provided the highest relative marginal utility (21%, P < 0.001), followed by discharge to home versus skilled nursing (20%, P < 0.001), moderate versus severe postdischarge pain (17%, P < 0.001), shorter hospital stay (16%, P < 0.001), secondary surgery (15%, P < 0.001), and mortality (10%, P = 0.02). Overall, no relative utility for operative versus nonoperative treatment was observed (2%, P = 0.54). However, respondents strongly preferred the treatment they received: operative patients valued operative treatment (utility, 0.37 vs. -0.37, P < 0.001); nonoperative patients valued nonoperative treatment (utility, 0.19 vs. -0.19, P < 0.001). CONCLUSIONS LC1 pelvis fracture patients valued independence with ambulation, shorter hospital stay, and avoiding secondary surgery and mortality in the month after their injury. Patients preferred the treatment they received rather than operative versus nonoperative care.
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Affiliation(s)
- Joseph T Patterson
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Joshua A Parry
- Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
| | | | | | - Joseph Baca
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Andrew Duong
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Joshua Senior
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Annabel Kim
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | | | - Nathan O'Hara
- University of Maryland Medical Center, Baltimore, MD
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Yoon YC, Tucker NJ, Kim YJ, Pollard TG, Mauffrey C, Parry JA. Surgical complications after fixation of minimally displaced lateral compression type 1 pelvic ring injuries. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-03915-9. [PMID: 38573380 DOI: 10.1007/s00590-024-03915-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 03/14/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE To review surgical complications after fixation of stress-positive minimally displaced (< 1 cm) lateral compression type 1 (LC1) pelvic ring injuries. METHODS A retrospective study at a level one trauma center identified patients who received surgical fixation of isolated LC1 pelvic ring injuries. Surgical complications and additional procedures were reviewed. RESULTS Sixty patients were included. The median age was 61 years (Interquartile range 40-70), 65% (n = 39) were women, and 57% (n = 34) had high-energy mechanisms. Anterior-posterior, posterior-only, and anterior-only fixation constructs were used in 77% (n = 46), 15% (n = 9), and 8% (n = 5) of patients. Anterior fixation was performed with rami screw fixation in 82% (49/60), external fixation in 2% (1/60), and open reduction and plate fixation in 2% (1/60). There were 15 surgical complications in 23% (14/60), and 12 additional procedures in 17% (10/60). Complications included loss of reduction ≥ 1 cm (8%), symptomatic hematomas (8%), symptomatic backout of unicortical retrograde rami screws (5%), deep infection of the pelvic space after a retrograde rami screw (1.6%), and iatrogenic L5 nerve injury (1.6%). All losses of reduction involved geriatric females with distal rami fractures sustained in ground-level falls. Loss of reduction was found to be more likely in patients with low energy mechanisms (proportional difference (PD) 62%, 95% confidence interval (CI) 18% to 76%; p = 0.01) and 2 versus 1 posterior pelvic screws (PD 36%; CI 0.4% to 75%; p = 0.03). CONCLUSIONS Surgical complications and additional procedures routinely occurred after fixation of LC1 injuries. Patients should be appropriately counseled on the risks of surgical fixation of these controversial injuries. LEVEL OF EVIDENCE Diagnostic, Level III.
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Affiliation(s)
- Yong-Cheol Yoon
- Department of Orthopaedics, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Nicholas J Tucker
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St MC 0188, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Ye Joon Kim
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St MC 0188, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Tom G Pollard
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Cyril Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St MC 0188, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua A Parry
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St MC 0188, Denver, CO, USA.
- University of Colorado School of Medicine, Aurora, CO, USA.
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Kendall J, Caines A, Buckley R. Do we fix front and back of every APC pelvic injury? Injury 2024; 55:111322. [PMID: 38232475 DOI: 10.1016/j.injury.2024.111322] [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] [Indexed: 01/19/2024]
Abstract
HISTORY-A 47-year-old male was on a cliff when he jumped into the water below. He jumped about 50 feet. Upon landing in the water, he felt his legs separate and abduct violently. He was taken to the Emergency unit of the nearest trauma center and was found to have no injuries except to his pelvis. He could not weight bear because of pelvic pain but had normal distal sensory and motor exam and rectal exam. His-pelvis was painful to examination anteriorly with minor left-sided posterior SI pain, and he had no blood at his meatus. X-rays and CT were done, (Figures 1-5).
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Affiliation(s)
- John Kendall
- Foothills Hospital, 3134 Hospital Drive NW Calgary, Alberta, T2N 5A1, Canada
| | - Andrew Caines
- Foothills Hospital, 3134 Hospital Drive NW Calgary, Alberta, T2N 5A1, Canada
| | - Richard Buckley
- University of Calgary, 0490 McCaig Tower, Foothills Hospital, 3134 Hospital Drive NW Calgary, Alberta, T2N 5A1, Canada.
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Elsissy JG, Ruckle DE, LeBrun C, Johnson JP. Pelvic Ring Injuries: Stable or Not? J Am Acad Orthop Surg 2024; 32:99-107. [PMID: 37816188 DOI: 10.5435/jaaos-d-23-00470] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 08/29/2023] [Indexed: 10/12/2023] Open
Abstract
Pelvic ring injuries occur in varying severity and in vastly different patient demographics. Knowledge regarding which of these injuries require surgical intervention and which can be managed nonsurgically continues to evolve. Previous studies have shown validated criteria for sacral fractures and the posterior ring, explored the role of examination under anesthesia, and other forms of dynamic imaging. Although there is substantial information available, a comprehensive synthesis of this information is lacking. This article provides a comprehensive review of radiographic markers suggestive of stability, discusses treatment strategies, and proposes a treatment algorithm that is easily understood and applicable to not only those with a trauma background but also the general orthopaedic surgeon who will see these injuries frequently while on call.
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Affiliation(s)
- Joseph G Elsissy
- From the Department of Orthopedic Surgery (Elsissy), Chief of Orthopaedic Traumatology, Arrowhead Regional Medical Center, Colton, CA, the Department of Orthopedic Surgery (Ruckle), Loma Linda University Health Loma Linda, CA, the Department of Orthopedic Surgery (LeBrun), Chief of Orthopaedic Traumatology, Riverside Community Hospital, Riverside, CA, and the Department of Orthopedic Surgery (Johnson), University of Alabama at Birmingham, Birmingham, AB
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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] [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.
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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
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Hasegawa IG, Gary JL. Intraoperative Imaging Challenges During Pelvic Ring Disruptions and Acetabular Fracture Surgery. Orthop Clin North Am 2024; 55:73-87. [PMID: 37980105 DOI: 10.1016/j.ocl.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Achieving high-quality intraoperative imaging is crucial for successful pelvic ring and acetabular fracture surgery, yet it remains clinically challenging. Due to the complex anatomy of the pelvic ring and acetabulum, it is necessary to obtain multiple images oriented in different planes to reliably confirm reduction accuracy and implant positioning. Intraoperative image quality can be compromised by factors such as patient body habitus, bowel gas, abdominal packing, contrast dye, and nonstandardized language between surgeon and radiology technician. This article reviews common intraoperative imaging challenges encountered during pelvic ring and acetabular fracture surgery, while providing practical and evidence-based solutions and prevention strategies.
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Affiliation(s)
- Ian G Hasegawa
- Keck School of Medicine of USC, 1520 San Pablo Street. HC2 - Suite 2000, Los Angeles, CA 90033, USA
| | - Joshua L Gary
- Keck School of Medicine of USC, 1520 San Pablo Street. HC2 - Suite 2000, Los Angeles, CA 90033, USA.
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Patterson JT, Mayfield CK, Gary JL, Chung P, Hasegawa IG, Becerra JA. Pelvic binder radiography detects occult instability in cadaveric simulated lateral compression type I (LC1) pelvic fractures. Injury 2023; 54:111067. [PMID: 37777368 DOI: 10.1016/j.injury.2023.111067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Abstract
OBJECTIVES Occult instability in minimally displaced lateral compression (LC) pelvic ring injuries may have clinical relevance for treatment. We describe two novel LC pelvis fracture stress examinations - pelvic binder stress radiography (PBR) and pelvic binder stress bladder manometry (PBM) - which do not require sedation, anesthesia, patient transport, or radiation of personnel. METHODS A biomechanical study was performed with five fresh elderly cadavers. Sequential osteotomies of the pelvis simulated increasingly unstable LC pelvis fracture patterns (OTA/AO 61A2.2, 61B1.1a, 61B1.1b, 61B2.1). Compressive force was quantitatively applied using a pelvic binder and scale. Pelvis fracture displacement was measured on AP and inlet fluoroscopic views. Pelvic bladder pressure (PBM) was measured using a Foley catheter as a water column. RESULTS Fracture displacement strongly correlated with force applied (R2=0.600-0.963). PBR discriminated between simulated LC injuries. Mean displacement of 61B1.1b injuries >1cm was observed at 3.8kg on AP view and 5kg on inlet view. Mean displacement of 61B1.1a injuries >1cm was observed at 8.2kg on AP view and 9.3kg on inlet view. 61A2.2 injuries did not displace >1cm at forces up to 10kg. >95% of 61B1.1a and 61B1.1b injuries displaced >1cm at 10kg. PBM moderately correlated with force applied (R2=0.517-0.842) but did not discriminate between LC injuries. CONCLUSIONS PBR is feasible, precisely quantified occult mechanical instability in simulated LC pelvis fractures in response to reproducible applied force, and discriminated between simulated LC pelvis fractures. PBM did not discriminate between simulated LC fractures. A clinical trial to validate the safety and efficacy of PBR for assessing occult instability in LC pelvis fracture is warranted.
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Affiliation(s)
- Joseph T Patterson
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery.
| | - Cory K Mayfield
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Joshua L Gary
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Phillip Chung
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Ian G Hasegawa
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
| | - Jacob A Becerra
- Keck School of Medicine of the University of Southern California, Department of Orthopaedic Surgery
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Saiz A, Lee C, DeKeyser G, Morellato J, Patterson J, Parry JA, Haller J, Marchand L, Wharton M, Tucker N, Kellam P, Shymon S, Warner S, Kim Y, Working Z. Fracture displacement of lateral compression type 1 (LC1) Pelvic Ring Injuries: Which measurement methods are reliable and does displacement correlate with adverse events? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03776-8. [PMID: 37991594 DOI: 10.1007/s00590-023-03776-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/26/2023] [Indexed: 11/23/2023]
Abstract
PURPOSE To determine the interobserver reliability of perceived displacement (PD) ≥ 1 cm of lateral compression type 1 (LC1) pelvic ring fractures and to determine if PD correlated with published methods of measuring fracture displacement and adverse events. METHODS The injury and follow-up radiographs of 10 patients with nonoperative minimally displaced LC1 injuries were reviewed by 27 orthopaedic trauma surgeons to determine if they perceived an interval fracture displacement ≥ 1 cm. Perceived displacement (PD) was compared to 11 measurements of displacement: the difference in heights of iliac crests (IC), sourcils, and ischial tuberosities on AP/outlet radiographs; the distance from femoral head (FH) to the sacral midline and the distance between the radiographic teardrops (TD) on the AP; the distance from the TD to sacral midline and the difference in distances between the SI joints and the contralateral TD on the inlet. The interobserver reliability and correlation of PD and measured displacement was calculated. The association between PD and adverse events was also evaluated. RESULTS PD had weak interobserver reliability (kappa = 0.46). Many of the measurements of displacement were poorly sensitive for PD. The magnification-corrected AP TD measurement had the highest sensitivity (100%) for PD and excellent interobserver reliability (Intraclass correlation 0.97), but had a low specificity (57.1%). All three patients with PD had adverse events while patients without PD had uneventful recoveries (p = 0.008). CONCLUSIONS The AP TD measurement detected all cases of PD and had excellent reliability. PD was associated with adverse events, suggesting that accurate and reliable measurements of displacement are warranted. LEVEL OF EVIDENCE III Diagnostic.
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Rojas C, Munjin A, Delgado G, Ewertz E. Diagnostic accuracy of MRI for detection of occult instability of type I anterior to posterior pelvic injuries. Injury 2023; 54 Suppl 6:110806. [PMID: 38143131 DOI: 10.1016/j.injury.2023.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 12/26/2023]
Abstract
Type I Young and Burgess anterior posterior compression (APC) pelvic injuries have been classically managed non operatively due to theoretical integrity of sacroiliac joint ligaments (SIJL), though examination under anesthesia (EUA) has been proven occult mechanical instability in up to 50% of these injuries. We sought to determine the diagnostic accuracy of magnetic resonance (MRI) for detection of occult instability on APC-I injuries when compared to EUA. METHODS Diagnostic test study of prospectively recruited patients admitted with APC-I pelvic injuries between 2015 and 2022. All patients consented to participate in this study were subjected to MRI and EUA. The evaluators of each of these tests were blinded. On MRI evaluation, SIJL were considered compromised when unilateral injury to anterior SIJL was visualized in three or more consecutive images or in bilateral injuries, when injury to the anterior SIJL in two or more consecutive images on each side was observed. Positive EUA was considered a symphyseal diastasis over 25 mm on stress fluoroscopy. Demographic data was collected as recruited and sensitivity, specificity, accuracy, and positive and negative predictive values were calculated. Confidence interval was set at 95%. EUA was considered the gold standard in statistical analysis. RESULTS A total of 32 patients mean aged 36 (24-61) years were included. Mean symphyseal diastasis at admission was 17.58 (11 - 25) mm. The median time from injury to EUA was 5 (0-21) days. Positive EUA was observed on 20 patients and 25 patients presented compromised SIJL. MRI presented a sensitivity of 95% (75.13% - 99.87%), specificity of 50% (21.09% - 78.91%), positive-predictive value of 73% (60.61% to 82.93%), negative-predictive value of 87% (48.66% - 98.08%). CONCLUSION Injury to SIJL on MRI presented an accuracy of 77% (58.29% - 89.64%) for the detection of occult pelvic instability on EUA.
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Affiliation(s)
- Claudio Rojas
- Hospital del Trabajador de Santiago, Department of orthopaedic surgery. Ramón Carnicer 185, Santiago 7501239, Chile
| | - Aleksandar Munjin
- Hospital del Trabajador de Santiago, Department of orthopaedic surgery. Ramón Carnicer 185, Santiago 7501239, Chile
| | - Gonzalo Delgado
- Hospital del Trabajador de Santiago, Department of orthopaedic surgery. Ramón Carnicer 185, Santiago 7501239, Chile
| | - Ernesto Ewertz
- Hospital del Trabajador de Santiago, Department of orthopaedic surgery. Ramón Carnicer 185, Santiago 7501239, Chile.
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Tucker NJ, Scott BL, Heare A, Stacey S, Mauffrey C, Parry JA. Early Outcomes of Operative Versus Nonoperative Management of Stress-Positive Minimally Displaced Lateral Compression Type 1 Pelvic Ring Injuries. J Orthop Trauma 2023; 37:506-512. [PMID: 37296089 DOI: 10.1097/bot.0000000000002642] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To compare the early outcomes of patients with stress-positive minimally displaced lateral compression type 1 (LC1b) pelvic ring injuries managed with or without operative fixation. DESIGN Retrospective comparison study. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS Forty-three patients with LC1b injuries. INTERVENTION Operative versus nonoperative. MAIN OUTCOME MEASUREMENTS Discharge to subacute rehabilitation (SAR); 2- and 6-week pain visual analog score, opioid use, assistive device use, percentage of normal single assessment numerical evaluation, SAR status; fracture displacement; and complications. RESULTS The operative group did not differ in age, gender, body mass index, high-energy mechanism, dynamic displacement stress radiographs, complete sacral fractures, Denis sacral fracture classification, Nakatani rami fracture classification, follow-up length, or American Society of Anesthesiologists classification. The operative group was less likely to be using an assistive device at 6 weeks [observed difference (OD) -53.9%, 95% confidence interval (CI) -74.3% to -20.6%, OD/CI 1.00, P = 0.0005], less likely to remain in an SAR at 2 weeks (OD -27.5%, CI, -50.0% to -2.7%, OD/CI 0.58, P = 0.02), and had less fracture displacement at follow-up radiographs (OD -5.0 mm, CI, -9.2 to -1.0 mm, OD/CI 0.61, P = 0.02). There were no other differences in outcomes between treatment groups. Complications occurred in 29.6% (n = 8/27) of the operative group compared with 25.0% (n = 4/16) of the nonoperative group resulting in 7 and 1 additional procedures, respectively. CONCLUSIONS Operative treatment was associated with early benefits over nonoperative management, including shorter time using assistive devices, less SAR use, and less fracture displacement at follow-up. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nicholas J Tucker
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
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Lawson MM, Rodgers FL, Ramsey DC, Friess DM, Working ZM. Post Post-Mobilization Films for LC1 Pelvic Ring Injuries: Follow up Stress Imaging Demonstrates Minimal Utility. J Orthop Trauma 2023; 37:513-518. [PMID: 37296088 DOI: 10.1097/bot.0000000000002643] [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: 05/30/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To assess the utility of outpatient postmobilization radiographs in the nonoperative treatment of lateral compression type I (LC1) (OTA/AO 61-B1) pelvic ring injuries. DESIGN Retrospective series. SETTING Academic, Level 1 trauma center, 2008-2018. PATIENTS/PARTICIPANTS A series of 173 patients with nonoperatively treated LC1 pelvic ring injuries was identified. Of these, 139 received a complete set of outpatient pelvic radiographs with which to assess displacement. INTERVENTION Outpatient pelvic radiographs to assess additional fracture displacement and potential need for surgical intervention. MAIN OUTCOME MEASUREMENTS Rate of conversion to late operative intervention based on radiographic displacement. RESULTS No patient in this cohort received late operative intervention. A majority of the patients sustained incomplete sacral fractures (82.6%) and unilateral rami fractures (75.1%), and 92.8% demonstrated less than 10 mm of displacement on their final radiographs. CONCLUSIONS There is a low utility of repeat outpatient radiographs of stable, nonoperative LC1 pelvic ring injuries as they do not undergo late displacement. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michelle M Lawson
- Department of Orthopaedics and Rehabilitation, Oregon Health and Science University, Portland, OR
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Brown M, Simister S, Paul A, Helmkamp J, McGowan S, DeBaun M. Bilateral Sacroiliac Joint Dislocation, Discussion and Surgical Strategies: A Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00008. [PMID: 37831804 DOI: 10.2106/jbjs.cc.23.00389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
CASE A 16-year-old male patient presented with isolated bilateral sacroiliac (SI) joint dislocation. In this report, we discuss the presentation and focus on strategies for operative reduction and fixation for this rare injury. CONCLUSION In conclusion, we present a case of a bilateral ligamentous SI joint dislocation in an adolescent. The patient was reduced in the supine position with a sacral bump and bilateral traction with direct and indirect reduction aids inserted through a lateral window. Bilateral SI screws stabilized the pelvis, facilitating uncomplicated healing.
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Affiliation(s)
- Matthew Brown
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Samuel Simister
- School of Medicine, University of Utah, Salt Lake City, Utah
| | - Alexandra Paul
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Joshua Helmkamp
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Sean McGowan
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Malcolm DeBaun
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
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14
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Flanagan CD, Fairchild R, McCaskey M, Sajid MI, Watson D, Mir H. Union and displacement characteristics following percutaneous screw fixation of superior pubic rami fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03681-0. [PMID: 37742300 DOI: 10.1007/s00590-023-03681-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/06/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE To determine union and displacement metrics following percutaneous screw fixation (antegrade or retrograde) of superior pubic rami fractures. METHODS This is a retrospective cohort study from a single level 1 trauma center. Skeletally mature patients with at least one superior pubic ramus fracture present as part of a lateral compression-type pelvic ring injury were included. RESULTS Eighty-five (85) patients with 95 superior pubic rami fractures met the study's inclusion criteria. LC1, LC2, and LC3 injuries occurred in 76.5%, 15.3%, and 8.2% of patients, respectively. The majority of patients underwent concurrent posterior pelvic ring fixation (94.1%). Superior ramus screw placement occurred predominantly via retrograde technique (81.1%) with cannulated screws of size 6.5 mm or larger (93.7%). Of the 95 eligible fractures, 90 (94.7%) achieved union at a mean of 14.0 weeks (7-40 weeks). Of these united fractures, 69 (76.7%) healed with no measurable displacement, while the remaining 23.3% healed with residual mean displacement of 3.9 mm (range: 0.5-9.0 mm). Multivariable analysis demonstrated a positive association between age (p = 0.04) and initial displacement (p = 0.04) on the final degree of residual displacement at union. A Kaplan-Meier survival analysis identified increased age to be significantly related to increased time to union (X2 (2) = 21.034, p < 0.001). CONCLUSIONS Union rates following percutaneous screw fixation of superior pubic rami fractures associated with lateral compression-type pelvic ring injuries approach 95%. Though minimal in an absolute sense, increasing age and a greater degree of initial displacement may influence the final degree of residual displacement at union. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Christopher D Flanagan
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, Florida Orthopaedic Institute, University of South Florida , 5 Tampa General Circle, Suite 710, Tampa, FL, 33606, USA
| | - Ryan Fairchild
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, Florida Orthopaedic Institute, University of South Florida , 5 Tampa General Circle, Suite 710, Tampa, FL, 33606, USA
| | - Meghan McCaskey
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, Florida Orthopaedic Institute, University of South Florida , 5 Tampa General Circle, Suite 710, Tampa, FL, 33606, USA
| | - Mir Ibrahim Sajid
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, Florida Orthopaedic Institute, University of South Florida , 5 Tampa General Circle, Suite 710, Tampa, FL, 33606, USA
| | - David Watson
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, Florida Orthopaedic Institute, University of South Florida , 5 Tampa General Circle, Suite 710, Tampa, FL, 33606, USA
| | - Hassan Mir
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, Florida Orthopaedic Institute, University of South Florida , 5 Tampa General Circle, Suite 710, Tampa, FL, 33606, USA.
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15
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Eastman JG, Warner SJ, Saiz AM, Bravin DA, Chip Routt ML. Imaging of Pelvic and Acetabular Trauma: Part 1, Osseous Findings. J Am Acad Orthop Surg 2023; 31:e694-e705. [PMID: 37476846 DOI: 10.5435/jaaos-d-23-00112] [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] [Received: 03/15/2023] [Accepted: 06/07/2023] [Indexed: 07/22/2023] Open
Abstract
Pelvic ring injuries and acetabular fractures are complex injuries and are often challenging to treat for a number of reasons. Orthopaedic trauma surgeons critically evaluate pelvic radiographs and CT images to generate an appropriate detailed injury and patient-specific preoperative plan. There are numerous crucial osseous details that surgeons should be aware of. Often, some of the most important factors that affect patients in treatment timing decisions, assessing reduction strategies, and deciding and inserting fixation constructs may be subtle on preoperative imaging. The radiographic and CT imaging findings covered subsequently should be sought out and appreciated preoperatively. Combining all the available osseous information helps the surgeon predict potential pitfalls and adjust surgical plans before incision. Ensuring a methodical and meticulous imaging review allows for the development of a detailed preoperative plan and helps avoid intraoperative missteps. This process will inherently streamline the surgical procedure and optimize the patient's surgical care. Maximizing the accuracy of the preoperative planning process can streamline the treatment algorithm and ultimately contribute to the best possible clinical outcome.
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Affiliation(s)
- Jonathan G Eastman
- From the Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, McGovern Medical School and Memorial Hermann Medical Center, Houston, TX (Eastman, Warner, and Chip Routt), the Department of Orthopaedic Surgery, University of California, Davis Medical Center, Sacramento, CA (Saiz), and the Department of Orthopaedic Surgery, University of Missouri, Springfield, MO (Bravin)
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16
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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.
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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.
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17
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Haase DR, Saiz AM, Warner SJ, Routt MLC, Eastman JG. Oblique anterior pelvic external fixator for intraoperative reduction of rotationally unstable pelvic ring injuries. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03648-1. [PMID: 37486418 DOI: 10.1007/s00590-023-03648-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023]
Abstract
Incomplete sacroiliac joint injuries are often associated with external rotation and extension deformities on the injured hemipelvis. To appropriately correct this deformity, an oblique reduction force from caudal to cranial and lateral to medial is helpful. These injuries are often associated with traumatic disruption of the pubic symphysis. However, in injuries without traumatic disruption to the pubic symphysis, a two-pin oblique anterior external fixator can be used to obtain and maintain reduction of the sacroiliac joint, while percutaneous fixation is subsequently placed. Through a small case series and three specific patient examples, we demonstrate that the oblique anterior external fixator frame is a simple and effective strategy with the reduction and stabilization process of these multiplanar hemipelvis deformities.
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Affiliation(s)
- Douglas R Haase
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, McGovern Medical School and Memorial Hermann Medical Center, 6400 Fannin St, Suite 1700, Houston, TX, USA
| | - Augustine M Saiz
- Department of Orthopaedic Surgery, University of California Davis Health, Sacramento, CA, USA
| | - Stephen J Warner
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, McGovern Medical School and Memorial Hermann Medical Center, 6400 Fannin St, Suite 1700, Houston, TX, USA
| | - Milton L Chip Routt
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, McGovern Medical School and Memorial Hermann Medical Center, 6400 Fannin St, Suite 1700, Houston, TX, USA
| | - Jonathan G Eastman
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, McGovern Medical School and Memorial Hermann Medical Center, 6400 Fannin St, Suite 1700, Houston, TX, USA.
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18
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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.
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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
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19
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Tucker NJ, Scott B, Mauffrey C, Parry JA. Geriatric Patients Presenting With Isolated Pubic Rami Fractures and Inability to Mobilize May Have Occult Lateral Compression Pelvic Ring Injuries With Dynamic Instability. J Orthop Trauma 2023; 37:356-360. [PMID: 36696401 DOI: 10.1097/bot.0000000000002576] [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: 01/20/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To determine the incidence of patients with isolated pubic rami fractures on computed tomography scans who have dynamic instability secondary to occult lateral compression pelvic ring injuries. DESIGN Retrospective comparison study. SETTING Urban level 1 trauma center. PATIENTS/PARTICIPANTS This study included geriatric patients with isolated pubic rami fractures and inability to mobilize secondary to pain. INTERVENTION Lateral stress radiographs of pelvis to evaluate for ≥1 cm dynamic instability. MAIN OUTCOME MEASUREMENTS Physical therapy clearance, hospital length of stay, and discharge location. RESULTS A total of 19 patients were identified over 12 months. Patients were predominantly geriatric (median age: 75 years, interquartile range: 67 to 90), woman (11/19), with unilateral (17/19) comminuted distal rami fractures (12/19) sustained in ground-level falls (12/19). Dynamic instability was identified in 42% of patients (8/19). Magnetic resonance imaging, obtained in 6 of these patients, demonstrated occult posterior ring fractures in all cases. Patients with dynamic instability were more likely to have comminuted distal rami fractures (Nakatani type 1b) and a longer hospital length of stay. There was also a trend for these patients to be unable to clear physical therapy by discharge (63% (5/8) versus 36% (4/11)). The 90-day mortality rate of the cohort was 16% (3/19). CONCLUSIONS Patients presenting with seemingly isolated pubic rami fractures on radiographs and computed tomography scans who are unable to mobilize may have occult lateral compression injuries with dynamic instability. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nicholas J Tucker
- Department of Orthopaedics, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO
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20
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Keltz E, Keren Y, Jain A, Stephens T, Rovitsky A, Ghrayeb N, Norman D, Peled E. Surgical stabilisation in equivocal pelvic ring injuries - Into the grey zone. Injury 2023; 54:110887. [PMID: 37453290 DOI: 10.1016/j.injury.2023.110887] [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: 01/06/2023] [Revised: 06/07/2023] [Accepted: 06/11/2023] [Indexed: 07/18/2023]
Abstract
Pelvic ring injuries comprise a spectrum of bony, ligamentous and muscular injuries, described by several common classification systems. However, the majority of injuries lie in areas of intermediate severity, where complexity and variable nature make it extremely hard to define in detail. This fact and associated injuries make it extremely difficult to conduct randomised control trials, with purpose to direct treatment guidelines. Thus, special interest and expertise are required by pelvic trauma surgeons, while surgical indications and fixation methods rely on their experience, at least in part. Namely, a significant grey zone of indication exists. As fixation methods evolve, specifically percutaneous fixation using osseous fixation pathways, some injuries in which morbidity bound with surgical fixation was considered too high relative to its benefits, may be considered eligible for surgical treatment nowadays. Moreover, due to significant progress in the treatment of the acute polytrauma casualties, the survival rate increased over the years, emphasizing the effect of long-term morbidity and functional outcome of pelvic ring injuries. The purpose of this manuscript is to describe the equivocal areas of controversies, hence "the grey zone", and to provide the readership with up-to-date published data. We aimed to collect and detail clinical and radiological clues in the diagnosis of intermediate unstable anterior-posterior compression and lateral compression injuries, and for the selection of treatment methods and sequence. Recent publications have provided some insights into specific injury features that are correlated with increased chance of instability, pain and delay in ambulation. Specific focus is given to the utility of examination under anaesthesia in selected cases. Other publications surveyed the shared experience of pelvic trauma surgeons as for the classification, indication and treatment sequence of pelvic ring injuries. Although the data hasn't matured yet to a comprehensive treatment algorithm, it may serve clinicians well when making treatment decisions in the grey zone of pelvic ring injuries, and serve as a basis for future prospective studies.
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Affiliation(s)
- Eran Keltz
- Department of Orthopedic Surgery, Alfred Health, Melbourne, Victoria, Australia.
| | - Yaniv Keren
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Arvind Jain
- Department of Orthopedic Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Terry Stephens
- Department of Orthopedic Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Alexey Rovitsky
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Nabil Ghrayeb
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Doron Norman
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Eli Peled
- Division of Orthopedic Surgery, Rambam Health Care Campus, Haifa, Israel
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21
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DeKeyser GJ, Taylor MA, Allen JD, Firoozabadi R, Githens M, Kleweno CP. The EMS stress view: occult pelvic instability revealed by pre-hospital pelvic binder placement. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03601-2. [PMID: 37289243 DOI: 10.1007/s00590-023-03601-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 05/23/2023] [Indexed: 06/09/2023]
Abstract
PURPOSE To describe and evaluate the serendipitous pelvic binder stress radiographs of lateral compression type (LC) pelvic ring injuries. METHODS This was a retrospective case series performed at a single, level I academic trauma center from 2016 to 2018. All patients presenting with a minimally displaced LC pelvic ring injury were reviewed (< 10 cm displacement on static pelvic radiographs). Patients with X-rays (XR) in a pelvic binder (EMS stress) and with the pelvic binder removed were included. Pelvic ring stability was determined by attending surgeon evaluation of EMS stress radiographs versus static XR of the pelvis. Patients were treated non-operatively and allowed to weight bear or taken to the operating room for exam under anesthesia (EUA) and potential operative fixation. Clinical success of treatment was determined by evaluation of further displacement at the completion of their most recent follow-up. RESULTS Thirty-seven patients of the initial 398 reviewed met inclusion criteria. Fourteen of 37 patients (38%) were categorized as stable with no significant pelvis displacement seen on EMS stress and were treated non-operatively without further sequelae (4.6 months mean follow-up). The remaining 23/37 (62%) were treated operatively. Occult instability was identified on EMS stress in 14 (61%) of those 23 patients and the remainder were determined to be unstable based upon fracture pattern or EUA. All patients went on to successful treatment without significant pelvic deformity (7.8 months mean follow-up). CONCLUSION The EMS stress XR is a valuable, opportunistic evaluation in LC pelvic ring injuries. This evaluation is a useful diagnostic adjunct to alert the provider that additional stress imaging may be indicated to evaluate for occult pelvic ring instability.
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Affiliation(s)
- Graham J DeKeyser
- Department of Orthopaedic Surgery, Oregon Health & Sciences University, Portland, OR, USA
| | - Mario A Taylor
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA
| | - Jerad D Allen
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA, USA
| | - Reza Firoozabadi
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA
| | - Michael Githens
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA
| | - Conor P Kleweno
- Department of Orthopedics and Sports Medicine, Harborview Medical Center, 325 9th Ave, Box 359798, Seattle, WA, 98104, USA.
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22
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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.
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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
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23
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Polmear MM, Nicholson TC, Blair JA, Thabet AM, Adler AH, Rajani R. Injuries Sustained With Falls From Height in Crossing the United States-Mexico Border at a Level I Trauma Center: A Prospective Cohort Study. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202306000-00004. [PMID: 37285513 DOI: 10.5435/jaaosglobal-d-23-00005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/04/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION The US Department of Homeland Security has reported increases in encounters and apprehensions at the US Southwest border for the past several years. The purposes of this study were to assess the demographics, patterns of injuries, and surgical interventions, associated with falls from height along the US-Mexico border. METHODS A prospective cohort study was conducted at a Level I trauma center from January 2016 through December 2021 of all patients who fell from height crossing the US-Mexico border and presented with injuries requiring admission. RESULTS A total of 448 patients were admitted with a median age of 30 years (interquartile range [IQR] 16, range 6 to 65). Monthly frequency of admissions increased markedly with a median of 18.5 (IQR 5.3) in 2021. Patients presented with limited health data, and comorbidities were identified in 111 patients (24.7%). Median height fallen was 5.5 m (18 ft). Patients sustaining a fall from ≥ 5.5 m were markedly more likely to have an Injury Severity Score (ISS) of > 15. Median length of stay was 9 days (IQR 11). There were a total of 1,066 injuries with 723 extremity and pelvic; 236 spine; and 107 head or neck, face, thorax, or abdominal injuries. Median ISS was 9.0 (IQR 7, range 1 to 75, 33% > 15). Tibial plafond fracture and spine injury were markedly associated with longer lengths of stay and ISS > 15. All injuries resulted in 635 separate surgical events and 930 procedures. Clinical follow-up occurred in 55 patients (12.2%), with median duration of 28 days (range 6 days to 8 months). DISCUSSION Injuries associated with border crossings and falls from height were serious and increased in frequency. As the US policy on border security evolves, surgeons in these regions should be prepared to handle the associated injuries and sequelae. Prevention of these serious and debilitating injuries should be undertaken to decrease the burden of disease.
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Affiliation(s)
- Michael M Polmear
- From theDepartment of Orthopaedic Surgery, Texas Tech University Health Sciences Center El Paso, El Paso, Texas (Dr. Polmear, Dr. Nicholson, Dr. Thabet, Dr. Adler, and Dr. Rajani); the Department of Orthopaedic Surgery, Medical College of Georgia at Augusta University, Augusta, GA (Dr. Blair)
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24
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Arthur RY, Johnson JP. Surgical treatment of sacral nonunions. Injury 2023:S0020-1383(23)00406-0. [PMID: 37179204 DOI: 10.1016/j.injury.2023.05.006] [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: 12/21/2022] [Revised: 04/25/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Abstract
Sacral fractures are complex injuries that follow a bimodal distribution, typically involving acute high energy trauma in young adults and low energy trauma in older adults (> 65 years old). Nonunion is a rare but debilitating potential complication of undiagnosed or improperly managed sacral fractures. Various surgical techniques, including open reduction and internal fixation, sacroplasty, and percutaneous screw fixation, have been used to manage these fracture nonunions. In addition to reviewing the initial management of sacral fractures and the risk factors for fracture nonunion, this article describes techniques, specific cases and outcomes of these treatment strategies.
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Affiliation(s)
- Rodney Y Arthur
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 510 20th St South, Faculty Office Tower 901, Birmingham, AL 35294, USA
| | - Joey P Johnson
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, 510 20th St South, Faculty Office Tower 901, Birmingham, AL 35294, USA.
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Djaja YP, Silitonga J, Dilogo IH, Mauffrey OJ. The management of pelvic ring fractures in low-resource environments: review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:515-523. [PMID: 36333484 DOI: 10.1007/s00590-022-03420-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022]
Abstract
Although improvement of pelvic trauma care has been successful in decreasing mortality rates in major trauma centers, such changes have not been implemented in low-resource environments such as low-middle-income countries (LMICs). This review details the evaluation and management of pelvic ring fractures and recommends improvements for trauma care in low-resource environments. Prehospital management revolves around basic life support techniques. Application of non-invasive pelvic circumferential compression devices, such as bed sheet or pelvic binders, can be performed as early as the scene of the accident. Upon arrival at the emergency department, rapid clinical evaluation and immediate resuscitation should be performed. Preperitoneal pelvic packing and external fixation devices have been considered as important first-line management tools to achieve bleeding control in hemodynamically unstable patients. After patient stabilization, immediate referral is mandated if the hospital does not have an orthopedic surgeon or facilities to perform complex pelvic/acetabular surgery. Telemedicine platforms have emerged as one of the key solutions for informing decision-making. However, unavailable referral systems and inaccessible transportation systems act as significant barriers in LMICs. Tendencies toward more "old-fashioned" protocols and conservative treatments are often justified especially for minimally displaced fractures. But when surgery is needed, it is important to visualize the fracture site to obtain and maintain a good reduction in the absence of intraoperative imaging. Minimizing soft tissue damage, reducing intraoperative blood loss, and minimizing duration of surgical interventions are vital when performing pelvic surgery in a limited intensive care setting.
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Affiliation(s)
- Yoshi Pratama Djaja
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia.
| | - Jamot Silitonga
- Department of Orthopaedic and Traumatology, Fatmawati General Hospital, Jakarta, Indonesia
| | - Ismail Hadisoebroto Dilogo
- Department of Orthopaedic and Traumatology, Rumah Sakit Umum Pusat Nasional Dr Cipto Mangunkusumo, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Océane J Mauffrey
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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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.
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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
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Hussain Z, Parmeshwar SS, Jain A, Chandra A. Use of calcaneal plates in the treatment of posterior pelvic ring injuries and displaced iliac blade fractures- A case series. J Clin Orthop Trauma 2023; 37:102091. [PMID: 36632341 PMCID: PMC9827374 DOI: 10.1016/j.jcot.2022.102091] [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: 02/22/2022] [Revised: 09/26/2022] [Accepted: 12/29/2022] [Indexed: 01/01/2023] Open
Abstract
Introduction The operative fixation of pelvic ring injuries and associated acetabulum fractures presents a challenging scenario to most of the orthopaedic trauma surgeons. Current development of anatomically contoured reconstruction (ACR) plates gained popularity in fixing complex pelvic ring fractures. This study was done to assess the functional and radiological outcomes using of lateral wall stainless steel (LWSS) calcaneal plates in posterior pelvic ring injuries and displaced iliac blade fractures. Materials and methods Retrospectively selected eight cases of pelvic ring injuries planned for fixing posterior pelvic instability and iliac blade fractures using LWSS plates. Mean follow-up was 18 months (Range 12-26 months). Results Average time for radiological bony union achieved in 18 weeks (Range 13-22). Seven patients returned to their normal work. Average Majeed score was 60 (Range 50-68). Mean duration of surgery was 160 min (Range 120-200). Conclusion This technique can be routinely used as supplementary fixation for posterior pelvic ring instability and iliac blade fractures. LWSS calcaneal plates showed no screw breakage or implant failure. Further this technique was cost effective in developing countries with limited resources.
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Affiliation(s)
- Zakir Hussain
- Department of Orthopaedics, SMS Medical College, Jaipur, Rajasthan, India
| | | | - Amit Jain
- Department of Orthopaedics, SMS Medical College, Jaipur, Rajasthan, India
| | - Abhishek Chandra
- Department of Trauma Surgery, AIIMS Rishikesh, Uttarakhand, India
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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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Wakefield SM, Giannoudis V, Messori M, Giannoudis PV. Atypical APC-1 pelvic fracture presenting with pelvic instability: successful management with pubic symphysis fusion. BMJ Case Rep 2022; 15:15/12/e252473. [PMID: 36549755 PMCID: PMC9791400 DOI: 10.1136/bcr-2022-252473] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
By definition, anteroposterior (AP) compression type 1 (APC-1) injury is a type of pelvic ring injury, which is widely acknowledged as 'stable'. Unstable forms of this injury are very rare and present a challenge for diagnosis and clinical management. Detailed herein is a man in his early 30s, referred to our institution with a 2-year history of pubic symphysis pain following a road traffic accident. Radiological investigation revealed an unstable APC-1 injury. This was subsequently managed with surgical reconstruction leading to the successful return of the patient to former function and recreational activities.
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Affiliation(s)
- Sophia M Wakefield
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Leeds, UK
| | - Vasileios Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Leeds, UK
| | - Matteo Messori
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Leeds, UK
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Muacevic A, Adler JR, Hormazabal J. Revisiting Non-operative Treatment of Lateral Compression Pelvic Fractures, Analysis of Rehabilitation, and Radiologic Outcomes in a Historical Cohort Using Today's Association of Osteosynthesis (AO) Stability Criteria. Cureus 2022; 14:e32101. [PMID: 36601154 PMCID: PMC9803861 DOI: 10.7759/cureus.32101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Type I lateral compression pelvic fractures (LC-I) have historically been treated conservatively. Inferior outcomes in a distinctive subset of these injuries have been reported, therefore their management has shifted towards surgery. Revisiting the historical series of LC-I allows us to determine whether non-operative management of these unstable patterns results in poorer outcomes. The objective was to evaluate the differences in the rehabilitation progress, fracture consolidation, and displacement in non-operatively treated LC-I fractures that would be considered unstable using today's Association of Osteosynthesis (AO) criteria. METHODS We conducted a retrospective review of conservatively treated LC-I injuries in a single-level I trauma center between June 2010 and June 2014. Patients were distributed in stable (group A) and unstable (group B) groups according to the 2018 AO classification. Time to walk independently (TWI), time to return to work (TRW), fracture consolidation, and displacement were analyzed. RESULTS 34 patients, mean age of 45.5 ±14.5 years, were included. Mean TWI in groups A and B were 71.2 ±31.9 and 105.9 ±50.9 days (p=0.027). Mean TRW was 106 ±51.3 and 157 ±84 days in groups A and B, respectively (p=0.038). A difference in mean TWI and TRW of 34.7 and 51.3 days between groups was observed. No significant differences in fracture consolidation or displacement were observed. CONCLUSION Unstable fractures presented significantly longer TWI and TRW. The revised AO classification contributes to the identification of fracture patterns that correlate with prolonged rehabilitation in which additional treatment strategies might be considered.
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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.
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Lateral Stress Radiographs of Lateral Compression Type 1 Pelvic Injuries, With the Injured Side Down or Up, Reliably Measure Occult Instability. J Orthop Trauma 2022; 36:494-497. [PMID: 35412510 DOI: 10.1097/bot.0000000000002374] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the interobserver reliability of measured displacement and occult instability of minimally displaced lateral compression type 1 (LC1) fractures on lateral stress radiographs (LSRs) and to compare differences in displacement between LSR with the injured side down (ID) and up (IU). DESIGN Retrospective review. SETTING Urban Level 1 trauma center. PATIENTS/PARTICIPANTS Twenty-three adult patients with minimally displaced (<1 cm) LC1 injuries. INTERVENTION None. MAIN OUTCOME MEASUREMENTS Three orthopaedic surgeons measured the distance between the radiographic teardrops on LSR and supine anteroposterior pelvic radiographs to calculate dynamic fracture displacement. The interobserver reliability of the measured displacement, a continuous variable, was assessed by calculating the intraclass correlation coefficient. The interobserver reliability of occult instability (≥10 mm of displacement on LSR), a categorical variable, was assessed by calculating the kappa value. Matched-pairs analysis was performed to calculate the mean difference of measurements between observers and between ID and IU LSR. RESULTS The interobserver reliability of the measured displacement was excellent (intraclass correlation coefficient 0.93). The mean difference in measurements between observers ranged from -1.8 to 0.96 mm. The mean difference in the measured displacement between ID and IU LSRs for each observer ranged from -0.6 to 0.3 mm. There was 83% (19/23 cases) agreement on the presence of occult instability (≥10 mm of displacement on LSR) on both ID and IU LSRs. The interobserver reliability of occult instability was moderate (kappa 0.76). CONCLUSIONS Measured fracture displacement and occult instability of minimally displaced LC1 injuries were reliably measured and identified on LSR, regardless of the laterality.
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Rami Comminution Is Associated With Displacement of Minimally Displaced Lateral Compression Type 1 Injuries on Lateral Stress Radiographs. J Orthop Trauma 2022; 36:489-493. [PMID: 35575625 DOI: 10.1097/bot.0000000000002403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/13/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether displacement on lateral stress radiographs (LSRs) in patients with minimally displaced lateral compression type 1 pelvic ring injuries is associated with any demographic and/or injury characteristics. DESIGN Retrospective comparative cohort. SETTING Urban level 1 trauma center. PATIENTS/PARTICIPANTS Ninety-three consecutive patients with minimally displaced lateral compression type 1 injuries. INTERVENTION Displacement of pelvic ring injury on LSR (≥10 mm vs. <10 mm). MAIN OUTCOME MEASUREMENTS Demographic and injury characteristics (mechanism of injury, Nakatani rami classification, rami comminution, Denis zone, complete/incomplete sacral fracture, sacral comminution). RESULTS 65.6% of patients (n = 61) had ≥10 mm of displacement on LSR. On univariate analysis, displacement was associated with increased age [median difference 11: confidence interval (CI), 2-23], female sex [proportional difference (PD): 25.1%, CI, 3.9%-44.4%], Nakatani classification (type I PD: 27.9%, type II PD: -19.5%), and rami comminution (PD: 55.6%, CI, 35.4%-71.3%). On multivariate analysis, displacement was only associated with rami comminution (odds ratio: 16.48, CI, 4.67-58.17). Displacement was not associated with energy of injury mechanism, sacral fracture Denis zone, complete sacral fracture, sacral comminution, or bilateral rami fractures. CONCLUSIONS Although rami comminution was the only variable found to be independently associated with displacement ≥10 mm on LSR, no single variable perfectly predicted displacement. Future studies are needed to determine whether displacement on stress radiographs should change the management of these injuries. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Critical review of the classification and treatment of pediatric pelvic fractures. Injury 2022; 53:3301-3309. [PMID: 35882582 DOI: 10.1016/j.injury.2022.07.009] [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: 04/11/2022] [Revised: 05/31/2022] [Accepted: 07/03/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Historically most pediatric pelvic fractures were treated non-operatively because of the presumed potential of the pediatric pelvis to remodel and the subsequent increased fracture stability. Currently a wide variety of classifications in pediatric pelvic fractures is used to assess fracture stability and guide treatment, yet none have proven to be ideal since the structural behavior of the pediatric pelvis differs greatly from the adult pelvis. The aim of this review is to critically appraise the use of these different classification systems, fracture (in)stability, the treatment of pediatric pelvic fractures and how it reflects on long-term complications such as pelvic asymmetry and functional outcome. METHODS A literature search was performed in Medline, Embase, Cochrane, PubMed, Google Scholar and references of the selected articles. Studies that reported on pain, leg length discrepancy (LLD), abnormal gait (GA), pelvic asymmetry, and functional outcomes of pediatric pelvic fractures were included. RESULTS A total of six different classification systems were used, the most common were Tile (n= 9, 45%) and Torode and Zieg (n= 8, 40%). There was great disparity in treatment choice for the same type of fracture pattern, resulting in several pelvic ring fractures that were defined as unstable being treated non-operatively. Pelvic asymmetry is seen in rates up to 48% in non-operatively treated patients. In contrast, pelvic asymmetry in surgically fixated unstable pelvic fractures was rare, and these patients often showed excellent functional outcomes during follow-up. CONCLUSION There is a substantial heterogeneity in which fracture patterns are considered to be unstable or in need of surgical fixation. Functional outcomes seem to be correlated with the frequency of pelvic asymmetry and are likely due to an underestimation of the stability of the pelvic fracture. Taking into consideration the force that is necessary to cause a facture in the pediatric pelvis, a fracture of the pelvic ring alone could be suggestive for instability. The results of this review imply that the field of pediatric pelvic surgery is currently not grasping the full scope of the complexity of these fractures, and that there is a need for a pediatric pelvic classification system and evidence-based treatment guideline.
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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
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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.
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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.
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Kelley N, Tucker NJ, Mauffrey C, Parry JA. Pelvic ring injuries after road and mountain bike accidents. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03374-0. [PMID: 36029341 DOI: 10.1007/s00590-022-03374-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE The purpose of this study was to compare patients with traumatic pelvic ring injuries sustained in road and mountain bicycling accidents to evaluate for differences in injury types and hospital courses. METHODS A retrospective review of 60 patients presenting with pelvic ring injuries after road (n = 46) and mountain (n = 14) bicycling accidents was performed to compare patient/injury characteristics and hospital course. RESULTS LC1 injuries were the most common pelvic ring injury (n = 31, 51.7%), 38.7% (n = 12) of which were considered unstable, followed by isolated iliac wing (n = 11, 18.3%), pubic rami (n = 6, 10.0%), and sacral fractures (n = 6, 10.0%). Hospital admission was required for 41 (68.3%) patients. The median hospital LOS was 4 days (IQR 2-9) and 12 (20%) patients received operative treatment. Patients in road versus mountain bicycling accidents were more likely to be older tobacco users and were similar in sex, body mass index, and injury severity score. Road bicycling resulted in more LC1 injuries (58.7% vs 28.6%, p = 0.04), while mountain bicycling resulted in more iliac wing fractures (42.9% vs. 10.9%, p = 0.01). Road cycling injuries required more days in the hospital to clear PT (median difference 2, CI 0-4, p = 0.04) and had longer hospital stays (median difference 2, CI 0-6, p = 0.02) but had no difference in the rate of admission, operative intervention, or discharge to rehabilitation facilities. CONCLUSION The majority of pelvic ring injuries from road and mountain bicycling accidents were LC1 injuries that were frequently unstable and often required hospital admission and operative fixation.
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Affiliation(s)
- Naomi Kelley
- University of Colorado School of Medicine, Aurora, CO, USA.
| | - Nicholas J Tucker
- University of Colorado School of Medicine, Aurora, CO, USA
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO, USA
| | - Cyril Mauffrey
- University of Colorado School of Medicine, Aurora, CO, USA
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO, USA
| | - Joshua A Parry
- University of Colorado School of Medicine, Aurora, CO, USA
- Department of Orthopaedics, Denver Health Medical Center, Denver, CO, USA
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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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Tucker NJ, Kelley N, Strage KE, Mauffrey C, Parry JA. Pelvic ring injuries after alpine ski and snowboard accidents. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03331-x. [PMID: 35831489 DOI: 10.1007/s00590-022-03331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/23/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE The purpose of this study was to analyze the patient/injury characteristics and associated hospital course of patients sustaining traumatic pelvic ring injuries after alpine ski and snowboard accidents at a level one trauma center in the Rocky Mountain region. METHODS Patient/injury characteristics were obtained from patients presenting with pelvic ring injuries after alpine ski (n = 55) and snowboard (n = 9) accidents. Characteristics and outcomes analyzed included mechanism of injury, pelvic ring classification (Young-Burgess and Tile), hospital admission, physical therapy (PT) clearance, ambulation, length of stay, inpatient morphine milligram equivalents (MME), and discharges to rehabilitation facility. RESULTS Snowboarders were more often younger, male, tobacco/substance users, and more likely to be injured by a fall from height than skiers. There were no differences in injury classification or hospital course outcomes between alpine sports. Most common injuries included lateral compression type 1 (LC1) injuries (37.5%), isolated pubic ramus fractures (31.3%), and isolated iliac wing fractures (15.6%). LC1 injuries were unstable in 50% of cases and associated with increased admissions (proportional difference: 47.5%, CI: 23.8-64.5%, p = 0.0002), longer time to PT clearance (median difference(MD): 1.0 day, CI: 0-2.0, p = 0.03), longer LOS (MD: 2.0, CI: 0-2.0, p = 0.02), and increased inpatient MMEs (MD: 197.9 MME, CI: 30.0-420.0, p = 0.02), as compared to other pelvic ring injuries. CONCLUSION The majority of pelvic ring injuries from alpine ski and snowboard accidents were LC1 injuries, half of which were unstable, resulting in longer hospital stays, time to PT clearance/ambulation, and opioid use.
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Affiliation(s)
- Nicholas J Tucker
- Department of Orthopedics, Denver Health Medical Center, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Naomi Kelley
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Katya E Strage
- Department of Orthopedics, Denver Health Medical Center, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Cyril Mauffrey
- Department of Orthopedics, Denver Health Medical Center, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Joshua A Parry
- Department of Orthopedics, Denver Health Medical Center, Denver Health, 777 Bannock St, MC 0188, Denver, CO, 80204, USA.
- University of Colorado School of Medicine, Aurora, CO, USA.
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Rickert MM, Windmueller RA, Ortega CA, Devarasetty VVNM, Volkmar AJ, Waddell WH, Mitchell PM. Sacral Insufficiency Fractures. JBJS Rev 2022; 10:01874474-202207000-00001. [PMID: 35849657 DOI: 10.2106/jbjs.rvw.22.00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Primary osteoporosis is the most common cause of sacral insufficiency fractures (SIFs). Therefore, a multidisciplinary team approach is necessary for treatment of the fracture and the underlying biologic pathology, as well as prevention of future fragility fractures. » The presentation of SIFs typically includes lower back or buttock pain after a ground-level fall or without an identified trauma. Symptoms often have an insidious onset and are nonspecific; consequently, a delay in diagnosis and treatment is common. Clinicians need to have a high index of suspicion, particularly in high-risk patients. » Postmenopausal women who are >55 years of age are the most common demographic affected by SIFs. Other risk factors include osteoporosis, history of a prior fragility fracture, local irradiation, long-term corticosteroid use, rheumatoid arthritis, metabolic bone disorders, vitamin D deficiency, pregnancy, history of prior multilevel spinal fusion, and malignancy. » Typical imaging on computed tomography (CT) shows sclerosis of cancellous bone in the sacral ala, with or without a discrete fracture line or displacement. Magnetic resonance imaging is more sensitive than CT and shows hypointense signal on T1-weighted sequences and hyperintensity on T2-weighted or short tau inversion recovery sequences. » The treatment of SIFs is dependent on the severity of symptoms, fracture displacement, and instability of the pelvis. Accepted treatments include nonoperative rehabilitation, sacroplasty, iliosacral screw fixation, transsacral bar or screw fixation, transiliac internal fixation, and lumbopelvic fixation.
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Affiliation(s)
- Mariel M Rickert
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Parry JA, Tucker NJ. Moving forward with the management of minimally displaced lateral compression pelvic ring injuries. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 32:1223-1224. [PMID: 35716214 DOI: 10.1007/s00590-022-03303-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/26/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Joshua A Parry
- Department of Orthopedics, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO, 80204, USA.
| | - Nicholas J Tucker
- Department of Orthopedics, Denver Health Medical Center, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO, 80204, USA
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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.
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Timmer RA, Verhage SM, Krijnen P, Meylaerts SAG, Schipper IB. Indications for surgical fixation of low-energy pelvic ring fractures in elderly: a systematic review. Arch Orthop Trauma Surg 2022; 143:2417-2428. [PMID: 35462589 PMCID: PMC10110636 DOI: 10.1007/s00402-022-04438-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 03/30/2022] [Indexed: 01/04/2023]
Abstract
INTRODUCTION There are no generally accepted criteria for when and how to fixate osteoporotic pelvic ring fractures in elderly. This systemic review aims to summarize the currently available literature regarding the indications and methods for surgical fixation of fragility fractures of the pelvic ring in elderly patients after low-energy trauma. MATERIALS AND METHODS The Pubmed and Embase databases were searched using the key words pelvic fractures, geriatric, fragility, osteoporosis, and surgical fixation, and their synonyms. Extracted data including the indication, method of operative fixation, and post-operative outcomes (pain levels, mobility, complications and mortality) were analyzed using descriptive statistics. The studies were too heterogeneous to perform a meta-analysis. RESULTS Eleven cohort studies (3 comparative and 8 noncomparative) were included. The methodological quality was poor to moderate; the studies were heterogeneous regarding study design and reported outcomes. In all included studies operative treatment for all fracture types was preceded by a period of conservative treatment comprising physiotherapy-guided full weight-bearing. Time to surgery differed widely. For posterior ring fixation, the majority of the included studies used minimally invasive surgery with trans-iliosacral screws. Five studies described a form of additional fixation of the anterior pelvic ring but did not report the indications. CONCLUSIONS Fixation of low-energy pelvic ring fractures in elderly is commonly performed after a period of conservative treatment, with persistent pain as the most frequent indication for fixation. Fracture classification based on stability seems to be of secondary importance. Timing for surgical fixation of the pelvic ring fracture in elderly patients remains diverse. Large well-designed comparative prospective studies and randomized controlled trials are needed to provide clearly substantiated guidelines.
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Affiliation(s)
- R A Timmer
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - S M Verhage
- Department of Trauma Surgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - P Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - S A G Meylaerts
- Department of Trauma Surgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - I B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Leiden, The Netherlands
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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.
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Affiliation(s)
- Graham J DeKeyser
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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Crist BD. Consider Emergency Department Stress Examinations on Lateral Compression Type-1 Pelvic Ring Injuries with Complete Sacral Fractures: Commentary on an article by Graham J. DeKeyser, MD, et al.: "Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable". J Bone Joint Surg Am 2022; 104:e13. [PMID: 35171132 DOI: 10.2106/jbjs.21.01367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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What is the long-term clinical outcome after fragility fractures of the pelvis? - A CT-based cross-sectional study. Injury 2022; 53:506-513. [PMID: 34656318 DOI: 10.1016/j.injury.2021.09.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 09/17/2021] [Accepted: 09/26/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Recently, Rommens and Hoffman introduced a CT-based classification system for fragility fractures of the pelvis (FFP). Although fracture characteristics have been described, the relationship with clinical outcome is lacking. The purpose of this study was to get insight into the type of treatment and subsequent clinical outcome after all types of FFP. METHODS A cross-sectional cohort study was performed including all elderly patients (≥ 65 years) with a CT-diagnosed FFP, between 2007-2019 in two level 1 trauma centers. Data regarding treatment, mortality and clinical outcome was gathered from the electronic patient files. Patients were asked to complete patient-reported outcome measures (PROMs) regarding physical functioning (SMFA) and quality of life (EQ-5D). Additionally, a standardized multidisciplinary treatment algorithm was constructed. RESULTS A total of 187 patients were diagnosed with an FFP of whom 117 patients were available for follow-up analysis and 58 patients responded. FFP type I was most common (60%), followed by type II (27%), type III (8%) and type IV (5%). Almost all injuries were treated non-operatively (98%). Mobility at six weeks ranged from 50% (type III) to 80% type II). Mortality at 1 year was respectively 16% (type I and II), 47% (type III) and 13% (type IV). Physical functioning (SMFA function index) ranged from 62 (type III and IV) to 69 (type II) and was significantly decreased (P=<0.001) compared to the age-matched general population. Quality of life was also significantly decreased, ranging from 0.26 (type III) to 0.69 (type IV). CONCLUSIONS FFP type I and II are most common. Treatment is mainly non-operative, resulting in good mobility after six weeks, especially for patients with FFP type I and II. Mortality rates at one year were substantial in all patients. Physical functioning and quality of life was about 20-30% decreased compared to the general population.
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Contributions of Pubic Rami Fracture Morphology and Fixation to Pelvic Ring Stability in Type 1 Lateral Compression Injuries: A Biomechanical Cadaveric Study. J Orthop Trauma 2022; 36:S7-S11. [PMID: 35061644 DOI: 10.1097/bot.0000000000002306] [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: 11/08/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Treatment of lateral compression type 1 (LC-1) injuries has historically been nonoperative with immediate weight-bearing. However, management of these injuries remains controversial, with reports of displacement at follow-up for nonoperatively managed LC-1 fractures. The goal of our study was to determine the effect of superior pubic ramus fracture morphology and fixation construct on pelvic stability. METHODS Ten fresh-frozen cadaveric were transected into hemi-pelvises. Incomplete Denis type 1 sacral fractures were made. Hemi-pelvises were randomized to receive a transverse-type or oblique-type superior pubic ramus fracture with the contralateral hemi-pelvis receiving the opposing morphology. A lateral load to 135N was applied with an Instron materials testing machine and lateral displacement of the hemi-pelvis was recorded. Deflection and stiffness were calculated. Statistical analysis was conducted using a t test assuming unequal variances with an alpha = 0.05. RESULTS Oblique-type superior pubic ramus fractures allowed more deflection compared with transverse-type fractures in the absence of fixation (P = 0.018). The posterior-only and combined anterior and posterior fixation configurations on average reduced deflection more than no fixation or anterior fixation only. In all fixation configuration cases, the average deflection for transverse-type fractures was less than that of the oblique-type fractures. CONCLUSIONS Our findings suggest that displacement of LC-1 pelvic injuries may be related to pubic rami fracture morphology. When looking at initial injury imaging, oblique-type pubic rami fractures may suggest an increased potential for displacement over time. In such cases, we recommend an examination under anesthesia to evaluate for underlying instability and consideration for fixation. LEVEL OF EVIDENCE Therapeutic Level V.
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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.
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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.
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Osterhoff G, Reise R, Riemer E, Höch A, Fakler JKM, Heyde CE, Schleifenbaum S. The pectineal ligament is a secondary stabilizer in anterior pelvic ring fractures - a biomechanical study. Injury 2022; 53:334-338. [PMID: 34920874 DOI: 10.1016/j.injury.2021.12.006] [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: 09/03/2020] [Revised: 09/27/2021] [Accepted: 12/04/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is ongoing discussion whether operative fixation of partially stable lateral compression fractures of the pelvis is beneficial for the patient. Recent studies suggest that the pectineal ligament may act as a secondary stabilizer of the anterior pelvis ring. The purpose of this study was to investigate the influence of the pectineal ligament's integrity on the biomechanical stability and displacement in anterior pelvic ring fractures. METHODS In a biomechanical setup, a cyclic loading protocol was applied with sinusoidal axial force from 100 to 500 N on cadaver hemipelves with soft tissues (n = 5). After testing the native specimens ("No fracture"), increasing degrees of injury were created on the samples: 1. an osseous defect to the pubic ramus ("Bone #"), 2. cutting of all soft tissues including obturator membrane except for the pectineal ligament intact ("ObtM #"), 3. cutting of the pectineal ligament ("PectL #") - with the loading protocol being applied to each sample at each state of injury. Fracture motion and vertical displacement were measured using a digital image correlation system and opto-metric analysis. RESULTS No failure of the constructs was observed. Creating a pubic ramus fracture (p = 0.042) and cutting the pectineal ligament (p = 0.042) each significantly increased relative fracture movement. The mean change in absolute movement was 0.067 mm (range, 0.02 mm to 0.19 mm) for ObtM # and 0.648 mm (range, 0.07 mm to 2.93 mm), for PectL # in relation to Bone # (p = 0.043). Also for absolute vertical movement, there was a significant change when the pectineal ligament was cut (p = 0.043), while there was no such effect with cutting all other soft tissues including the obturator membrane. CONCLUSIONS Based on the findings of this in vitro study, the pectineal ligament significantly contributes to the stability of the anterior pelvic ring. An intact pectineal ligament reduces fracture movement in presence of a pubic ramus fracture.
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Affiliation(s)
- Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.
| | - Rebekka Reise
- Centre for Research on Musculoskeletal Systems, Leipzig University, Leipzig, Germany
| | - Elena Riemer
- Centre for Research on Musculoskeletal Systems, Leipzig University, Leipzig, Germany
| | - Andreas Höch
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Johannes K M Fakler
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Christoph-Eckhard Heyde
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Schleifenbaum
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany; Centre for Research on Musculoskeletal Systems, Leipzig University, Leipzig, Germany
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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.
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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
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