Clinical Guidelines for the Diagnosis and Treatment of Fragility Fractures of the Pelvis

Prevalence of fracture progression in fragility fractures of the pelvis: Systematic review and meta-analysis

BACKGROUND

Fragility fractures of the pelvis (FFP) are a growing problem in aging populations. Fracture progression (FP) occasionally occurs during FFP treatment; however, its prevalence remains unclear. This systematic review and meta-analysis aimed to assess the prevalence of FP among patients with FFP.

METHODS

We performed a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. All cohort studies that reported the prevalence of FP in patients with FFP were included. FP was defined as the appearance of additional pelvic fractures after the initial FFP. We searched the CENTRAL, MEDLINE, and EMBASE databases until April 2024. The pooled prevalence was generated using a random-effects model and presented as a 95 % confidence interval (CI) and prediction interval (PI). We assessed the risk of bias in each study using the Joanna Briggs Institute's Prevalence Critical Appraisal Tool.

RESULTS

This review included eight studies (925 patients). The pooled prevalence of FP in patients with FFP was 11 % (95 % CI, 5-19 %; 95 % PI, 0-44 %). Subgroup analysis showed that the pooled prevalence of FP in patients with FFP (conservative treatment vs. surgery for initial FFP) was 16 % (95 % CI, 9-24 %) and 2 % (95 % CI, 0-11 %), respectively (test for subgroup difference, P = 0.03). Additional analysis showed that in patients with FP, the pooled prevalence of the fractured site (ipsilateral site, contralateral site, and both sites) was 66 %, 12 %, and 19 %, respectively. The pooled prevalence of fractured bone (pubis, ischium, ilium, and sacrum) was 25 %, 0 %, 15 %, and 68 %, respectively. The risk of bias in the patient sampling method and sufficient data analysis in all included studies was high.

CONCLUSION

This review suggests that the prevalence of FP in patients with FFP is relatively high. Clinicians should recognize FP as a possible diagnosis in patients experiencing additional pain after FFP. However, further prospective studies with adequate patient sampling are required to confirm the true prevalence.

Microbiota-bone axis in ageing-related bone diseases

Bone homeostasis in physiology depends on the balance between bone formation and resorption, and in pathology, this homeostasis is susceptible to disruption by different influences, especially under ageing condition. Gut microbiota has been recognized as a crucial factor in regulating host health. Numerous studies have demonstrated a significant association between gut microbiota and bone metabolism through host-microbiota crosstalk, and gut microbiota is even an important factor in the pathogenesis of bone metabolism-related diseases that cannot be ignored. This review explores the interplay between gut microbiota and bone metabolism, focusing on the roles of gut microbiota in bone ageing and aging-related bone diseases, including osteoporosis, fragility fracture repair, osteoarthritis, and spinal degeneration from different perspectives. The impact of gut microbiota on bone metabolism during aging through modification of endocrinology system, immune system and gut microbiota metabolites are summarized, facilitating a better grasp of the pathogenesis of aging-related bone metabolic diseases. This review offers innovative insights into targeting the gut microbiota for the treatment of bone ageing-related diseases as a clinical therapeutic strategy.

[Diagnostics and treatment of insufficiency fractures of the pelvis]

Insufficiency fractures of the pelvis have increased in recent years, primarily due to the demographic change and the incidence will continue to rise. In addition to conventional X‑rays, the diagnostics always require slice imaging. Unlike high-energy trauma magnetic resonance imaging (MRI) plays an important role in insufficiency fractures. Once the fracture has been diagnosed, in addition to the extent of instability in the anterior and posterior pelvic rings, the pain symptoms are crucial for the decision on surgical treatment. The basic principle is to stabilize as little as possible but as much as necessary. There are currently a variety of procedures that can be applied as a minimally invasive procedure, especially for the often slightly or displaced insufficiency fractures. The decisive factor for treatment is that it enables early mobilization of the patients. All of these measures must be accompanied by thorough diagnostics of osteoporosis and the appropriate treatment.

TiRobot-Assisted Percutaneous Cannulated Screw Fixation for Elderly Patients with Fragility Fractures of the Pelvis: A Retrospective Study

OBJECTIVE

The incidence of fragility fractures of the pelvis (FFPs) is increasing in the elderly population, and FFPs that require fixation are a challenge for orthopedic surgeons. The insertion of implants is not risk free due to the complex anatomical and osteoporotic bones and requires a steep learning curve. This study aimed to investigate the clinical efficacy of TiRobot-assisted percutaneous cannulated screw fixation in the treatment of elderly FFP patients.

METHOD

The clinical data of 46 elderly FFP patients who had been treated with percutaneous cannulated screw fixation from May 2020 to September 2022 were retrospectively analyzed. Twenty-four patients were treated with percutaneous cannulated screw fixation assisted by the TiRobot (TiRobot-assisted group) and 22 patients were treated with conventional freehand surgery (freehand group). Postoperative outcomes, including Matta value, excellent and good rate (EGR) of fracture reduction, and accuracy of screw placement (ASP), were compared. Changes in the Visual analog scale (VAS) pain score and the Majeed score were recorded and compared between groups before and after surgery and during the 24-week follow-up. Repeated-measures analysis of variance (ANOVA) and effect sizes were used as analysis methods.

RESULTS

A total of 90 screws were implanted, 51 screws in the TiRobot-assisted group and 39 screws in the freehand group. The operation time of the two groups was 34.1 ± 2.67 min versus 64.5 ± 4.19 min (p < 0.001). There were no screw-related complications or revision surgeries in any group. The Matta value of the TiRobot-assisted group was 5.13 ± 3.52, which was significantly lower than that of the freehand group (9.00 ± 3.68, p < 0.001), while the EGR was 91.67% versus 72.73%, with statistical significance (p < 0.001). The ASP was 100% in the TiRobot-assisted group, better than that in the freehand group, where it was 85.7% (p = 0.043). At each timepoint in the early postoperative period, the VAS score of the TiRobot-assisted group was significantly lower than that of the freehand group and was close to consistent by the last follow-up; the Majeed score of the former was significantly higher than that of the latter at each timepoint of follow-up, with statistical significance (p < 0.001).

CONCLUSION

TiRobot-assisted percutaneous cannulated screw fixation of elderly FFP patients is advantageous over conventional freehand surgery, with less invasion, more accurate screw placement, better fracture reduction, early pain relief, and rapid recovery, suggesting that Freehand method to stabilize FFP in the elderly population.