When and How to Operate Fragility Fractures of the Pelvis?

Treatment of Type IV Fragility Fractures of Pelvis With Robotic-Assisted Minimally Invasive Triangular Fixation

OBJECTIVE

Type IV fragility fractures of pelvis (FFP IV) are serious and complicated and the treatment is challengeable. Robotic-assisted minimally invasive triangular fixation (RoboTFX) is a new and advanced technique to treat this injury. The objective of this report is to evaluate the clinical outcomes of FFP IV treated with RoboTFX.

METHODS

From March 2017 to December 2022, 22 consecutive patients with FFP IV were included in the study. Patients were divided into two groups according to the surgical method employed (RoboTFX or robotic-assisted minimally invasive iliosacral screws, RoboISS). Between two groups, we compared clinical data on operation time, intraoperative bleeding, intraoperative fluoroscopy time, favorable fracture healing rate, implant loosening rate, and Majeed pelvic outcome score.

RESULTS

All operations were undertaken from 3 to 15 days (average 5.7 ± 1.7 days) following primary injuries. All patients were followed up continuously 15 months. The average surgical time was 125.3 ± 15.5 (55-190) min in group RoboTFX, 137.1 ± 17.2 min in group RoboISS (p > 0.05). The average amount of intraoperative bleeding was 320.4 ± 25.2 (50-550) mL in group RoboTFX, 302.4 ± 21.5 (50-500) mL in Group 2 (p > 0.05). The average intraoperative fluoroscopy time of the two groups was 23.3 ± 4.5 (15-35) s in group RoboTFX and 40.3 ± 3.8 (10-75) s in group RoboISS (p < 0.05). No patients experienced loss of reduction, 5 of 40 screws had implant loosening in group RoboTFX, meanwhile 13 of 48 screws had implant loosening in Group 2. Four of 20 vertical sacral fractures were healed undesirable including 2 nonunion and the favorable healing rate of 80% in group RoboTFX, meanwhile 8 of 24 fractures were undesirable including 4 nonunion and the favorable healing rate was 66.7% in group RoboISS. Implant loosening rate in the RoboTFX group were all significantly better than those of the RoboISS group (p < 0.05). There were no occurrences of wound infection in both groups, and Majeed scores for the last follow-up were 76.2 ± 3.4 in group RoboTFX and 74.2 ± 2.7 in group RoboISS (p > 0.05).

CONCLUSION

RoboTFX has the advantages of less intraoperative fluoroscopy and implant loosening rate compared to RoboISS which is better than other methods. We thus recommend RoboTFX as an effective option for treating FFP IV. However, the indications of its operation should be strictly evaluated.

Augmented ilio-sacral screws for the treatment of fragility pelvic fractures: review of literature, presentation of a novel low-cost technique, and clinical results of a case series

PURPOSE

Fragility pelvic fractures are an increasingly entity due to increase in life expectancy. A large proportion of these fractures require surgical treatment with stabilization of the posterior ring with ilio-sacral screws. Due to the poor bone quality of these patients, cement augmentation of the ilio-sacral screws can be performed and thus avoid treatment failures. The purpose of this review is to make a revision of the literature and present a novel cementation technique with clinical examples of patients treated with this surgical technique.

METHOD

Review of current literature on fragility pelvic fractures and modern treatment alternatives. We also describe a novel, easy to perform and low-cost technique for cement augmentation of ilio-sacral screws that we find useful when not having specific commercial instruments for this purpose. Additionally, we present a case series of five patients operated between 2017 and 2024 with augmented ilio-sacral screws due to fragility pelvic fracture.

CONCLUSION

The surgical technique presented is easy to perform, has a low training curve and requires standard instruments easy to find in a trauma center. Further clinical studies are required to demonstrate superiority of cement augmentation over the standard technique without augmentation.

Treatment Outcomes of Lower Urinary Tract Symptoms due to Fragility Sacral Fractures: A Review of Eight Patients and Literature

BACKGROUND

Sacral fractures can cause lower urinary tract symptoms (LUTS) due to damage to the cauda equina. While several studies have reported on sacral fractures due to high-energy trauma, those due to fragility fractures have only been reported in case reports and their clinical differences are not well known. This study aimed to investigate the clinical characteristics of LUTS caused by fragility sacral fractures and propose a novel treatment strategy.

METHODS

This study is retrospective, uncontrolled, clinical case series. The inclusion criteria were sole sacral fractures due to low-energy trauma and appearance of LUTS after injury. Patients with additional spinal fractures or combined abdominal or pelvic organ injuries that could cause LUTS were excluded. Improvement in LUTS, period from onset to improvement, and imaging findings were recorded.

RESULTS

Eight patients met the inclusion criteria (4 surgical and 4 conservative treatment cases). Six patients showed improvement in LUTS. In surgical cases, the mean period from onset of LUTS to surgery and from onset of LUTS to improvement was 14.5 and 21.5 days, respectively. Intraoperative rupture or laceration of the dural sac was not observed. In 2 conservatively improved cases, the period from onset to improvement of LUTS was 14 and 17 days.

CONCLUSIONS

LUTS can improve even with conservative treatment and should be utilized as the primary choice. LUTS caused by severe sacral canal deformity and stenosis can be reversible, and the decision to perform surgical treatment is still timely if LUTS do not improve with conservative treatment for several weeks.

[Translated article] Spinopelvic dissociation: Current concepts

INTRODUCTION

Spinopelvic dissociation is an uncommon injury, but, at the same time, very serious, since it can associate important complications with high morbidity and mortality. Its low frequency means that the experience of the specialists who have to deal with it is often very limited.

OBJECTIVE

To analyze the treatment indications based in classifications and surgery techniques.

METHOD

A search for scientific articles from high-impact journals was performed through international databases, such as Pubmed, Cochrane Library, Scopus, Science Direct and OVID.

CONCLUSIONS

The management of the injury we are analyzing represents a challenge. The diagnosis is carried out through a meticulous anamnesis and physical examination, supported by imaging tests, where tomography acquires special relevance. The treatment is fundamentally surgical, reserved the conservative option for a few cases. Triangular fixation is nowadays considered the treatment of choice.

Spinopelvic dissociation: Current concepts

INTRODUCTION

Spinopelvic dissociation is an uncommon injury, but, at the same time, very serious, since it can associate important complications with high morbidity and mortality. Its low frequency means that the experience of the specialists who have to deal with it is often very limited.

OBJECTIVE

To analyze the treatment indications based in classifications and surgery techniques.

METHOD

A search for scientific articles from high-impact journals was performed through international databases, such as Pubmed, Cochrane Library, Scopus, Science Direct and OVID.

CONCLUSIONS

The management of the injury we are analyzing represents a challenge. The diagnosis is carried out through a meticulous anamnesis and physical examination, supported by imaging tests, where tomography acquires special relevance. The treatment is fundamentally surgical, reserved the conservative option for a few cases. Triangular fixation is nowadays considered the treatment of choice.

Evaluation of a treatment protocol based on conservative therapy for fragility fractures of the pelvis

PURPOSE

In an aging society, fragility fractures of the pelvis (FFP) have increased significantly. However, there is no clear consensus on the timing and criteria for transitioning from conservative treatment to surgery for these fractures. Thus, we aimed to investigate the effects of our treatment protocol for FFP based on conservative treatment.

METHODS

We conducted a retrospective study including 74 patients with FFP at our institution between 2015 and 2021. All patients were treated conservatively for the first two weeks. During this period, only wheelchair transfer was allowed. If the patient could not walk after this period, surgery was performed. Fracture type (Rommens classification), walking ability, presence of complications after admission, presence of fracture union, and surgical treatment was investigated. Patients were divided into two groups: a stable group (type I/II) and an unstable group (type III/IV).

RESULTS

Fracture union was achieved in all patients. Thirteen patients developed complications after being admitted to our hospital; seven showed decreased walking ability, and six required surgeries. The stable and unstable groups comprised 47 and 27 patients, respectively. There were no statistically significant differences between the groups regarding the percentage of patients who developed complications or experienced decrease in walking ability. The percentage of patients who required surgery was significantly higher in the unstable group (p < 0.05).

CONCLUSION

Our FFP management protocol was effective regardless of fracture type. It is important to provide a period for careful assessment of instability, and to try to prevent fracture progression.

The role of sarcopenia in fragility fractures of the pelvis - is sarcopenia an underestimated risk factor?

BACKGROUND

Fragility fractures of the pelvis (FFPs) represent a significant health burden, particularly for the elderly. The role of sarcopenia, an age-related loss of muscle mass and function, in the development and impact of these fractures is not well understood. This study aims to investigate the prevalence and impact of osteoporosis and sarcopenia in patients presenting with FFPs.

METHODS

This retrospective study evaluated 140 elderly patients with FFPs. The diagnosis of sarcopenia was assessed by psoas muscle area (PMA) and the height-adjusted psoas muscle index (PMI) measured on computed tomography (CT) scans. Clinical data, radiological findings and functional outcomes were recorded and compared with the presence or absence of sarcopenia and osteoporosis.

RESULTS

Our study cohort comprised 119 female (85.0%) and 21 (15.0%) male patients. The mean age at the time of injury or onset of symptoms was 82.26 ± 8.50 years. Sarcopenia was diagnosed in 68.6% (n = 96) patients using PMA and 68.8% (n = 88) using PMI. 73.6% (n = 103) of our study population had osteoporosis and 20.0% (n = 28) presented with osteopenia. Patients with sarcopenia and osteoporosis had longer hospital stays (p < 0.04), a higher rate of complications (p < 0.048) and functional recovery was significantly impaired, as evidenced by a greater need for assistance in daily living (p < 0.03). However, they were less likely to undergo surgery (p < 0.03) and the type of FFP differed significantly (p < 0.04). There was no significant difference in mortality rate, pre-hospital health status, age or gender.

CONCLUSION

Our study highlights the important role of sarcopenia in FFPs in terms of the serious impact on health and quality of life in elderly patients especially when osteoporosis and sarcopenia occur together. Identifying and targeting sarcopenia in older patients may be an important strategy to reduce pelvic fractures and improve recovery. Further research is needed to develop effective prevention and treatment approaches that target muscle health in the elderly.

Pelvic Ring Fractures: A Biomechanical Comparison of Sacral and Lumbopelvic Fixation Techniques

BACKGROUND CONTEXT

Pelvic ring fractures are becoming more common in the aging population and can prove to be fatal, having mortality rates between 10% and 16%. Stabilization of these fractures is challenging and often require immediate internal fixation. Therefore, it is necessary to have a biomechanical understanding of the different fixation techniques for pelvic ring fractures.

METHODS

A previously validated three-dimensional finite element model of the lumbar spine, pelvis, and femur was used for this study. A unilateral pelvic ring fracture was simulated by resecting the left side of the sacrum and pelvis. Five different fixation techniques were used to stabilize the fracture. A compressive follower load and pure moment was applied to compare different biomechanical parameters including range of motion (contralateral sacroiliac joint, L1-S1 segment, L5-S1 segment), and stresses (L5-S1 nucleus stresses, instrument stresses) between different fixation techniques.

RESULTS

Trans-iliac-trans-sacral screw fixation at S1 and S2 showed the highest stabilization for horizontal and vertical displacement at the sacral fracture site and reduction of contralateral sacroiliac joint for bending and flexion range of motion by 165% and 121%, respectively. DTSF (Double transiliac rod and screw fixation) model showed highest stabilization in horizontal displacement at the pubic rami fracture site, while the L5_PF_W_CC (L5-Ilium posterior screw fixation with cross connectors) and L5_PF_WO_CC (L5-Ilium posterior screw fixation without cross connectors) showed higher rod stresses, reduced L1-S1 (approximately 28%), and L5-S1 (approximately 90%) range of motion.

CONCLUSIONS

Longer sacral screw fixations were superior in stabilizing sacral and contralateral sacroiliac joint range of motion. Lumbopelvic fixations displayed a higher degree of stabilization in the horizontal displacement compared to vertical displacement of pubic rami fracture, while also indicating the highest rod stresses. When determining the surgical approach for pelvic ring fractures, patient-specific factors should be accounted for to weigh the advantages and disadvantages for each technique.

[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.

Corona mortis and pelvic dissection: Understanding the relationship between anatomical structures and bone areas

Pelvic fractures are becoming increasingly frequent. The gold standard for surgical managements remains open procedures. Despite its excellent biomechanically results, it can lead to many complications. Minimally invasive surgery could reduce these complications. For complex pelvic trauma, extraperitoneal endoscopic technique has never been described. The aim of this study is to determine anatomical landmarks which are useful for endoscopic pelvic ring surgery using an extraperitoneal approach. The second objective is to compare this minimally invasive procedure to expose the bone versus a traditional open approach. After preparing the vessels with latex injections, 10 specimens are dissected alternately, using an endoscopic method (MIS) on one side and an open method on the other side. Both procedures are performed on the same subject. The visualized bone areas are drilled with burr holes. The marked surfaces are measured with photogrammetry. Finally, the data are processed (surface analysis). An extraperitoneal endoscopic dissection that follows anatomical landmarks can be performed. Bone area (mm2 ) visualized by endoscopy was 74 ± 14 (59-94) compared to 71 ± 16 (48-94) by open method. Paired t-test was performed with no significant difference between the two methods. Skin and muscular incisions were significantly lower in the MIS group (5.1, IC95% [4.1; 6.1], p < 0.001). An extraperitoneal endoscopic dissection of the pelvis can be performed. We also find no significant difference between our method and an open traditional approach concerning bone exposure. We offer a holistic approach to treat pelvic fractures by identifying key anatomical structures.

Sacroplasty for Sacral Insufficiency Fractures: Narrative Literature Review on Patient Selection, Technical Approaches, and Outcomes

Sacral insufficiency fractures commonly affect elderly women with osteoporosis and can cause debilitating lower back pain. First line management is often with conservative measures such as early mobilization, multimodal pain management, and osteoporosis management. If non-operative management fails, sacroplasty is a minimally invasive intervention that may be pursued. Candidates for sacroplasty are patients with persistent pain, inability to tolerate immobilization, or patients with low bone mineral density. Before undergoing sacroplasty, patients' bone health should be optimized with pharmacotherapy. Anabolic agents prior to or in conjunction with sacroplasty have been shown to improve patient outcomes. Sacroplasty can be safely performed through a number of techniques: short-axis, long-axis, coaxial, transiliac, interpedicular, and balloon-assisted. The procedure has been demonstrated to rapidly and durably reduce pain and improve mobility, with little risk of complications. This article aims to provide a narrative literature review of sacroplasty including, patient selection and optimization, the various technical approaches, and short and long-term outcomes.

Sacroiliac versus transiliac-transsacral screw osteosynthesis in osteoporotic pelvic fractures: a biomechanical comparison

INTRODUCTION

Pelvic fractures were often associated with high-energy trauma in young patients, but data show a significant increase in osteoporotic pelvic fractures in old age due to the progressive demographic change. There is an ongoing discussion about the best fixation techniques, which are ranging from lumbopelvic fixation to sacral bars or long transiliac-transsacral (TITS) screws. This study analyzes TITS screw osteosynthesis and sacroiliac screw osteosynthesis (SI), according to biomechanical criteria of fracture stability in osteoporotic human pelvic cadavers ex vivo.

METHODS

Ten osteoporotic cadaveric pelvises were randomized into two groups of 5 pelvises each. An FFP-IIc fracture was initially placed unilaterally and subsequently surgically treated with a navigated SI screw or a TITS screw. The fractured side was loaded in a one-leg stance test setup until failure. Interfragmentary movements were assessed by means of optical motion tracking.

RESULTS

No significant difference in axial stiffness were found between the SI and the TITS screws (21.2 ± 4.9 N and 18.4 ± 4.1 N, p = 0.662). However, there was a significantly higher stability of the fracture treatment in the cohort with TITS-screws for gap angle, flexion, vertical movement and overall stability. The most significant difference in the cycle interval was between 6.000 and 10.000 for the gap angle (1.62 ± 0.25° versus 4.60 ± 0.65°, p = 0.0001), for flexion (4.15 ± 0.39 mm versus 7.60 ± 0.81 mm, p = 0.0016), interval 11.000-15.000 for vertical shear movement (7.34 ± 0.51 mm versus 13.99 ± 0.97 mm, p < 0.0001) and total displacement (8.28 ± 0.66 mm versus 15.53 ± 1.07 mm, p < 0.0001) for the TITS and the SI screws.

CONCLUSIONS

The results of this biomechanical study suggest a clear trend towards greater fracture stability of the TITS screw with significantly reduced interfragmentary movement. The application of a TITS screw for the treatment of the osteoporotic pelvic ring fracture may be prioritized to ensure the best possible patient care.

Do we need to fix the anterior fracture component in insufficiency fractures of the pelvis? A biomechanical comparison on an FFP type IIIc fracture in an osteoporotic pelvic bone model

There is a growing understanding of the specific characteristics of insufficiency fractures of the pelvis and of general requirements for the treatment of affected patients with focus on early mobilization and effective pain reduction as the main goals of therapy. While there is consensus on the significance of achieving stability of the dorsal pelvic ring structures there is still an open discussion about the potential benefits of additional stabilization of an anterior fracture component. Within a biomechanical test setup, two established methods of dorsal fracture fixation were tested under axial loading (25-1200 N; 1000 test cycles) on an explicit osteoporotic bone model (n = 32) with a standardized FFP type IIIc fracture with and without additional fixation of the anterior fracture component. Dorsal fixation was performed with and long and a short 7.3 mm cannulated screw in S1 in one group (n = 16), and a trans sacral bar with an additional short 7.3 mm cannulated screw in S1 in the other group (n = 16). Half of the samples received a 7.3 mm cannulated retrograde transpubic screw for anterior fixation. The fixation with the trans sacral bar and the additional anterior screw fixation showed the highest rate of stability (p = 0.0014), followed by the double SI-screw fixation with stabilization of the anterior fracture (p = 0.0002). During testing, we observed the occurrence of new sacral fractures contralateral to the initial fracture in 22/32 samples. The results let us assume that stabilization of an additional anterior fracture component relevantly improves the stability of the entire ring construct and might prevent failure of the dorsal stabilization or further fracture progression.

Gluteal Muscle Fatty Atrophy: An Independent Risk Factor for Surgical Treatment in Elderly Patients Diagnosed with Type-III Fragility Fractures of the Pelvis

BACKGROUND

Gluteal muscle fatty atrophy (gMFA) might impair pelvic stability and negatively influence remobilization in patients with fragility fractures of the pelvis (FFP). This study aimed to investigate the association between gMFA and surgical indication in patients with FFP.

METHODS AND MATERIALS

A retrospective analysis of 429 patients (age ≥80) diagnosed with FFP was performed. gMFA of the gluteus maximus, medius, and minimus was evaluated using a standard scoring system based on computer tomography images.

RESULTS

No significant difference was found in gMFA between genders or among FFP types. The severity of gMFA did not correlate with age. The severity of gMFA in the gluteus medius was significantly greater than in the gluteus maximus, whereas the most profound gMFA was found in the gluteus minimus. gMFA was significantly more severe in patients who underwent an operation than in conservatively treated patients with type-III FFP, and an independent correlation to surgical indication was found using logistic regression.

CONCLUSION

Our findings imply that gMFA is an independent factor for surgical treatment in patients with type-III FFP. Besides focusing on the fracture pattern, the further evaluation of gMFA could be a feasible parameter for decision making toward either conservative or surgical treatment of type-III FFP.

Cemented Sacroiliac Screw Fixation versus Conservative Therapy in Fragility Fractures of the Posterior Pelvic Ring: A Matched-Pair Analysis of a Prospective Observational Study

The aim of this study was to compare the outcome of cemented sacroiliac screw fixation to that of conservative treatment in nondisplaced fragility fractures of the sacrum during a 12-month follow-up. Therefore, matched-pair analysis including 40 patients from a previously performed prospective observational study was conducted. Pain was assessed using the visual analogue scale (VAS), functional capabilities and mobility were assessed using the Barthel index, and health-related quality of life (HRQL) was assessed using the EQ-5D questionnaire at 6 weeks, 6 months, and 12 months after the fracture, respectively. No significant differences between the two groups were seen regarding pain. In the operative group, a significantly improved Barthel index was observed after 6 months. A significantly higher HRQL was identified after 6 weeks in the operative group. Their mobility was comparable between the two groups before the fracture; after 6 weeks, mobility was significantly improved in the operative group. After 12 months, no significant differences were found regarding the functional outcome, HRQL or mobility. The 1-year mortality rate was 25% in the conservative group versus 5% in the operative group (not statistically significant). The present study revealed favorable short-term outcomes concerning the functional outcome, HRQL and mobility after sacroiliac screw fixation. After 12 months, the outcomes were similar to those of the patients managed conservatively.

Analysis of the Spinopelvic Parameters in Patients with Fragility Fractures of the Pelvis

BACKGROUND

We investigated the spinopelvic parameters of lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS) in patients with fragility fractures of the pelvis (FFPs). We hypothesized that these parameters differ from asymptomatic patients.

METHODS

All patients treated for FFPs in a center of maximal care of the German Spine Society (DWG) between 2017 and 2021 were included. The inclusion criteria were age ≥ 60 years and the availability of a standing lateral radiograph of the spine and pelvis in which the spine from T12 to S1 and both femoral heads were visible. The baseline characteristics and study parameters were calculated and compared with databases of asymptomatic patients. The two-sample t-Test was performed with p < 0.05.

RESULTS

The study population (n = 57) consisted of 49 female patients. The mean age was 81.0 years. The mean LL was 47.9°, the mean PT was 29.4°, the mean SS was 34.2° and the mean PI was 64.4°. The mean value of LLI was 0.7. LL, LLI and SS were significantly reduced, and PI and PT were significantly increased compared to asymptomatic patients.

CONCLUSIONS

The spinopelvic parameters in patients with FFPs differ significantly from asymptomatic patients. In patients with FFPs, LL, LLI and SS are significantly reduced, and PI and PT are significantly increased. The sagittal spinopelvic balance is abnormal in patients with FFPs.

FFP: Indication for minimally invasive navigation technique

An 85-year-old female patient was transferred to our clinic for surgical treatment of a complex FFP IIc. She had suffered a ground level fall 10 days ago and was still living independently. The patient was initially treated conservatively with pain medication and immobilization in an outward hospital. Due to the clinical symptoms and complex fracture pattern a physiotherapeutic assisted mobilization was not possible. The clinical examination revealed severe bilateral pain at the anterior and posterior pelvic ring. We performed a minimally invasive and an image-guided surgical stabilization. After surgical treatment the patient was mobilized with crutches for short distances. On the third day after surgical intervention the patient was discharged from our hospital into rehabilitation. This case shows the successful use of minimally invasive and modern navigation technique for treatment of a complex FFP.

Clinical implications of additional posterior fractures in combined anterior-posterior pelvic ring fractures in elderly patients

OBJECTIVES

Historically, pelvic ring fractures (PRF) are considered to occur predominantly in the anterior ring and therfore to be mechanically stable. Combined anterior and posterior (A + P) PRF are expected to be less mechanically stable and therefore to be associated with higher levels of pain and reduced mobility compared to isolated anterior fractures. The current study investigates the clinical relevance of combined A + P PRF in elderly patients.

METHODS

A prospective multicentre cohort study was conducted in patients >70 years of age with anterior PRF after low-energy trauma diagnosed on conventional radiographs. All patients underwent an additional CT-scan. Patients were divided into two groups; isolated anterior or combined A + P fractures. Patients were treated conservatively with adequate analgesia for at least one week. If patients could not be mobilised after conservative treatment, surgical fixation was performed. Numerical Rating Scale (NRS) pain scores, dependence on walking aids and Activities of Daily Living scores (ADL) were measured at 2-4 weeks, and 3, 6 and 12 months after fracture.

RESULTS

102 patients (age 81.1 ± 7.6 years) were included. Isolated anterior fractures were diagnosed in 25 (24.5%) and A + P fractures in 77 (75.5%) patients. Baseline characteristics did not differ between the two groups. Most patients were successfully treated conservatively and 5 (4.9%) underwent percutaneous trans-iliac, trans-sacral screw fixation after failure of conservative treatment. At 2-4 weeks post trauma, patients with A + P fractures had similar median pain scores (3 (range 0-8) vs. 5 (0-10), p = 0.19) and ADL scores (85 (25-100) vs. 78.6 (5-100), p = 0.67), but were more dependent on walking aids (92.8% vs. 72.2%; p = 0.02) compared to patients with isolated anterior fractures. There were no significant differences at 3 months. At one year follow-up the median NRS pain and ADL scores for both fracture groups were 0 and 100, respectively. Mortality was 10.8%, and additional loss to follow-up was 17.6%.

CONCLUSIONS

The vast majority of elderly patients with PRF have combined A + P fractures. The clinical implications of additional posterior pelvic ring fractures in elderly patients appears to be limited.

A systematic review regarding clinical characteristics, complications, and outcomes of surgical and non-surgical patients with fragility fracture of the pelvis

We conducted this systematic review to clarify the clinical characteristics, complications, and outcomes of surgical and non-surgical patients with fragility fracture of the pelvis (FFP). We searched PubMed, Google Scholar, Cochrane Library, Web of Science, and MEDLINE for English language articles on FFP. We calculated pooled odds ratios (ORs) or mean differences (MDs) of surgical patients in comparison to non-surgical patients for clinical characteristics (Rommens FFP classification, age, sex, dementia, osteoporosis, diabetes mellitus, pulmonary disease, cardiovascular disease, and malignancy), complications (pneumonia, urinary tract infection, cardiac event, thrombosis, pulmonary embolism, pressure ulcer, multiple organ failure, anemia caused by surgical bleeding, and surgical site infection), and outcomes (hospital mortality and one-year mortality). Five studies involving 1,090 patients with FFP (surgical patients, n = 432; non-surgical patients, n = 658) were included. FFP type III and IV (OR = 8.44; 95% confidence interval [CI] 5.99 to 11.88; p<0.00001), a younger age (MD = -3.29; 95% CI -3.83 to -2.75; p<0.00001), the absence of dementia (OR = 0.36; 95% CI 0.23 to 0.57; p<0.0001), and the presence of osteoporosis (OR = 1.74; 95% CI 1.29 to 2.35; p = 0.0003) were significantly associated with the surgical patients. Urinary tract infection (OR = 2.06; 95% CI 1.37 to 3.10; p = 0.0005), anemia caused by surgical bleeding (OR = 4.55; 95% CI 1.95 to 10.62; p = 0.0005), and surgical site infection (OR = 16.74; 95% CI 3.05 to 91.87; p = 0.001) were significantly associated with the surgical patients. There were no significant differences in the outcomes between the surgical and non-surgical patients. Our findings may help to further understand the treatment strategy for FFP and improve clinical outcomes.

Percutaneous sacroiliac screw fixation in fragility fractures of the pelvis: Comparison of two different augmentation techniques

OBJECTIVE

Fragility fractures of the pelvis (FFP) are becoming increasingly common. Percutaneous sacroiliac screw fixation is an accepted and safe treatment method for FFP. Augmentation is an option to optimize fixation strength of the screws. This study aims to compare patient mobility and the occurrence of complications after operative treatment of FFP utilizing two different augmentation techniques.

METHODS

All patients who received augmented sacroiliac screws for the treatment of FFPs between 01.01.2017 and 31.12.2018 at one of the two participating hospitals were included. The operative techniques only differed with regards to the augmentation method used. At the one hospital cannulated screws were used. Definitive screw placement followed augmentation. At the other hospital cannulated and fenestrated screws were used, permitting definitive screw placement prior to augmentation.

RESULTS

In total, 59 patients were included. The NRS score for pain was significantly lower after surgery. Preoperative mobility levels could be maintained or improved in 2/3 of the patients. There were no fatal complications. Two revision surgeries were performed because of screw misplacement. There were no significant differences between the two augmentation techniques in terms of complications.

CONCLUSION

Both augmentation techniques have a low complication rate and are safe methods to maintain patients' mobility level. The authors advocate early consideration of surgical treatment for patients with FFP. Augmentation can be considered a safe addition when performing percutaneous sacroiliac screw fixation.

Safety and efficacy of two ilioiliac tension band plates osteosynthesis of fragility fractures of the pelvis

The study retrospectively determined the efficacy and safety of fixation of the pelvis (FFP) fragility fractures type IV using two tension band ilioiliac locking compression plates. Forty-one patients with FFP were treated in 2017-2020. 16 patients with FFP type IV, unable to walk weight-bearing, were treated by fixation using two tension band ilioiliac locking compression plates without fixing the anterior ring. Preoperatively and one year postoperatively, the functional outcome and performance were assessed using Pelvic Discomfort Index (PDI) and Timed Up and Go (TUG) test. Pre- and postoperative hemoglobin level was evaluated. Operation time and intra-and postoperative complications were documented. One year postoperatively, an X-ray was taken. The arithmetic mean (x) and standard deviations (±) of quantitative variables were calculated. T-test for dependent samples was used for pre-and postoperative results comparison. The PDI improved (p < 0.001) from x = 81.42 ± 4.04 to x = 36.19 ± 15.58. Preoperatively none of the patients was able to perform the TUG test. Postoperatively, the result exceeded x = 13.13 ± 3.99 s. The operation lasted x = 42.80 ± 8.90 min. Hemoglobin decreased (p < 0.001) from 11.63 ± 1.11 to 9.07 ± 1.21 g/dL. No complications nor fixation loosening were noted. The study support fixation using two tension band ilioiliac locking compression plates as an efficient and safe treatment of the FFP type IV.

Investigation of the risk of common femoral artery injury with anterior subcutaneous internal fixation in patients with fragility fractures of the pelvis

INTRODUCTION

The incidence of the fragility fractures of the pelvis (FFPs) has been increasing in recent years. Operative treatment is effective in patients who are unable to ambulate due to pain. Anterior subcutaneous internal fixation (ASIF) is a minimally invasive and stable fixation used to treat the FFPs, with few reported vascular complications. However, we experienced a case in which the rod directly pressed the common femoral artery (CFA).

OBJECTIVES

The purpose of this study was to examine the relationship between the rod position as defined by ASIF and the CFA in the FFPs patients, and between BMI and the rod-to-CFA distance.

MATERIALS AND METHODS

Pelvic measurements were performed in 47 patients with FFPs using trauma CT. We identified the anterior inferior iliac spine (AIIS) on both sides in axial CT images. Next, we performed a simulation study using the CT images, in which the virtual fixation rod was bent according to the shape of the patients' abdomen in the supine position. The shortest rod-to-CFA distance when the virtual rod was positioned directly above the AIIS in the CT image was measured. The correlation between body mass index (BMI) and the rod-to-CFA distance was measured.

RESULTS

The average shortest rod-to-CFA distance was 18.4 ± 11.1 mm, and the simulated rod compressed the CFA in three of the 47 cases (6.4%). A statistically significant positive correlation between BMI and the rod-to-CFA distance was found (r = 0.47, p = 0.001).

CONCLUSIONS

The course of the CFA should be confirmed before ASIF surgery, and if there is danger of compression of the CFA such as in patients with low BMI, the rod-to-AIIS distance should be adjusted to the optimal distance. However, considering the disadvantages, such as decreased stability of the fixation, when adjusting the rod-to-AIIS distance, and skin irritation and abrasion by the rod, ASIF is not recommended in cases in which the rod is close to the CFA.

Indications for surgical fixation of low-energy pelvic ring fractures in elderly: a systematic review

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.

[Minimally invasive stabilization of fragility fractures of the pelvis with transsacral bar and retrograde transpubic screw]

OBJECTIVE

Stabilization of fragility fractures of the pelvis (FFP) using a minimally invasive technique. Insertion of a transsacral rod into the transsacral corridor of S1. Insertion of a retrograde transpubic screw through the superior branch of the pubic bone.

INDICATIONS

Uni- or bilateral displaced fragility fractures of the sacrum or sacroiliac joint. Nondisplaced fractures of the sacrum or sacroiliac joint in case of nonsuccessful conservative treatment. Uni- or bilateral fractures of the superior branch of the pubic bone, which are present in combination with a posterior pelvic instability.

CONTRAINDICATIONS

Fragility fractures of the pelvis, which can be successfully treated conservatively. Absence of transsacral corridor in sacral body S1. Major displacement, nonreducible fractures of the superior branch of the pubic bone. Soft tissue infection at insertion site of implants.

SURGICAL TECHNIQUE

The transsacral bar is inserted under fluoroscopic control from ilium to ilium through the transsacral corridor of the sacral body S1. The retrograde transpubic screw is inserted from the pubic tubercle through the superior branch of the pubic bone past the acetabulum into the body of the ilium.

POSTOPERATIVE MANAGEMENT

An early mobilization with weight bearing of both lower extremities as tolerated by the patient is allowed. Conventional radiographs for control of the position of the implants and fractures are taken after mobilization RESULTS: In all, 64 patients with FFP type II, FFP type III or FFP type IV were stabilized with a transacral bar osteosynthesis in the posterior pelvis. In 32 patients (50%), additional sacroiliac screws were inserted. In 29 patients (45.3%) the transsacral bar osteosynthesis was combined with a transpubic retrograde screw. Median length of hospital stay was 17.5 days. In all, 20 patients (31.3%) suffered general, 10 patients (15.6%) suffered surgery-related complications, and 41 patients (64.1%) were mobile in the room or on the ward at discharge. One-year mortality was 10.9%. The values of the SF‑8 Physical and Mental Component Scores, Parker Mobility Score and Numeric Rating Scale were moderate, yet comparable with the values of patients of the same age.

An evaluation of emergency pain management practices in fragility fractures of the pelvis

BACKGROUND

Inadequately treated pain is associated with significant morbidity in older adults. We aimed to describe current pain management practices for patients with fragility pelvic fractures, a common emergency department (ED) presentation in older adults.

METHODS

We performed a health records' review of adults ≥ 65 years old who presented to two academic EDs with nonoperative fragility pelvic fractures between 01/2014 and 09/2018. The primary outcome measures were type and timing of analgesic medications. Secondary outcome measures included ancillary service consultation, ED length of stay, admission rate and rate of return to ED at 30 days. Data were reported using descriptive statistics.

RESULTS

We included 411 patients. The majority were female (339, 82.5%) with mean age 83.9 (SD 8.1) years. Nearly, one-third (130, 31.6%) did not receive any analgesia for their fracture. Analgesia was initiated in 123 (29.9%) patients through paramedic and nursing medical directives; 244 (59.4%) patients received physician-initiated opioids (hydromorphone 228 (55.5%); morphine 28 (6.8%)). Only 23.1% of patients received one or more ancillary services: physiotherapy (10.5%), social work (7.3%), geriatric nurse assessment (14.1%), and homecare (3.9%). Mean ED length of stay was 11.6 (SD 7.1) h; 210 (51.1%) patients were admitted; of those discharged, 45 (22.4%) returned to the ED within 30 days.

CONCLUSION

One in three older adults presenting to the ED with nonoperative fragility pelvic fractures receive no analgesia during the course of their prehospital and ED care. Barriers to quality care must be identified and processes implemented to ensure adequate pain management for this population.

Midterm follow-up of elderly patients with fragility fractures of the pelvis: A prospective cohort-study comparing operative and non-operative treatment according to a therapeutic algorithm

INTRODUCTION

The treatment of fragility fractures of the pelvis (FFP) is a challenge. The variations of non-operative- and of operative treatment are manifold and a structured treatment algorithm is lacking. The purpose of this study was to evaluate the outcome of elderly patients with a FFP who were treated with a therapeutic algorithm based on the FFP-classification.

PATIENTS AND METHODS

In a prospective cohort study 154 patients (mean age: 81.8 ±.61 (65-96); female: (86.8%; 131/154). BMI: 23.7 ±.34 (15-43)) with a FFP after inadequate mono trauma were treated according to a strict therapeutic algorithm between 04/2016 and 12/2018. According to a classification based on CT-scans either a standardized operative treatment or conservative therapy was induced and the outcome regarding objective measurements of mobility, pain, need for analgesics and mortality during hospital stay and after one year was analyzed.

RESULTS

82/154 participants (53.2%) were assigned to the conservative treatment group and 72 participants (46.8%) to the operative treatment group. The overall one-year survival rate was 78.1% (118/151). The survival of the operative treatment group was 90.7% (49/54) and significantly higher than the survival of the conservative treatment group (74.7%; 56/75; p=.023). The one-year follow up showed a high dispersion of the pain level in the operatively treated patients and a significantly higher mean in comparison to conservatively treated patients. Both treatment groups showed increasing numbers of patients with unlimited mobilization but also immobile patients. Overall in 31.0% (18/58) of the operative participants and in 14.9% (14/93) of the non-operatively treated participants complications occurred (p=.04).

CONCLUSION

The strict compliance to the presented treatment algorithm of FFP with an operative strategy starting from FFP IIc leads to a significantly lower mortality within one year in comparison to the conservatively treated patients. The worst outcome and the highest mortality was seen in patients who refused the recommendation of operative stabilization. The results of this study justify to proceed with the strict classification dependent treatment algorithm and also support the early switch-over to operative treatment of patients with failed conservative therapy in FFP I to FFP IIb.

Reliability of Fossae Lumbales Laterales and Pelvic Incidence for Estimating Transsacral Corridors Assessed Using Reconstruction Computed Tomography

Background

The present study aimed to evaluate the effect of fossae lumbales laterales and pelvic incidence (PI) on transsacral corridors.

Methods

Patients who underwent pelvic computed tomography (CT) during routine therapy in a single center between 2015 and 2020 were retrospectively reviewed. The patients’ age and sex were documented during CT examination. Measurements were performed for both the upper and second sacral segments. Height and weight of the patients were determined using appropriate tools and body mass index (BMI) was calculated. Transsacral corridors were identified in true coronal and true sagittal planes and their width was determined as the maximum gap measured so that no screws could come out of the transacral corridors. PI was measured.

Results

Our study included 244 (57%) male and 184 (43%) female patients, who had a mean age of 49.3 ± 14.15 years (range, 18–89 years) and a mean BMI of 26.57 ± 2.38 kg/m². No statistically significant correlation was found between the detection of the dimple sign in physical examination and the presence of an adequate corridor. The PI was statistically significantly higher in the patients with dimples (p < 0.001). PI of the female patients was higher than that of the male patients (p = 0.026). The correlation between PI and the existence of adequate corridors for S1 and S2 screws was not statistically significant (p = 0.858 and p = 0.129, respectively). On the relationship between the presence of adequate S1 and S2 corridors where transsacral screws could be sent, an inverse relationship was detected: if the S1 transsacral corridor was adequate, the S2 corridor was inadequate or vice versa.

Conclusions

We could not obtain meaningful results on the use of the dimples of Venus or PI instead of CT to evaluate the adequacy of transverse corridors. Nevertheless, we confirmed that an increased PI was associated with the presence of dimples of Venus.

Fragility Fractures of the Pelvis and Sacrum: Current Trends in Literature

Fragility fractures of the pelvis (FFP) and fragility fractures of the sacrum (FFS), which are emerging in the geriatric population, exhibit characteristics that differ from those of pelvic ring disruptions occurring in the younger population. Treatment of FFP/FFS by a multidisciplinary team can be helpful in reducing morbidity and mortality with the goal of reducing pain, regaining early mobility, and restoring independence for activities of daily living. Conservative treatment, including bed rest, pain therapy, and mobilization as tolerated, is indicated for treatment of FFP type I and type II as loss of stability is limited with these fractures. Operative treatment is indicated for FFP type II when conservative treatment has failed and for FFP type III and type IV, which are displaced fractures associated with intense pain and increased instability. Minimally invasive stabilization techniques, such as percutaneous fixation, are favored over open reduction internal fixation. There is little evidence regarding outcomes of patients with FFP/FFS and more literature is needed for determination of optimal management. The aim of this article is to provide a concise review of the current literature and a discussion of the latest recommendations for orthopedic treatment and management of FFP/FFS.

Iliosacral screw corridors in Japanese subjects: a study using reconstruction CT scans

Objectives:

To investigate the characteristics of iliosacral (IS) screw corridors of Japanese pelves.

Methods:

Computer tomography images of 42 adult Japanese subjects without any pelvic injury were analyzed at a workstation. Using the manual reconstruction function, the width of a simulated horizontal corridor for an IS screw on the true coronal and true axial planes in the upper (S1), second (S2), and the third (S3) sacral segments was measured. For pelves without an adequate S1 corridor, a cranially tilted corridor was sought. A corridor was defined as “adequate” if its width on both planes was 10 mm or more.

Results:

An adequate horizontal corridor was found in S1 in 17 (40.5%) subjects, in S2 in 29 (69.0%) subjects, and in S3 in no subject. An independent factor affecting the adequacy of the S1 corridor was the adequacy of the S2 corridor (OR: 0.09). Similarly, an independent factor affecting S2 adequacy was S1 adequacy (OR: 0.10). A tilted, 10 mm diameter corridor was found in all 25 subjects who did not have an adequate horizontal corridor in the S1 segment. The angle required to obtain a 10 mm diameter corridor inversely correlated with the diameter of a horizontal corridor on the true coronal plane (R = −0.713, P = .000).

Conclusions:

The characteristics of IS screw corridors in the 42 Japanese subjects were similar to those reported in previous studies conducted in the West. The importance of preoperative planning using reliable techniques, such as three-dimensional reconstruction, should be emphasized.

Level of evidence: Diagnostic Level III. See Instructions for Authors for a complete description of level of evidence.

Instability of the posterior pelvic ring: introduction of innovative implants

BACKGROUND

Increasing numbers of posterior pelvic ring fractures, especially in elderly patients, demonstrate the need for soft tissue protecting surgical techniques. Standard of care is iliosacral screw osteosynthesis. This type of osteosynthesis has its limitations especially in patients with reduced bone properties. Therefore, the development of new and straightforward surgical techniques and implant designs is favorable.

METHODS

Introducing this modular system for the posterior pelvic ring, known complications of iliosacral screw osteosynthesis, such as implant loosening and malpositioning may be reduced, due to innovative mechanical characteristics.

RESULTS

The shown cases demonstrate the potential benefits of the system with a wide range of treatment options due to its modularity.

CONCLUSION

The modular implant system presented here can significantly facilitate and improve the stabilization of posterior pelvic ring instabilities.

Comparison of lumbopelvic fixation and iliosacral screw fixation for the treatment of bilateral sacral fractures

Background

Bilateral sacral fractures result in traumatic disruption of the posterior pelvic ring. Treatment for unstable posterior pelvic ring fractures should aim for fracture reduction and rigid fixation to facilitate early mobilization. Iliosacral screw fixation (ISF) and lumbopelvic fixation (LPF) were recommended for the treatment of these injuries. No algorithm or gold standard exists for surgery of these fractures.

Purpose

The purpose of this study was to evaluate the differences between ISF and LPF in bilateral sacral fractures regarding intraoperative procedures, complications and postoperative mobilization. The secondary aim was to determine whether demographics influence surgical treatment.

Methods

Over a 4-year period (2016–2019), 188 consecutive patients with pelvic ring injuries were treated at one academic level 1 trauma center and retrospectively identified. Fractures were classified according to the AO/OTA classification system. Seventy-seven patients were treated with LPF or ISF in combination with internal fixation of pubic rami fractures and could be included in this study. Comparisons were made between demographic and perioperative data. Infection, hematoma and hardware malpositioning were used as complication variables. Mobilization with unrestricted weight bearing was used as outcome variable. Follow-up was at least 6 months postoperatively.

Results

Operative stabilization of bilateral posterior pelvic ring injuries was performed in 77 patients. Therefore, 29 patients (females 59%) underwent LPF whereas 48 patients (females 83%) had bilateral ISF. The ISF group was older (76 yrs.) compared to the LPF group (62 yrs.) (p = 0.001), but no differences regarding BMI or comorbidities were detected. Time for surgery was reduced for patients who were treated with ISF compared to lumbopelvic fixation (73 min vs. 165 min; respectively, p < 0.001). But this did not result in reduced fluoroscopic time or radiation exposure. Overall complication rate was not different between the groups. Patients with LPF had a greater length of stay (p = 0.008) but were all weight bearing as tolerated when discharged (p < 0.001).

Conclusion

Bilateral posterior pelvic ring injuries of the sacrum can be sufficiently treated by LPF or ISF. LPF allows immediate weight bearing which may benefit younger patients and patients with an elevated risk for pneumonia or other pulmonary complications. Treatment with ISF reduces operative time, length of stay and postoperative wound infection. Elderly patients may be better suited for treatment with ISF if there is concern that the patient may not tolerate the increased operative time.

The FFP-classification: From eminence to evidence

Fragility fractures of the pelvis (FFP) are a clinical entity with a rapidly growing incidence among elderly women. The characteristics of these fractures are different from those appearing after high-energy trauma. In 2013, the comprehensive FFP-classification provided a new framework for analysis of these fractures. It is based on the estimation of loss of stability in the pelvic ring. It is connected with recommendations for surgical treatment, justified by the fact that higher instabilities will need surgical stabilization. Since ist appearance, we can observe an increasing clinical-scientific interest in FFP. Multiple publications use the FFP-classification studying the characteristics of fractures, choice of treatment and outcome. Other studies focus on minimal-invasive techniques for stabilization. The actual knowledge describes higher mortality rates as the reference population, lower mortality rates after operative treatment but for the price of surgery-related complications. Mobility, independency and quality of life are worse than before the fracture, independent of the FFP-classification and the type of treatment. The classification triggered a rapid increase of expertise. This publication gives a detailed overview on the evolution from eminence to evidence.

Operative treatment of fragility fractures of the pelvis is connected with lower mortality. A single institution experience

Background

Fragility fractures of the pelvis (FFP) represent an increasing clinical entity. Until today, there are no guidelines for treatment of FFP. In our center, recommendation for operative treatment was given to all patients, who suffered an FFP type III and IV and to patients with an FFP type IIwith unsuccessful non-operative treatment. We performed a retrospective observational study and investigated differences between fracture classes and management alternatives. We hypothetized that operative treatment may reduce mortality.

Materials and methods

The medical charts and radiographs of 362 patients were analysed. Patient demographics, FFP-classification, length of hospital stay (LoS), type of treatment, general and surgery-related complications, mortality, Short Form-8 physical component score (SF-8 PCS) and mental component score (SF-8 MCS), Parker Mobility Score (PMS) and Numeric Rating Scale (NRS) were documented.

Results

238 patients had FFP type II and 124 FFP type III and IV. 52 patients with FFP type II (21.8%) and 86 patients with FFP type III and IV (69.4%) were treated operatively (p<0.001). Overall mortality did not differ between the fracture classes (p = 0.127) but was significantly lower in the operative group (p<0.001). Median LoS was significantly higher in FFP type III and IV (p<0.001) and in operated patients (p<0.001). There were more in-hospital complications in patients with FFP type III and IV (p = 0.001) and in the operative group (p = 0.006). More patients of the non-operative group were mobile (p<0.001) and independent (p<0.001) at discharge. Half of the patients could not return in their living environment.203 of the 235 surviving patients (86%) answered the questionnaires after a mean follow-up time of 38 months. SF-8 PCS, SF-8 MCS and PMS did not differ between the fracture classes and treatment groups. Pain perception was higher in the operated group (p = 0.013).

Conclusion

In our study, we observed that operative treatment of FFP provides low mortality rates, although LoS and in-hospital complications were higher in the operative group. At discharge, the non-operative group was more mobile and independent. At follow up, quality of life and mobility were comparable between the groups. Further prospective studies are needed to clarify the impact of operative treatment of FFP on mortality and functional outcome.

[Angle stable plate for treatment for insufficiency fractures of the pelvis (minimally invasive posterior locked compression plate) : Video article]

Operationsziel

Belastungsstabile Versorgung des Beckenringes mit hoher Primärstabilität.

Indikation

Instabilität und ausbleibende Mobilisierbarkeit bei osteoporotischen Beckenbrüchen.

Kontraindikationen

Dekubitalgeschwüre, Infekte.

Operationstechnik

Minimal-invasive winkelstabile Versorgung durch 4,5 LCP (locked compression plate, DePuy Synthes, Zuchwil, Schweiz) von dorsal.

Weiterbehandlung

Sofortige Mobilisation mit Vollbelastung, Röntgenverlaufskontrolle.

Evidenz

Die Nachuntersuchung eines Kollektivs von 34 Patienten zeigte keine Implantatlockerungen sowie eine vergleichsweise niedrige Strahlenexposition.

Video online

Die Online-Version dieses Beitrags (10.1007/s00113-021-01039-x) enthält das Video zur hier beschriebenen Operationstechnik „Winkelstabile Platte zur Behandlung der Insuffizienzfrakturen des Beckens“.

Detecting pelvic fracture on 3D-CT using deep convolutional neural networks with multi-orientated slab images

Pelvic fracture is one of the leading causes of death in the elderly, carrying a high risk of death within 1 year of fracture. This study proposes an automated method to detect pelvic fractures on 3-dimensional computed tomography (3D-CT). Deep convolutional neural networks (DCNNs) have been used for lesion detection on 2D and 3D medical images. However, training a DCNN directly using 3D images is complicated, computationally costly, and requires large amounts of training data. We propose a method that evaluates multiple, 2D, real-time object detection systems (YOLOv3 models) in parallel, in which each YOLOv3 model is trained using differently orientated 2D slab images reconstructed from 3D-CT. We assume that an appropriate reconstruction orientation would exist to optimally characterize image features of bone fractures on 3D-CT. Multiple YOLOv3 models in parallel detect 2D fracture candidates in different orientations simultaneously. The 3D fracture region is then obtained by integrating the 2D fracture candidates. The proposed method was validated in 93 subjects with bone fractures. Area under the curve (AUC) was 0.824, with 0.805 recall and 0.907 precision. The AUC with a single orientation was 0.652. This method was then applied to 112 subjects without bone fractures to evaluate over-detection. The proposed method successfully detected no bone fractures in all except 4 non-fracture subjects (96.4%).

Plate fixation of the anterior pelvic ring in patients with fragility fractures of the pelvis

Introduction

In fragility fractures of the pelvis (FFP), fractures of the posterior pelvic ring are nearly always combined with fractures of the anterior pelvic ring. When a surgical stabilization of the posterior pelvis is performed, a stabilization of the anterior pelvis is recommended as well. In this study, we aim at finding out whether conventional plate osteosynthesis is a valid option in patients with osteoporotic bone.

Materials and methods

We retrospectively reviewed medical charts and radiographs of all patients with a FFP, who underwent a plate osteosynthesis of the anterior pelvic ring between 2009 and 2019. Patient demographics, fracture characteristics, properties of the osteosynthesis, complications and revision surgeries were documented. Single plate osteosynthesis (SPO) at the pelvic brim was compared with double plate osteosynthesis (DPO) with one plate at the pelvic brim and one plate anteriorly. We hypothesized that the number and severity of screw loosening (SL) or plate breakage in DPO are lower than in SPO.

Results

48 patients with a mean age of 76.8 years were reviewed. In 37 cases, SPO was performed, in 11 cases DPO. Eight out of 11 DPO were performed in patients with FFP type III or FFP type IV. We performed significantly more DPO when the instability was located at the level of the pubic symphysis (p = 0.025). More patients with a chronic FFP (surgery more than one month after diagnosis) were treated with DPO (p = 0.07). Infra-acetabular screws were more often inserted in DPO (p = 0.056). Screw loosening (SL) was seen in the superior plate in 45% of patients. There was no SL in the anterior plate. There was SL in 19 of 37 patients with SPO and in 3 of 11 patients with DPO (p = 0.16). SL was localized near to the pubic symphysis in 19 of 22 patients after SPO and in all three patients after DPO. There was no SL in DPO within the first month postoperatively. We performed revision osteosynthesis in six patients (6/48), all belonged to the SPO group (6/37). The presence of a bone defect, unilateral or bilateral anterior pelvic ring fracture, post-operative weight-bearing restrictions, osteosynthesis of the posterior pelvic ring, and the presence of infra- or supra-acetabular screws did not significantly influence screw loosening in SPO or DPO.

Conclusion

There is a high rate of SL in plate fixation of the anterior pelvic ring in FFP. In the vast majority, SL is located near to the pubic symphysis. DPO is associated with a lower rate of SL, less severe SL and a later onset of SL. Revision surgery is less likely in DPO. In FFP, we recommend DPO instead of SPO for fixation of fractures of the anterior pelvic ring, which are located in or near to the pubic symphysis.

[Reliability of the FFP classification in pelvic fractures]

BACKGROUND

Pelvic fractures are typical for frail geriatric patients. They are characterized by increasing pain and loss of mobility. As geriatric pelvic fractures differ from the typical high velocity injuries, Rommens and Hofmann recommended a new classification for fragility fractures of the pelvis (FFP) in 2013. In addition to the location of the fracture they also assessed the degree of dislocation.

OBJECTIVE

Compared to known fracture classifications of the pelvis, the FFP classification appears complex. Therefore, this study was designed to investigate the interobserver reliability of the FFP classification.

MATERIAL AND METHODS

The members of the Section of Geriatric Traumatology (DGOU) were presented with 10 DICOM data sets with fractures of the pelvis for classification. As a reference the classification of P.M. Rommens, the author of the FFP, was established.

RESULTS

In this study 24 consultants (47%) and 27 (53%) residents took part. Also, six radiologists were invited to participate. A total of 493 assessments were made. In 184 (37%) cases there was agreement with the reference, in 183 (37%) computed tomography images the fractures were classified lower, in 26 (26%) higher than the reference. This initially resulted in a Cohens κ coefficient of 0.36. This corresponds to a sufficient agreement (fair) according to Garbuz. With the reduction of the classification to four main groups, the Cohens κ coefficient increased to a satisfactory value.

CONCLUSION

The reasons for the partly low agreement could be the participants' lack of experience and an inaccurate description of the classification levels. In the end, however, the FFP classification is the only one that meaningfully represents pelvic fractures of geriatric and frail patients. By simplifying to the four main groups, a better interobserver reliability is achieved. For a successful treatment, however, attention to the individual patient and the "fracture personality" is essential.

Low-Energy Pelvic Ring Fractures: A Care Conundrum

Introduction:

A need exists for improved care pathways for patients experiencing low-energy pelvic ring fractures. A review of the current literature was performed to understand the typical patient care and post-acute rehabilitation pathway within the US healthcare system. We also sought to summarize reported clinical outcomes worldwide. Significance: Low-energy pelvic ring fracture patients usually do not qualify for inpatient admission, yet they often require post-acute rehabilitative care. The Center for Medicare and Medicaid Services’ (CMS) 3-day rule is a barrier to obtaining financial coverage of this rehabilitative care.

Results:

Direct admission of some patients to post-acute care facilities has shown promise with decreased cost, improved patient outcomes, and increased patient satisfaction. Secondary fracture prevention programs may also improve outcomes for this patient population.

Conclusions:

Post-acute care innovation and secondary fracture prevention should be prioritized in the low-energy pelvic fragility fracture patient population. To demonstrate the effect and feasibility of these improved care pathways, further studies are necessary.

Delayed lower extremity paresis following iliosacral screws: Atypical complication and treatment

Percutaneous iliosacral screw placement has become the technique of choice for treating injuries to the posterior pelvis. However, the technique requires an understanding of the anatomy surrounding the bone corridors to avoid complications and detect them early if they occur. We present the clinical case of a patient with a U-shaped fracture of the sacrum that evolves with gluteal pain and left foot equine paresis after percutaneous fixation with iliosacral screws. Angio-CT of the pelvis shows active arterial bleeding from the superior gluteal artery associated to extensive hematoma in the thickness of the gluteus medius muscle. Emergency embolization is performed by installing coil and gelatin. Successful control of bleeding is achieved. To avoid this complication, a complete imaging study is recommended in planning the surgery and to avoid multiple repositioning of the guide or screw. Arterial injury should be suspected in case of increasing pain despite analgesia, functional impairment or neurological deficit and the angiographic study and resolution by selective embolization of the bleeding vessels must be performed.

Fragility Fractures of the Pelvic Ring – Does the Evidence of Oedema Lead us to More Surgeries?

Introduction The choice of therapy for fragility fractures of the pelvis (FFP) is largely determined by the diagnosed fracture morphology. It is now unclear whether the change in diagnostic options – sensitive detection of fracture oedema in the sacrum using MRI and dual-energy computed tomography (DECT) – has an impact on the therapeutic consequences. The aim of this retrospective study was therefore to evaluate the change in the diagnostics used and the resulting therapy regimen in our patient population.

Materials and Methods We performed a monocentric-retrospective analysis of 196 patients with a fragility fracture of the pelvis in our clinic (national TraumaZentrum® DGU and SAV approval) in the period from 2008 to 2017. We examined changes in epidemiology, diagnostics/classification and therapy of the pelvic ring fractures treated by us.

Results The diagnostic procedures used are subject to a clear change towards oedema detection using MRI and DECT. The graduation has changed towards more severe forms of fracture after FFP. There is now also an increasing proportion of patients treated by surgery (2008 – 2009: 5.3% vs. 2015 – 2017: 60.3%).

Conclusion We were able to show that the introduction of sensitive diagnostic procedures coincided with a higher classification of the fractures. It is also noteworthy that the increase in operations is not only due to a higher degree of classification; also in relative terms, more patients are operated on within type FFP II.

Sacral fractures: issues, challenges, solutions

Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma.This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagnosis, underestimation and inadequate treatment. The diagnosis should be made by assessing specific features during the clinical presentation, while computed tomography (CT) scan continues to be the choice of investigation.Sacral fractures can be treated non-operatively or surgically. Non-operative treatment is based on rest, pain relief therapy and early mobilization as tolerated. Surgical techniques can be split into two main groups: posterior pelvic fixation techniques and lumbopelvic fixation techniques. Anterior pelvic fixation techniques should be considered when sacral fractures are associated with anterior pelvic ring injuries, in order to increase stability and reduce the risk of posterior implant failure. To improve fracture reduction, different solutions could be adopted, including special positioning of the patient, manipulation techniques and use of specific reduction tools. Patients suffering from spinopelvic dissociation with associated neurologic lesions hardly ever recover completely, with residual lower-limb neurologic sequelae, urinary problems and sexual disfunction.Herein, we present issues, challenges and solutions related to the management of sacral fractures. Cite this article: EFORT Open Rev 2020;5:299-311. DOI: 10.1302/2058-5241.5.190064.

Safety and efficacy of 2D-fluoroscopy-based iliosacral screw osteosynthesis: results of a retrospective monocentric study

Introduction

Iliosacral screw osteosynthesis is a well-accepted procedure for stabilization of sacral fractures and iliosacral (fracture) dislocations.

Materials and Methods

In this monocentric study, safety and efficacy of conventional 2D-fluoroscopic-guided iliosacral screw insertion were evaluated.

Results

During a 10-year period (2005–2014), 98 patients between the age of 18 and 65 years received 207 iliosacral screws in 101 procedures. Average patient age was 43.2 years. There were 46 Type B and 40 Type C injuries in the AO/OTA classification, nine patients had a fragility fracture of the pelvis. In three patients, primary radiological data were missing. The indication for surgical treatment was a sacral fracture in 97 patients, a pure iliosacral dislocation in 37 patients and a fracture-dislocation in 31 patients. 70 procedures were performed with the patient in supine position, 31 with the patient in prone position. Surgery was done in a minimal-invasive technique in 76 patients, in 22 patients an open reduction was necessary before screw insertion. 81 patients received a unilateral, 17 patients a bilateral screw osteosynthesis. 199 screws were inserted in S1, only eight screws in S2. 65 patients received two screws unilaterally, ten patients two screws bilaterally. There were no vascular or neurologic complications. During in-hospital stay, there were seven complications, which needed 12 operative revisions: three wound infections, two hematomas, one screw malalignment and one early screw loosening. In 28 patients with 56 iliosacral screws, a pelvic CT-scan was performed during follow-up. A penetration of a cortical layer was diagnosed in 20 of these screws. All penetrations were seen in double screw osteosynthesis of S1. In none of the patients, complaints could be explained by the malalignment of these screws. Five operative revisions were performed during follow-up: two for screw loosening, two for fracture healing problems and one for screw malalignment. Metal removal was performed in 39 patients with 75 screws. 2D-fluoroscopic-guided iliosacral screw osteosynthesis is a safe and efficient procedure in clinical practice.

Discussion

A thorough preoperative evaluation of the morphology of the upper sacrum and careful operative procedure are indispensable. Fluoroscopic views in AP, lateral, inlet and outlet must allow recognition of all anatomical landmarks. The indication for double screw osteosynthesis in S1 should be taken with caution. Screw malalignments do not inevitably correlate with complaints.

Risks and Strategies to Avoid Approach-Related Complications During Operative Treatment of Pelvic Ring or Acetabular Fractures

Injuries of the pelvic ring or the acetabulum are either to be found in young patients with high energy trauma mechanisms or in geriatric patients after simple falls with very low impact energy. The indication for surgical stabilization is given by the grade of instability. Exact knowledge of the different possible surgical approaches is essential for the planning of the surgical treatment. Both, knowledge of reachable anatomical structures and possible risks of the different approaches are important. In this review, we summarize the standard surgical approaches to the pelvic ring and to the acetabulum. We describe the reachable anatomical structures for each approach, approach-related pitfalls, and we focus on strategies to reduce approach-related complications.

[Fragility fractures of the pelvis]

Fragility fractures of the pelvis are increasing in frequency. In most cases patients suffer a minor injury, have intense pain in the pelvic region and impaired mobility. The new fragility fractures of the pelvis (FFP) classification distinguishes between four types with increasing instability. The FFP types I and II are treated conservatively. For FFP types III and IV and type II with unsuccessful conservative treatment, minimally invasive stabilizing techniques are recommended. Both the posterior and anterior pelvic ring must be stabilized. Alternative techniques for dorsal stabilization are iliosacral screw and transsacral bar osteosynthesis, transiliac internal fixator and lumbopelvic fixation. External fixation, retrograde transpubic screw fixation, anterior internal fixation and plate and screw osteosynthesis are alternatives for the anterior pelvic ring. Treatment of fragility fractures of the pelvis should be carried out as part of an orthogeriatric co-management.