Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures

BACKGROUND

There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment.

MATERIALS AND METHODS

The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment.

RESULTS

Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated.

CONCLUSIONS

This consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients.

LEVEL OF EVIDENCE

IV.

TRIAL REGISTRATION

not applicable (consensus paper).

Italian Consensus Conference on Guidelines for preoperative treatment in acetabular fractures

Preoperative management of acetabular fracture is a major problem and no consensus has been reached in literature on the optimal treatment of this problem. We present the results of the First Italian Consensus Conference on Acetabular fracture. An extensive review of the literature has been undertaken by the organizing committee and forwarded to the panel. Members were appointed by surgical experience with acetabular fractures. From November 2017 to January 2018, the organizing committee undertook the critical revision and prepared the presentation to the Panel on the day of the Conference. Then 11 recommendations were presented according to the 11 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on, a second debate took place in September 2018 to reach a unanimous consent. We present results of the following questions: does hip dislocation require reduction? Should hip reduction be performed as soon as possible? In case of unsuccessful reduction of the dislocation after attempts in the emergency department, how should it be treated? If there is any tendency toward renewed dislocation, how should it be treated? Should Computed Tomography (CT) scan be performed before reduction? Should traction be used? How can we treat the pain? Is preoperative ultrasound exam to rule out vein thrombosis always necessary? Is tranexamic acid intravenous (IV) preoperatively recommended? Which antibiotic prophylactic protocols should be used? Is any preoperative heterotopic ossification prophylaxis suggested? In this article we present the indications of the First Italian Consensus Conference: a hip dislocation should be reduced as soon as possible. If unsuccessful, surgeon may repeat the attempts optimizing the technique. Preoperative CT scan is not mandatory before reduction. Skeletal traction is not indicated in most of the acetabular fracture. Standard pain and antibiotic prophylactic protocols for trauma patient should be used. Preoperative ultrasound exam is not recommended in all acetabular fracture. Tranexamic acid should be preoperatively used. There is no indication for preoperative heterotopic ossification.

Rhizarthrosis Bilateral – Trapeziectomy Versus Arthroplasty with Dual Mobility Prosthesis: Case Report

Background: The trapeziometacarpal joint is the second joint affected by osteoarthritis in the hand. The symptoms and clinical presentation are characterized by pain, limited range of motion, muscle weakness with loss of strength, bone deformities and disability. The symptomatology often is not related to the radiographic grade of osteoarthrosis. Therefore, in addition to the radiographic stage of the disease, the treatment is influenced by multiple variables such as age, functional requirement, symptoms and stability of the joint. Objective: There are several options of surgical treatments. Although trapeziectomy and its technical variation is the gold standard for treatment, prosthesis replacement can be used with good results. This case report discusses the case of a 70-year-old male who presents bilateral trapeziometacarpal osteoarthrosis treated with two different techniques with different timelines. Methods: The patient underwent a trapeziectomy on the right hand and arthroplasty with implant on the left. In both TMC the stage of the disease was grade III according to the Eaton Litter classification and the results were evaluated according to clinical and radiographic criteria. The NPRS pain scale and the Quick Dash functional scale were used in subsequent checks. The mean follow-up was 12 months. Conclusion: There were no significantly different results with respect to pain, activities of daily living, mobility or strength. No complications were observed. The patient is satisfied with the treatment having found a better and earlier resumption of daily activity of the left hand treated with prosthesis replacement.

Why a surgically treated humeral shaft fracture became a nonunion: review of 11 years in two trauma centers

AIM

The aim of this study was to evaluate nonunion causes of surgically treated humeral shaft fractures in two different trauma centers.

METHODS

A total of 327 cases of humeral shaft fractures were treated in 11 years in two trauma centers. We retrospectively reviewed in detail some factors in order to understand the reasons for nonunion: (1) fracture type, according to the AO classification, (2) grade of open fracture, according to Gustilo-Anderson, (3) timing, (4) reduction and (5) fixation.

RESULTS

We observed 19 nonunions, 10 women and 9 men, with an average age of 57 years. Fractures were 1 A1 case, 2 A2 cases, 4 B2 cases, 6 B3 cases, 2 C1 cases, 1 C2 case and 3 C3 cases. Three cases had a simple fracture with two fragments; all the other were comminuted. Fifteen cases were closed, four open. The major criticalities observed were fracture comminution, exposure, unstable fixation and bone resorption. All 19 patients with nonunion underwent surgical fixation with compression plate and frozen cortical bone graft. A 4.5 LCP plate was used in 17 cases. The remaining 2 cases had an anatomical site-specific proximal humeral 3.5-mm LCP plate (Synthes, Paoli, PA, USA). In 17 patients, the nonunion healed: 15 cases treated with a 4.5 straight plate, and 2 cases with an anatomical site-specific proximal humeral 3.5 mm LCP plate, at a mean of 5 months. In 2 cases, consolidation was not reached.

CONCLUSIONS

We believe that humeral diaphyseal fractures should be treated surgically to avoid many complications. Our retrospective analysis indicates that factors that lead to a fixation failure are fracture comminution, open fracture, unstable fixation. The 19 nonunions treated with compression plating and frozen bone graft demonstrated consolidation in almost 90% of the cases.

Lumboiliac fixation in lumbosacral dislocation and associated injuries of the pelvis and lumbosacral junction: a long-term radiological and clinical follow-up

INTRODUCTION

The goal of the study was to evaluate both clinical and radiological outcome of a consecutive series of 11 patients submitted to lumboiliac fixation after lumbopelvic disjunction or associated injuries of the pelvis and lumbosacral tract in mid- and long-term follow-up.

MATERIAL AND METHODS

The following were evaluated from clinical charts: damage control preoperative procedures, surgery, and pre-, intra- and post-operative complications; imaging was also evaluated from the preoperative assessment to the final follow-up (4 to 13.2 years; average 7.2 years).

RESULTS

One patient died a few days after surgery; therefore, long-term follow-up was possible in 10 patients. One of the 10 patients could be evaluated only radiologically because he was non-compliant due to severe mental illness. There were four early complications: one patient had a massive pulmonary embolism, which was fatal; one had wound dehiscence; one developed pulmonary infection and one had caecal fistula, which was repaired by the general surgeon. Late complications were as follows: three patients required hardware removal or substitution because of deep infection (after 1year), system breakage (after 9 years) and screws loosening (after 7 years). Clinical evaluation was available in nine patients and was assessed using Oswestry forms and a Visual Analogue Scale (VAS). All patients were able to walk at least 1 kilometre without external support, two patients were using pain medication regularly and three patients were classified with severe disability at final follow-up. Degenerative changes in the joints close to the fused area were observed in two patients more than 10 years after the operation, but the correlation with surgery is questionable.

DISCUSSION

Lumbopelvic disjunctions generally follow high-energy trauma often involving internal thoracic and abdominal organs; therefore, a well-trained team approach is mandatory to preserve patient life and to provide adequate treatment of skeletal injuries. Mechanical complications may occur several years after surgery, thus a long-term follow-up is mandatory.

CONCLUSIONS

Lumbopelvic fixation is an effective surgical technique for treatment of spinopelvic disjunction. The patient numbers in this series, and in the literature in general, are low; therefore, a multicentre study is advisable to give evidence and statistical importance to our findings.

Bone graft from greater trochanter in posterior wall fractures with impacted fragments

Background

Posterior wall fracture is the most common acetabular fracture. Comminuted fractures with an impacted segment represent a subtype of this injury. The subchondral bone of the articular zone is compressed and causes a bone defect. The impacted fragment should be isolated, mobilized, and then reduced. A bone graft should be used to fill the gap. The other fragments are fixed following the reduction of the impacted segment.

Materials and methods

Ten patients with comminuted fractures and impacted segments with bone defects were enrolled in our study, from January 2010 to July 2012. Autogenous bone grafts from the greater trochanter were used to fill the gap in all patients. The reduction was achieved through the insertion of the graft above the impacted fracture, and plate fixation was performed subsequently. Merle d’Aubigne and Postel scoring, modified by Matta, was applied to evaluate the patients during follow-up. The mean follow-up was 12 months.

Results

The clinical results included one “excellent”, four “very good”, four “good” and one “poor”. Pain in the zone of graft harvesting was not detected in any patient. Femoral head necrosis was observed in one case. No other severe complications were detected.

Conclusions

Using an autogenous bone graft to fill the bone defect supplies excellent mechanical stability without any severe complications at the donor site. This surgical technique seems to be effective and safe in treating a comminuted fracture of the posterior wall in association with an impacted segment.

Level of evidence

Level IV.

Critical review of pelvic fractures associated with external iliac artery lesion: a series of six cases

INTRODUCTION

Bleeding associated with pelvic fracture mostly comes from the pre-sacral and lumbar venous plexus, or directly from the fracture site. Bleeding as a consequence of arterial lesion is less common (15-20%), and that resulting from lesion of the external iliac artery (EIA) is extremely rare. The mortality rate associated with iliac artery injury ranges from 38% to 72%. Total body CT-scan with contrast medium, angiography or packing can be performed when there is arterial injury. In some cases, embolisation can stop bleeding; however, when there is involvement of the aorta, common iliac artery or EIA, immediate surgery is mandatory. The aim of this study was to report our experience of pelvic fractures associated with EIA lesion.

MATERIALS AND METHODS

Six patients with pelvic fracture and associated rupture of the EIA have been observed at our unit from 2004 to 2009. According to Tile classification there were three cases of type C and two cases of type B fracture. One case was a two-column acetabular fracture. Angiography was performed in all cases.

RESULTS

Three patients died on the day of trauma: two after angiography, and one after surgery of vascular repair. Three patients survived: two underwent a hemipelvectomy, and one underwent hip disarticulation.

DISCUSSION

Haemodynamic instability in patients with pelvic ring fracture is usually because of venous bleeding from the pre-sacral and lumbar plexus, or from the fracture site. Arterial injury is present in around 20% of cases. EIA lesions require immediate surgical treatment to restore blood flow. Depending on the type of injury, vascular surgery can be associated with pelvic fracture stabilisation.

CONCLUSIONS

Pelvic ring fracture associated with an EIA lesion is extremely rare, with few cases reported in the literature. Angiography is used for diagnosis, and immediate surgical treatment is required to restore blood flow. Associated injuries and open fracture can lead to fatal complications or amputation. Rates of mortality and severe disability are extremely high.

Methods to avoid gamma nail complications

Femoral neck fractures are progressively increasing, due to higher survival rates, particularly among the female population. The gamma nail was created to treat intertrochanteric fracture types 31-A1, 31-A2 and 31-A3 and in some cases basicervical fractures of type 31-B2-1. Complications can be classified as intraoperative and postoperative. The intraoperative might be related to the nail's introduction site, lag and distal locking screw positions. Postoperative complications depend mostly on an incorrect surgical technique, which can lead to an inaccurate nail position and consequent implant failure. We rarely observe failures caused by severe bone osteoporosis.

Long-term results with cementless Fitek (or Fitmore) cups

Fitek cementless cups have been adopted in our department in 1989. The first 100 consecutive Fitek implants were analyzed clinically (Harris hip score) and radiographically (anteroposterior and lateral x-rays) with a mean follow-up of 9.7 years. We did not have any case of cup loosening or any other problem requiring cup revision. In this series, we had 86 excellent, 10 good, 2 fair, and 2 poor results. The 2 poor results were because of 2 cases of aseptic loosening of the stem (1 cemented and 1 cementless). The x-rays showed an average angle of cup inclination of 36.5 degrees (range 16 degrees -54 degrees ) after surgery and no variations at the last follow-up. Bidimensional linear wear of the acetabular component showed 6 cases of measurable wear with an average wear rate per year of 0.265 mm. The overall wear rate per year was 0.02 mm. At the time of the last follow-up examination, we had 3 femoral osteolysis and no case of acetabular osteolysis. In our series, we observed "lack of contact" zones above the polar depression in 71 cases immediately after surgery. The average thickness of these lines was 1 (range 0.5-3.5) mm. Of these, at the last follow-up, 61 cases (86%) showed a complete "filling" of the "lack of contact," whereas in 10 (24%), the "filling" was incomplete (4 cases still showing a radiolucent line [<or=0.5 mm] in zone II). In the first group with "complete filling," we found 23 (37%) cases with bone ingrowth and no migration of the cup, whereas 38 (63%) cases showed bone ingrowth with evidence of cup migration. The Mann-Whitney nonparametric U test and the Kruskal-Wallis test showed that the survival rate of the 100 analyzed cups, after a follow-up time of 9.7 years, was 100% (end point: revision for any cause). Fitek cup showed good clinicoradiographic results.

IMHS clinical experience in the treatment of peritrochanteric fractures. The results of a multicentric Italian study of 981 cases

This retrospective study evaluates the results obtained in five Italian departments of traumatology in the treatment of peritrochanteric (pertrochanteric and subtrochanteric) fractures by the intramedullary hip screw (IMHS; Smith & Nephew Richards, Memphis, TN, USA) nail. One thousand two hundred and seventy-three patients were treated with the IMHS nail between March 1992 and February 2000. The results of these operations were evaluated clinically and radiological in 981 patients. The 90.3% of patients could walk unaided or with simple support. Because of the low complication rate requiring re-operation (postoperative shaft fractures, screw penetrated the acetabulum, cut out and non-union) (1.7%), we think that this device is an advance in the treatment of peritrochanteric fractures.