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The Journal of the American Academy of... Feb 2024Pelvic ring injuries occur in varying severity and in vastly different patient demographics. Knowledge regarding which of these injuries require surgical intervention... (Review)
Review
Pelvic ring injuries occur in varying severity and in vastly different patient demographics. Knowledge regarding which of these injuries require surgical intervention and which can be managed nonsurgically continues to evolve. Previous studies have shown validated criteria for sacral fractures and the posterior ring, explored the role of examination under anesthesia, and other forms of dynamic imaging. Although there is substantial information available, a comprehensive synthesis of this information is lacking. This article provides a comprehensive review of radiographic markers suggestive of stability, discusses treatment strategies, and proposes a treatment algorithm that is easily understood and applicable to not only those with a trauma background but also the general orthopaedic surgeon who will see these injuries frequently while on call.
Topics: Humans; Anesthesia; Fractures, Bone; Pelvic Bones; Spinal Fractures
PubMed: 37816188
DOI: 10.5435/JAAOS-D-23-00470 -
The Journal of the American Academy of... Sep 2019Treatment of anterior pelvic ring injuries involves both acute stabilization during the initial resuscitation and definitive fixation. Definitive management has evolved... (Review)
Review
Treatment of anterior pelvic ring injuries involves both acute stabilization during the initial resuscitation and definitive fixation. Definitive management has evolved substantially over the past 40 years with improved patient mobilization and long-term outcomes. Although its use has recently declined, external fixation remains a favorable option in certain situations. Symphyseal plating is the preferred technique for stabilization of symphyseal diastasis because of superior stability and low morbidity. Ramus screws can be effective for simple ramus fractures but require a careful technique because of the proximity of neurovascular structures. The subcutaneous internal fixator provides a good option for obese patients in whom external fixation would be poorly tolerated. Regardless of fixation strategy, posterior ring reduction and stabilization is crucial.
Topics: Bone Plates; Bone Screws; External Fixators; Fracture Fixation; Fractures, Bone; Humans; Internal Fixators; Pelvic Bones
PubMed: 30889037
DOI: 10.5435/JAAOS-D-17-00839 -
Journal of Orthopaedic Trauma Dec 2019Pediatric pelvic fractures are rare and differ from adults in etiology, fracture type, and associated injuries. They are observed in multitrauma patients, with severe... (Review)
Review
Pediatric pelvic fractures are rare and differ from adults in etiology, fracture type, and associated injuries. They are observed in multitrauma patients, with severe associated injuries. Treatment of these children in specialized hospitals is likely to provide the best outcome because of the rarity of these fractures. Only a small percentage of the fractures, particularly the displaced ones, need operative treatment with the aim to restore the anatomy of the pelvic ring. In a significant proportion of the operated patients, morbidity and mortality were not linked to the pelvic fractures but to the other associated injuries. Long-term prognosis depends on restoring pelvic symmetry. Nondisplaced fractures of the acetabulum or fractures with minimal displacement with a relatively low roof-arc angle or crush injuries of the triradiate physis are managed nonoperatively. In young patients where continuation of growth is expected, fixation that does not cross the physis anatomically could be used. In some very young children, plate removal may be indicated to allow for continued growth of the acetabulum. One of the major complications in this patient cohort is acetabular dysplasia.
Topics: Acetabulum; Adolescent; Age Factors; Bone Nails; Bone Plates; Child; Female; Fracture Fixation, Internal; Fracture Healing; Fractures, Bone; Humans; Injury Severity Score; Male; Pediatrics; Pelvic Bones; Rare Diseases; Risk Assessment; Sex Factors
PubMed: 31688525
DOI: 10.1097/BOT.0000000000001644 -
Journal of Orthopaedic Research :... Mar 2021Unstable pelvic ring fractures are severe and complex injuries, and surgical fixation is challenging and can be complicated by early failure due in part to difficulties...
Unstable pelvic ring fractures are severe and complex injuries, and surgical fixation is challenging and can be complicated by early failure due in part to difficulties with securely fixing screws in low-density bone. There is limited information in the literature about how the density distribution across the pelvic bones changes with age and sex. In this study, we used 60 sets of calibrated bone density measurements obtained opportunistically from clinical computed tomography scans of the pelvis. Three-dimensional models of the innominate bone were produced and the effects of age and sex on cortical bone density modeled. Overall trends and regions where these factors had a significant effect were identified, and the results visualized. Across the entire innominate bone, the mean loss of density was found to be 1.6 mg/cc per year, with several specific areas (pubic body, iliac fossa, posterior ilium, and anterior inferior iliac spine for example) showing significant rates of loss up to three times greater than the rest of the bone. Areas significantly affected by sex included the posterior pubic root, anterior aspect of the pubic body, and iliac crest. Despite overall trends of attenuation, there remains significant variability between individuals. This supports the need to further explore subject-specific planning tools for pelvic fracture repair. Statement of clinical significance: Bone density changes across the innominate bone due to age and sex tend to vary between individuals, although consistent effects were seen at specific regions. This information may help in surgical planning of unstable fracture repairs.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Aging; Bone Density; Cortical Bone; Female; Humans; Male; Middle Aged; Pelvic Bones; Retrospective Studies; Sex Characteristics; Tomography, X-Ray Computed; Young Adult
PubMed: 32617998
DOI: 10.1002/jor.24792 -
European Journal of Orthopaedic Surgery... Apr 2023Although improvement of pelvic trauma care has been successful in decreasing mortality rates in major trauma centers, such changes have not been implemented in... (Review)
Review
Although improvement of pelvic trauma care has been successful in decreasing mortality rates in major trauma centers, such changes have not been implemented in low-resource environments such as low-middle-income countries (LMICs). This review details the evaluation and management of pelvic ring fractures and recommends improvements for trauma care in low-resource environments. Prehospital management revolves around basic life support techniques. Application of non-invasive pelvic circumferential compression devices, such as bed sheet or pelvic binders, can be performed as early as the scene of the accident. Upon arrival at the emergency department, rapid clinical evaluation and immediate resuscitation should be performed. Preperitoneal pelvic packing and external fixation devices have been considered as important first-line management tools to achieve bleeding control in hemodynamically unstable patients. After patient stabilization, immediate referral is mandated if the hospital does not have an orthopedic surgeon or facilities to perform complex pelvic/acetabular surgery. Telemedicine platforms have emerged as one of the key solutions for informing decision-making. However, unavailable referral systems and inaccessible transportation systems act as significant barriers in LMICs. Tendencies toward more "old-fashioned" protocols and conservative treatments are often justified especially for minimally displaced fractures. But when surgery is needed, it is important to visualize the fracture site to obtain and maintain a good reduction in the absence of intraoperative imaging. Minimizing soft tissue damage, reducing intraoperative blood loss, and minimizing duration of surgical interventions are vital when performing pelvic surgery in a limited intensive care setting.
Topics: Humans; Fractures, Bone; Pelvis; Pelvic Bones; Acetabulum; External Fixators
PubMed: 36333484
DOI: 10.1007/s00590-022-03420-x -
Zeitschrift Fur Gerontologie Und... Jul 2022Sacral fractures in geriatric patients are increasing and form a distinct entity. Clinical findings can be unspecific, which is why they are easily overlooked. It is...
Sacral fractures in geriatric patients are increasing and form a distinct entity. Clinical findings can be unspecific, which is why they are easily overlooked. It is mandatory to analyze the whole pelvic ring for evaluation of pelvic stability and for making treatment decisions. The primary diagnostics are made using plain X‑radiography; however, for assessment of the posterior pelvic ring an examination using sectional imaging is regularly necessary. The fragility fractures of the pelvis (FFP) classification is suitable as a guideline for the surgical treatment to be used. Stable fractures without relevant displacement after initial mobilization should be treated conservatively. Instability, failure of mobilization and persistent pain are, however, common reasons for surgical treatment. Fracture displacement determines if minimally invasive procedures for posterior and anterior pelvic ring stabilization are possible. Otherwise, complex open procedures such as spinopelvic fixation may be necessary.
Topics: Aged; Fracture Fixation, Internal; Fractures, Bone; Humans; Pelvic Bones; Retrospective Studies; Spinal Fractures
PubMed: 35641795
DOI: 10.1007/s00391-022-02061-3 -
Acta Chirurgiae Orthopaedicae Et... 2024Pelvic reconstructions after massive bone resections are among the most challenging practices in orthopedic surgery. Whether the bone gap results after a trauma, a tumor...
PURPOSE OF THE STUDY
Pelvic reconstructions after massive bone resections are among the most challenging practices in orthopedic surgery. Whether the bone gap results after a trauma, a tumor resection, or it is due to a prosthetic revision, it is mandatory to reconstruct pelvic bone continuity and rebuild the functional thread that connects spine and hip joint. Several different approaches have been described in literature through the decades to achieve those goals.
MATERIAL AND METHODS
To this date, 3D-printed implants represent one of the most promising surgical technologies in orthopedic oncology and complex reconstructive surgery. We present our experience with 3D-printed custom-made pelvic prostheses to fulfi ll bone gaps resulting from massive bone loss due to tumor resections. We retrospectively evaluated 17 cases treated with pelvic bone reconstruction using 3D-printed prostheses. Cases were evaluated in terms of both oncological and functional outcomes.
RESULTS
At the last follow-up, local complications were found in 6 cases (36%): in 4 (23.5%) of them the cause was a local recurrence of the disease, whereas only 2 (12.5%) had non-oncologic issues. The mean MSTS score in our population increased from 8.2 before surgery to 22.3 at the latest clinical control after surgery.
DISCUSSION
3D-printing technology, used to produce cutting jigs and prosthetic implants, can lead to good clinical and functional outcomes. These encouraging results are comparable with the ones obtained with other more frequently used reconstructive approaches and support custom-made implants as a promising reconstructive approach.
CONCLUSIONS
Our data confi rm 3D-printing and custom-made implants as promising technologies that could shape the next future of orthopedic oncology and reconstructive surgery.
KEY WORDS
custom made prosthesis, pelvic reconstruction, orthopedic oncology, cutting jigs, 3D-printing.
Topics: Humans; Retrospective Studies; Printing, Three-Dimensional; Technology; Pelvic Bones; Arthrodesis; Neoplasms
PubMed: 38447560
DOI: 10.55095/achot2024/004 -
Computer Methods in Biomechanics and... May 2022The objective is developing an XFEM model that is capable of predicting different types of fracture in the pelvic bone under various loading conditions. Previously...
The objective is developing an XFEM model that is capable of predicting different types of fracture in the pelvic bone under various loading conditions. Previously published mechanical and failure characteristics of cortical and cancellous tissues were implemented and assigned to an intact pelvic bone with specified cortical and cancellous tissues. Various loading conditions, including combined load directions, were applied to the acetabulum to model different types of fracture (e.g., anterior/posterior wall fracture and transverse fracture) in the pelvic bone. The predicated types of fracture and the maximum force at fracture were compared to those acquired from previously published experimental tests. Anterior/posterior wall fracture and transverse fracture were the most common types of fractures determined in the simulations. The XFEM simulations were able to predict similar fractures to those reported in the experimental tests. The maximum fracture force in the XFEM model was found to be 18.6 kN compared to 8.85 kN reported in the previous experimental tests. The results revealed that different types of fracture in the pelvic bones can be caused by the various loading conditions in unstable high-rate impact loads. Using proper mechanical and failure behaviors of cortical and cancellous tissues, XFEM modeling of pelvic bone is capable of predicting bone fracture. In future work, the XFEM models of cancellous and cortical tissues can be assigned to other bones in human body skeleton so that the failure mechanism in such bones can be investigated.
Topics: Acetabulum; Finite Element Analysis; Fractures, Bone; Humans; Pelvic Bones
PubMed: 34587835
DOI: 10.1080/10255842.2021.1981883 -
Acta Bio-medica : Atenei Parmensis Dec 2019Pelvic ring fractures represent a challenge for orthopaedic surgeon. Their management depends on patient's condition, pattern of fracture and associated injuries....
BACKGROUND AND AIM
Pelvic ring fractures represent a challenge for orthopaedic surgeon. Their management depends on patient's condition, pattern of fracture and associated injuries. Optimal timing for synthesis is not yet clear. The aim of this study was to define if surgical timing influenced clinic and radiographic outcomes following open reduction and internal fixation for Tile B and C fractures.
MATERIALS AND METHODS
38 patients were included. Patients underwent a clinical examination with the Majeed Score, Iowa Pelvic Score and Orlando Pelvic Score. The radiographic assessment was performed according to Matta Pelvic Score. A statistical analysis of the data compared patients who were operated within 3 weeks (group 1) and those operated later (group 2).
RESULTS
Both clinical and radiological outcomes were influenced by timing of surgery.
CONCLUSION
Pelvic ring fractures interest many polytrauma patients and, therefore, their surgical orthopedic approach is frequently delayed as consequence of the severity of the associated clinical conditions. An early surgery of pelvic rong fractures allows a better quality of reduction and osteosynthesis.
Topics: Adult; Female; Fracture Fixation, Internal; Fractures, Bone; Humans; Male; Middle Aged; Open Fracture Reduction; Pelvic Bones; Radiography; Time Factors; Treatment Outcome
PubMed: 31821288
DOI: 10.23750/abm.v90i12-S.8949 -
Korean Journal of Radiology May 2023To investigate the association between pelvic bone computed tomography (CT)-derived body composition and patient outcomes in older adult patients who underwent surgery...
OBJECTIVE
To investigate the association between pelvic bone computed tomography (CT)-derived body composition and patient outcomes in older adult patients who underwent surgery for proximal femur fractures.
MATERIALS AND METHODS
We retrospectively identified consecutive patients aged ≥ 65 years who underwent pelvic bone CT and subsequent surgery for proximal femur fractures between July 2018 and September 2021. Eight CT metrics were calculated from the cross-sectional area and attenuation of the subcutaneous fat and muscle, including the thigh subcutaneous fat (TSF) index, TSF attenuation, thigh muscle (TM) index, TM attenuation, gluteus maximus (GM) index, GM attenuation, gluteus medius and minimus (Gmm) index, and Gmm attenuation. The patients were dichotomized using the median value of each metric. Multivariable Cox regression and logistic regression models were used to determine the association between CT metrics with overall survival (OS) and postsurgical intensive care unit (ICU) admission, respectively.
RESULTS
A total of 372 patients (median age, 80.5 years; interquartile range, 76.0-85.0 years; 285 females) were included. TSF attenuation above the median (adjusted hazard ratio [HR], 2.39; 95% confidence interval [CI], 1.41-4.05), GM index below the median (adjusted HR, 2.63; 95% CI, 1.33-5.26), and Gmm index below the median (adjusted HR, 2.33; 95% CI, 1.12-4.55) were independently associated with shorter OS. TSF index (adjusted odds ratio [OR], 6.67; 95% CI, 3.13-14.29), GM index (adjusted OR, 3.45; 95% CI, 1.49-7.69), GM attenuation (adjusted OR, 2.33; 95% CI, 1.02-5.56), Gmm index (adjusted OR, 2.70; 95% CI, 1.22-5.88), and Gmm attenuation (adjusted OR, 2.22; 95% CI, 1.01-5.00) below the median were independently associated with ICU admission.
CONCLUSION
In older adult patients who underwent surgery for proximal femur fracture, low muscle indices of the GM and gluteus medius/minimus obtained from their cross-sectional areas on preoperative pelvic bone CT were significant prognostic markers for predicting high mortality and postsurgical ICU admission.
Topics: Female; Humans; Aged; Aged, 80 and over; Proximal Femoral Fractures; Retrospective Studies; Pelvic Bones; Body Composition; Tomography
PubMed: 37133212
DOI: 10.3348/kjr.2022.0835