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The Journal of the American Academy of... Dec 2019Surgical treatment of the pelvic ring and acetabulum continues to evolve. Improved imaging technology and means for closed reduction have meant that percutaneous... (Review)
Review
Surgical treatment of the pelvic ring and acetabulum continues to evolve. Improved imaging technology and means for closed reduction have meant that percutaneous techniques have gained popularity in the treatment of the pelvic ring and, more recently, in the acetabulum. Potential benefits include decreased soft-tissue dissection, blood loss, and surgical time. However, these are technically demanding procedures that require substantial expertise from both the surgeon and the radiographer. This article details the necessary fluoroscopic views and general methods used in percutaneous techniques around the pelvis and acetabulum. Despite most studies reporting good-to-excellent clinical and radiographic results, further work is needed to facilitate standardization and optimization of these outcomes.
Topics: Acetabulum; Bone Screws; Clinical Competence; Fluoroscopy; Fracture Fixation, Internal; Hip Fractures; Humans; Pelvic Bones
PubMed: 31192885
DOI: 10.5435/JAAOS-D-18-00102 -
Asian Journal of Surgery Jan 2021Straddle fracture, a superior and inferior ramus fracture of both sides, is generally treated conservatively. However, posterior pelvic ring injury is often associated... (Review)
Review
Straddle fracture, a superior and inferior ramus fracture of both sides, is generally treated conservatively. However, posterior pelvic ring injury is often associated with straddle fracture, leading to unstable pelvic bone fracture that requires surgical treatment. The present study reports the clinical and radiological outcomes of straddle fracture with posterior pelvic ring injury. This study included 73 patients (41 men, 32 women) with a straddle fracture injury. The injury mechanism, injury severity score (ISS), accompanying injuries, presence of posterior pelvic ring injury, and fixation methods for the pelvic fracture were analyzed, and outcomes were evaluated functionally and radiologically. Of the 73 patients, 56 (77%) had a posterior pelvic ring injury and 7 died. In 43 patients, the posterior pelvic ring injuries constituted unstable pelvic injury and were treated surgically. The fixation method was determined based on the severity of the posterior pelvic injury. The patients' mean ISS was 24.7 points. Radiological evaluation of surgical outcomes in 43 patients revealed the outcomes as anatomic in 20, nearly anatomic in 14, moderate in 5, and poor in 4, whereas functional evaluation revealed the outcomes as excellent in 21, good in 9, fair in 7, and poor in 6. Posterior pelvic ring fracture can accompany straddle fractures, which may lead to pelvic injury instability. Thus, special attention is required for patients with a straddle fracture.
Topics: Adult; Aged; Female; Fracture Fixation, Internal; Fractures, Bone; Humans; Male; Middle Aged; Pelvic Bones; Pelvis; Radiography; Trauma Severity Indices; Treatment Outcome; Young Adult
PubMed: 32376214
DOI: 10.1016/j.asjsur.2020.03.021 -
Injury Aug 2023Pelvic ring injuries comprise a spectrum of bony, ligamentous and muscular injuries, described by several common classification systems. However, the majority of... (Review)
Review
Pelvic ring injuries comprise a spectrum of bony, ligamentous and muscular injuries, described by several common classification systems. However, the majority of injuries lie in areas of intermediate severity, where complexity and variable nature make it extremely hard to define in detail. This fact and associated injuries make it extremely difficult to conduct randomised control trials, with purpose to direct treatment guidelines. Thus, special interest and expertise are required by pelvic trauma surgeons, while surgical indications and fixation methods rely on their experience, at least in part. Namely, a significant grey zone of indication exists. As fixation methods evolve, specifically percutaneous fixation using osseous fixation pathways, some injuries in which morbidity bound with surgical fixation was considered too high relative to its benefits, may be considered eligible for surgical treatment nowadays. Moreover, due to significant progress in the treatment of the acute polytrauma casualties, the survival rate increased over the years, emphasizing the effect of long-term morbidity and functional outcome of pelvic ring injuries. The purpose of this manuscript is to describe the equivocal areas of controversies, hence "the grey zone", and to provide the readership with up-to-date published data. We aimed to collect and detail clinical and radiological clues in the diagnosis of intermediate unstable anterior-posterior compression and lateral compression injuries, and for the selection of treatment methods and sequence. Recent publications have provided some insights into specific injury features that are correlated with increased chance of instability, pain and delay in ambulation. Specific focus is given to the utility of examination under anaesthesia in selected cases. Other publications surveyed the shared experience of pelvic trauma surgeons as for the classification, indication and treatment sequence of pelvic ring injuries. Although the data hasn't matured yet to a comprehensive treatment algorithm, it may serve clinicians well when making treatment decisions in the grey zone of pelvic ring injuries, and serve as a basis for future prospective studies.
Topics: Humans; Fractures, Bone; Pelvic Bones; Prospective Studies; Fracture Fixation; Radiography; Fracture Fixation, Internal; Retrospective Studies
PubMed: 37453290
DOI: 10.1016/j.injury.2023.110887 -
The American Surgeon Jul 2022Pelvic fractures are often complicated by hemorrhage contributing to morbidity and mortality. Management of these patients is multifaceted and computed tomography (CT)...
BACKGROUND
Pelvic fractures are often complicated by hemorrhage contributing to morbidity and mortality. Management of these patients is multifaceted and computed tomography (CT) imaging plays an integral diagnostic role. The purpose of this study was to identify radiographic and clinical predictors of therapeutic angiography in patients with blunt pelvic fractures.
METHODS
All patients with blunt pelvic fractures who underwent angiography following admission CT scan were identified over a 6-year period. A radiologist reviewed the CT scans to identify potential predictors of pelvic hemorrhage. Patients were stratified by intervention [therapeutic angiography (TA) vs non-therapeutic angiography (NTA)] and compared. Multivariable logistic regression (MLR) was performed to determine independent predictors of TA. Youden's index was used to identify the optimal value of selected predictors identified on MLR.
RESULTS
177 patients were identified: 42% underwent TA and 58% underwent NTA. Patients undergoing TA were more likely to have a higher injury burden and greater resuscitative transfusion requirements, display both a brighter blush density on arterial phase CT and a larger % change in arterial to venous phase blush density. The optimal arterial blush density was determined to be 250 HU. MLR identified pre-angiography transfusion requirements (OR 1.175; 95% CI 1.054-1.311, = .0189) and arterial blush density (OR 1.011; 95% CI 1.005-1.016, < .0001) as independent predictors of therapeutic angiography.
CONCLUSION
CT imaging remains vital in assessing patients with pelvic fractures and associated hemorrhage following blunt trauma. For patients requiring multiple resuscitative transfusions with CT findings of an arterial blush measuring ≥250 HU, early angiography should be the preferred approach.
Topics: Angiography; Embolization, Therapeutic; Fractures, Bone; Hemorrhage; Humans; Pelvic Bones; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 35404149
DOI: 10.1177/00031348221080429 -
The Surgeon : Journal of the Royal... Jun 2022Horse riding related accidents can present with devastating pelvic and acetabular fractures. This study examines the nature, management and treatment outcomes of severe...
INTRODUCTION
Horse riding related accidents can present with devastating pelvic and acetabular fractures. This study examines the nature, management and treatment outcomes of severe pelvic and acetabular trauma in amateur horse riders presenting to a national tertiary referral centre. We also aim to define certain at-risk groups.
METHODS
This was a retrospective descriptive cohort of all patients who were referred to the National Centre for Pelvic and Acetabular trauma resulting from horse riding accidents. All patients who were referred to the National Centre for Pelvic and Acetabular Trauma between January 2018 and July 2020 were included. Professional horse riders were excluded. Clinical and treatment outcome measures were stratified to four different mechanisms of injury: fall from horse (FFH), horse crush (HC), Horse Kick (HK) and Saddle Injury (SI).
RESULTS
There were 31 equestrian related injuries referred to our centre between January 2018 and July 2020. One patient was a professional jockey and was thus excluded from the study. Eighteen were female and the mean age at referral was 37 years old. The majority of these were pelvic ring injuries (73%). Fifty per cent of patients required surgical intervention and the majority of these were male.
CONCLUSION
Horse riding is a potentially dangerous recreational pursuit with significant risk of devastating injury. Pelvic and acetabular fractures secondary to horse riding are frequently associated with other injuries and the need operative intervention is common in this group. Young women and older men are higher risk groups.
Topics: Accidental Falls; Acetabulum; Aged; Animals; Athletic Injuries; Female; Fractures, Bone; Hip Fractures; Horses; Humans; Male; Pelvic Bones; Retrospective Studies
PubMed: 33975806
DOI: 10.1016/j.surge.2021.04.001 -
Zeitschrift Fur Orthopadie Und... Apr 2023The "floating hip" is a rare and complex fracture involving the pelvis and the ipsilateral femur and is therefore difficult to treat. Data and studies on this topic are...
INTRODUCTION
The "floating hip" is a rare and complex fracture involving the pelvis and the ipsilateral femur and is therefore difficult to treat. Data and studies on this topic are still scarce. The optimal strategy for surgical treatment and thus the resulting quality of treatment are still being debated; a femur-first strategy is often the preferred treatment.
METHODS
Retrospectively, patients with a pelvic fracture treated at the Level I Trauma Centre of the University of Tübingen between 2003 and 2017 were identified. Patients with an additional ipsilateral femur fracture were identified in this collective. We compared the quality of treatment of pelvic fractures between floating and non-floating hip injuries.
RESULTS
Proximal femur fractures were more common with pelvic ring fractures (n = 16) than with acetabular fractures (n = 1). Floating hip injuries occur more frequently in younger polytraumatised male patients. Pelvic fractures in floating hip injuries are operated more frequently (62.8% vs. 39.1%; p = 0.003) and the clinical course is significantly longer (27.8 ± 19.3 vs. 19.9 ± 23.1 days; p < 0.001). However, the quality of treatment of pelvic fracture, exemplified by morbidity (18.6% vs. 14.6%; p = 0.610) and mortality (7.0% vs. 2.6%; p = 0.108), shows no differences.
CONCLUSION
Injury severity and complexity of pelvic fracture is significantly higher in floating hip injuries, but without affecting the resulting quality of treatment. A "femur first" treatment strategy is preferable. Algorithms for emergency treatment and definitive care are proposed in a flowchart.
Topics: Humans; Male; Retrospective Studies; Fractures, Bone; Femoral Fractures; Hip Fractures; Pelvic Bones; Hip Injuries; Acetabulum
PubMed: 36195111
DOI: 10.1055/a-1918-2243 -
Journal of Orthopaedics and... May 2020Iliosacral screw fixation is safe and effective but can be complicated by loss of fixation, particularly in patients with osteopenic bone. Sacral morphology dictates...
BACKGROUND
Iliosacral screw fixation is safe and effective but can be complicated by loss of fixation, particularly in patients with osteopenic bone. Sacral morphology dictates where iliosacral screws may be placed when stabilizing pelvic ring injuries. In dysmorphic sacra, the safe osseous corridor of the upper sacral segment (S1) is smaller and lacks a transsacral corridor, increasing the need for fixation in the second sacral segment (S2). Previous evidence suggests that S2 is less dense than S1. The aim of this cross-sectional study is to further evaluate bone mineral density (BMD) of the S1 and S2 iliosacral osseous pathways through morphology stratification into normal and dysmorphic sacra.
MATERIALS AND METHODS
Pelvic computed tomography scans of 50 consecutive trauma patients, aged 18 to 50 years, from a level 1 trauma center were analyzed prospectively. Five radiographic features (upper sacral segment not recessed in the pelvis, mammillary bodies, acute alar slope, residual S1 disk, and misshapen sacral foramen) were used to identify dysmorphic characteristics, and sacra with four or five features were classified as dysmorphic. Hounsfield unit values were used to estimate the regional BMD of S1 and S2. Student's t-test was utilized to compare the mean values at each segment, with statistical significance being set at p < 0.05. No change in clinical management occurred as a result of inclusion in this study.
RESULTS
A statistical difference in BMD was appreciated between S1 and S2 in both normal and dysmorphic sacra (p < 0.0001), with 28.4% lower density in S2 than S1. Further, S1 in dysmorphic sacra tended to be 4% less dense than S1 in normal sacra (p = 0.047). No difference in density was appreciated at S2 based on morphology.
CONCLUSIONS
Our results would indicate that, based on BMD alone, fixation should be maximized in S1 prior to fixation in S2. In cases where S2 fixation is required, we recommend that transsacral fixation should be strongly considered if possible to bypass the S2 body and achieve fixation in the cortical bone of the ilium and sacrum.
LEVEL OF EVIDENCE
Level III.
Topics: Adolescent; Adult; Bone Density; Bone Screws; Cross-Sectional Studies; Female; Humans; Ilium; Male; Middle Aged; Orthopedic Procedures; Pelvic Bones; Sacrum; Tomography, X-Ray Computed; Young Adult
PubMed: 32451838
DOI: 10.1186/s10195-020-00545-9 -
Journal of Neurosurgery. Spine Dec 2022The purpose of this study was to describe the genesis of the AO Spine Sacral and Pelvic Classification System in the context of historical sacral and pelvic grading... (Review)
Review
OBJECTIVE
The purpose of this study was to describe the genesis of the AO Spine Sacral and Pelvic Classification System in the context of historical sacral and pelvic grading systems.
METHODS
A systematic search of MEDLINE, EMBASE, Google Scholar, and Cochrane databases was performed consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all existing sacral and pelvic fracture classification systems.
RESULTS
A total of 49 articles were included in this review, comprising 23 pelvic classification systems and 17 sacral grading schemes. The AO Spine Sacral and Pelvic Classification System represents both the evolutionary product of these historical systems and a reinvention of classic concepts in 5 ways. First, the classification introduces fracture types in a graduated order of biomechanical stability while also taking into consideration the neurological status of patients. Second, the traditional belief that Denis central zone III fractures have the highest rate of neurological deficit is not supported because this subgroup often includes a broad spectrum of injuries ranging from a benign sagittally oriented undisplaced fracture to an unstable "U-type" fracture. Third, the 1990 Isler lumbosacral system is adopted in its original format to divide injuries based on their likelihood of affecting posterior pelvic or spinopelvic stability. Fourth, new discrete fracture subtypes are introduced and the importance of bilateral injuries is acknowledged. Last, this is the first integrated sacral and pelvic classification to date.
CONCLUSIONS
The AO Spine Sacral and Pelvic Classification is a universally applicable system that redefines and reorders historical fracture morphologies into a rational hierarchy. This is the first classification to simultaneously address the biomechanical stability of the posterior pelvic complex and spinopelvic stability, while also taking into consideration neurological status. Further high-quality controlled trials are required prior to the inclusion of this novel classification within a validated scoring system to guide the management of sacral and pelvic injuries.
Topics: Humans; Retrospective Studies; Sacrum; Pelvic Bones; Fractures, Bone; Pelvis; Spinal Fractures
PubMed: 35907199
DOI: 10.3171/2022.5.SPINE211468 -
Injury Oct 2021There exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive...
INTRODUCTION
There exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive survey on the management of pelvic ring injuries among an international group of pelvic trauma surgeons to determine areas of agreement and disagreement.
METHODS
A 45-item questionnaire was developed using an online survey platform and distributed to 30 international pelvic trauma surgeons. The survey consisted of general questions on the acute management of pelvic ring injuries and questions regarding 5 cases: Lateral compression (LC) type 1 injury, LC-3, Anterior-posterior compression (APC) type 3 injury, a combined vertical shear (VS) injury through the sacrum, and VS injury through sacroiliac joint. Respondents were shown blinded anteroposterior pelvis radiographs and axial computed tomography (CT) images for each case and asked if the injury needed fixation, the type of fixation, the order of fixation, and postoperative weight-bearing status. The Kappa statistic was calculated to assess agreement between respondents for each question.
RESULTS
Nineteen out of 30 pelvic trauma surgeons completed the survey. Respondents practiced in Brazil (n = 1), Germany (n = 1), India (n = 1), Italy (n = 1) United Kingdom (n = 1), and the United States (n = 14). Of the 45 questions in this survey, 38 (84%) had minimal to no agreement among the respondents. There was moderate agreement, for performing lumbopelvic fixation when indicated, for anterior and posterior fixation of the LC-3 injury, and on forgoing EUA or stress X-rays for the APC-3 injury. There was strong agreement for open reduction and internal fixation of the anterior pelvic ring in the APC-3 injury and the VS injury through the SI joint. In contrast, LC-1 injury and combined VS pelvic ring injury through the sacrum had no areas of moderate to strong agreement.
DISCUSSION
This study identified specific areas of pelvic ring injury management with minimal to no agreement among pelvic trauma surgeons. Future research should target these areas with a lack of agreement to decrease practice variability and improve patient outcomes.
Topics: Fracture Fixation, Internal; Fractures, Bone; Humans; Pelvic Bones; Retrospective Studies; Surgeons; Surveys and Questionnaires
PubMed: 32943214
DOI: 10.1016/j.injury.2020.07.027 -
International Orthopaedics Sep 2023Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged...
PURPOSE
Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe.
METHODS
A standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents).
RESULTS
The Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization).
CONCLUSION
The Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences' impact on outcomes needs to be further explored.
Topics: Humans; Fractures, Bone; Fracture Fixation, Internal; Pelvic Bones; Tomography, X-Ray Computed; Pelvis; Retrospective Studies
PubMed: 37328569
DOI: 10.1007/s00264-023-05859-x