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Archives of Orthopaedic and Trauma... Mar 2023The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and... (Review)
Review
PURPOSE
The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.
METHODS
A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.
RESULTS
A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.
CONCLUSION
The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.
Topics: Humans; United States; Venous Thromboembolism; Powders; Fractures, Bone; Pelvic Bones; Acetabulum
PubMed: 34854977
DOI: 10.1007/s00402-021-04278-0 -
Medical Engineering & Physics Nov 2023Endoprosthetic reconstruction of the pelvic bone using 3D-printed, custom-made implants has delivered early load-bearing ability and good functional outcomes in the...
Endoprosthetic reconstruction of the pelvic bone using 3D-printed, custom-made implants has delivered early load-bearing ability and good functional outcomes in the short term to individuals with pelvic sarcoma. However, excessive stress-shielding and subsequent resorption of peri‑prosthetic bone can imperil the long-term stability of such implants. To evaluate the stress-shielding performance of pelvic prostheses, we developed a sequential modeling scheme using subject-specific finite element models of the pelvic bone-implant complex and personalized neuromusculoskeletal models for pre- and post-surgery walking. A new topology optimization approach is introduced for the stress-shielding resistant (SSR) design of custom pelvic prostheses, which uses 3D-printable porous lattice structures. The SSR optimization was applied to a typical pelvic prosthesis to reconstruct a type II+III bone resection. The stress-shielding performance of the optimized implant based on the SSR approach was compared against the conventional optimization. The volume of the peri‑prosthetic bone predicted to undergo resorption post-surgery decreased from 44 to 18%. This improvement in stress-shielding resistance was achieved without compromising the structural integrity of the prosthesis. The SSR design approach has the potential to improve the long-term stability of custom-made pelvic prostheses.
Topics: Humans; Prosthesis Design; Prostheses and Implants; Pelvic Bones; Pelvis; Artificial Limbs; Finite Element Analysis
PubMed: 37985018
DOI: 10.1016/j.medengphy.2023.104012 -
Orthopaedic Surgery Apr 2022To evaluate the clinical outcomes of the treatment of unilateral unstable sacral fractures by fixation with the posterior INFIX (posterior pelvic ring screw-rod internal...
OBJECTIVE
To evaluate the clinical outcomes of the treatment of unilateral unstable sacral fractures by fixation with the posterior INFIX (posterior pelvic ring screw-rod internal fxation).
METHODS
Data of 60 patients with unilateral unstable sacral fractures who underwent surgery from March 2013 to March 2020 were retrospectively analyzed according to the selection criteria. All patients were associated with anterior pelvic ring injuries, and the operations were performed by the same team of surgeons. According to the different types of internal fixation, the patients were divided into two groups, which both included 30 patients: the posterior INFIX group and iliosacral screw fixation group. The demographic and clinical data of the two patient groups, such as age, sex, sacral fracture types based on the Denis classification, operation time, amount of intraoperative bleeding, intraoperative fluoros copy time, Majeed pelvic score at final follow-up, and quality of fracture reduction based on Mears and Velyvis's imaging classification criteria were collected by the same researcher and compared statistically.
RESULTS
All patients were continuously followed up for 23.17 ± 3.34 months (range, 12 to 46 months). All sacral fractures healed with an average healing time of 9.3 ± 2.24 months (range, 6 to 18 months). None of the patients had re-displacement of the fracture or fixation failure. Compared to the iliosacral screw group, the posterior INFIX group patients had more intraoperative bleeding (t = 3.59, P < 0.001), shorter operation time (t = 4.49, P < 0.001), and shorter intraoperative fluoroscopy time (t = 6.26, P < 0.001). There were no statistical differences between the two groups in terms of age, sex, fracture type, Majeed score, and quality of fracture reduction (P > 0.05). In the posterior INFIX group, one patient had a superficial wound infection and one patient complained of discomfort due to a prominent fixation. In the iliosacral screw fixation group, one patient had intraoperative iatrogenic S1 nerve injury and vessel injury. The posterior INFIX fixation was a simpler manipulation with higher safety, shorter time of operation and intraoperative fluoroscopy, and similar clinical outcomes compared to iliosacral screw fixation.
CONCLUSION
For the treatment of unilateral unstable sacral fractures, the posterior INFIX fixation can be recommended in clinic application.
Topics: Fracture Fixation, Internal; Fractures, Bone; Humans; Pelvic Bones; Retrospective Studies; Sacrum; Spinal Fractures
PubMed: 35343061
DOI: 10.1111/os.13251 -
European Journal of Orthopaedic Surgery... Feb 2021Although the second (S2) and third (S3) sacral segments have been established as potential osseous fixation pathways for screw fixation, the S2 body has been...
BACKGROUND
Although the second (S2) and third (S3) sacral segments have been established as potential osseous fixation pathways for screw fixation, the S2 body has been demonstrated to have inferior bone density when compared to the body of the first (S1) sacral segment. Caution regarding the use of iliosacral screws at this level has been advised as a result. As transiliac-transsacral screws traverse the lateral cortices of the posterior pelvis, they may be relying on bone with superior density for purchase, which could obviate this concern. The objective of this study was to compare the bone density of the posterior ilium and sacroiliac joint to that of the sacral body at the first (S1), second (S2), and third (S3) sacral levels.
MATERIALS AND METHODS
A retrospective case series was performed, reviewing the CT scans of 100 patients without prior pelvic trauma. Each CT was confirmed to have available osseous fixation pathways at the first (S1), second (S2), and third (S3) sacral segments. The bone density of the posterior ilium/sacroiliac joint (PISJ) and sacral body (SB) was measured using the embedded standardized Hounsfield units (HU) tool at each sacral level.
RESULTS
The average S2 PISJ bone density (320.1) was significantly higher than the S1 (286.5) and S3 (278.9) PISJ (p < 0.0001) and S1 and S3 PISJ was not statistically different. The S1 sacral body bone density (231.1) was significantly higher than the S2 (182.1) and S3 (126.8) bone density (p < 0.0001). The PISJ bone density is greater than the sacral body at every sacral level (p < 0.0001).
CONCLUSION
The S2 PISJ bone density is significantly greater than S1. The S1, S2, and S3 PISJ bone density is greater than the sacral body at all sacral levels, and the S1 body has higher bone density than the S2 and S3 bodies. These differences in bone density may have implications for the stability of posterior pelvic ring fixation constructs with regard to screw purchase.
LEVEL OF EVIDENCE
Level III-Case cohort series.
Topics: Bone Density; Bone Screws; Fracture Fixation, Internal; Fractures, Bone; Humans; Ilium; Pelvic Bones; Pelvis; Retrospective Studies; Sacrum
PubMed: 32902718
DOI: 10.1007/s00590-020-02782-4 -
Orthopaedics & Traumatology, Surgery &... Apr 2022Posterior pelvic ring disruption includes sacral fractures, sacroiliac joint fracture dislocations and ilium fractures. Percutaneous iliosacral screw fixation of sacral...
INTRODUCTION
Posterior pelvic ring disruption includes sacral fractures, sacroiliac joint fracture dislocations and ilium fractures. Percutaneous iliosacral screw fixation of sacral fractures and sacraoiliac joint fracture dislocations have been prevailing, it has the advantages of minimal invasiveness, less blood loss and low wound infection rate.
HYPOTHESIS
This study was to evaluate the application of three-dimensional (3D) printed patient-specific guide template in closed reduction and iliosacral screw fixation of posterior pelvic ring disruption.
MATERIAL AND METHODS
The data of patients, who were treated with closed reduction and iliosacral screw fixation of posterior pelvic ring disruption with the assistance of 3D printed guide template from December 2014 to September 2018, were collected. The screw placement time, fluoroscopy time, intraoperative blood loss, fracture reduction, screw position, and functional assessment were recorded.
RESULTS
There were 17 cases of unstable pelvic fractures,and 20 screws were inserted for fixation of sacral fractures or sacroiliac joint dislocations, with bilateral screw placement in 3 cases. The average time for each screw placement was 45.9±8.6min (30-60min). The average fluoroscopy time for each screw insertion was 50.3±19.7s (24-96 s). The mean blood loss for each screw placement was 32.0±11.1ml (20-50ml). According to Matta scale, the fracture reduction was graded as excellent in all the 17 cases. According to the modified Gras classification, the 3D CT reconstruction of the pelvis demonstrated Grade 1 for 18 screws and Grade 2 for 2 screw. Functional outcome 1 year postoperatively was rated as 15 excellent and 2 good, according to the Majeed functional scale.
DISCUSSION
It is feasible and safe to stabilize the posterior pelvic ring disruption using iliosacral screw fixation under assistance of the 3D printed guide template. It could reduce fluoroscopy time, screw placement time and intraoperative blood loss and achieve good postoperative recovery.
LEVEL OF PROOF
IV; Retrospective study.
Topics: Blood Loss, Surgical; Bone Screws; Fracture Dislocation; Fracture Fixation, Internal; Fractures, Bone; Humans; Joint Dislocations; Pelvic Bones; Pelvis; Retrospective Studies; Sacrum; Spinal Fractures
PubMed: 35077898
DOI: 10.1016/j.otsr.2022.103210 -
Diagnostic and Interventional Imaging 2022The purpose of this study was to evaluate the efficacy of cone-beam computed tomography (CBCT) navigation to achieve percutaneous screw fixation (PSF) of pelvic bone...
PURPOSE
The purpose of this study was to evaluate the efficacy of cone-beam computed tomography (CBCT) navigation to achieve percutaneous screw fixation (PSF) of pelvic bone metastases (PBM).
MATERIALS AND METHODS
Thirty-five consecutive patients (12 men and 23 women; mean age, 62 ± 11.3 [SD]; range: 39-89 years) treated between 2019 and 2021 were retrospectively included. CBCT navigation software was systematically used. Manual drawing of the entry point (MDEP) was performed when CBCT automatic positioning failed. Influence of metastasis pattern, ablation, body mass index, number of screws, and MDEP on procedure duration (PD) and total Air Kerma (AK) was evaluated. Local pain was assessed before, one and six months after treatment. Variables were compared using Pearson correlation, Student t and Wilcoxon tests.
RESULTS
Seventy-five screws were inserted successfully (mean: 2.1 ± 1.1 [SD]; range: 1-5 per patient). CBCT automatic positioning was obtained for 41 screws (55%, 41/75), whereas 34 (45%, 34/75) required MDEP. Mean procedure duration, fluoroscopy time, kerma air product and AK were 73.3 ± 44.8 (SD) min (range: 19-233 min), 13.1 ± 9.5 (SD) min (range: 1.4-38.6 min), 73.8 ± 66.3 (SD) Gy.cm (range: 11.6-303.7 Gy.cm) and 301.7 ± 242.1 (SD) mGy (range: 49.4-1111.5 mGy), respectively. Procedure duration was not significantly longer in patients with mixed or blastic PBM compared to those with lytic PBM or when performing ablation, and no significant correlations were observed with the number of screws inserted (P = 0.19), MDEP (P = 0.37) and BMI (P = 0.44). No adverse events were reported during the follow-up (median: 6 months; IQR: 6-6.5 months). Thirteen patients died during the follow-up related to cancer progression. Local pain decreased from 35 ± 32 (SD) mm (range: 0-10 mm) to 11 ± 20 (SD) mm (range: 0-80 mm) at one month (P = 0.001); and to 22 ± 23 (SD) mm (range: 0-60 mm) at six months (P = 0.001).
CONCLUSION
CBCT navigation allows to effectively performing PSF of PBM even in the presence of steep angulations.
Topics: Adult; Aged; Aged, 80 and over; Bone Screws; Cone-Beam Computed Tomography; Female; Fluoroscopy; Humans; Male; Middle Aged; Pain; Pelvic Bones; Retrospective Studies; Surgery, Computer-Assisted
PubMed: 35033489
DOI: 10.1016/j.diii.2022.01.002 -
Scientific Reports Nov 2020The dugong (Dugong dugon Müller) is recognized as an endangered marine mammal. There is limited available anatomical data on the dugong's skeletal system, while what is...
The dugong (Dugong dugon Müller) is recognized as an endangered marine mammal. There is limited available anatomical data on the dugong's skeletal system, while what is available has not been well established due to the limited number of archived samples and limited access to them. Importantly, there are certain key questions that should be answered when examining the bones and/or remains of animals such as; what kind of bone is it?; what species does it belong to?; what sex was the animal?; how old was the animal? or how big was it?, etc. In this study, we have focused on the pelvic bone of the dugong by asserting the hypothesis that pelvic bone morphology is related to age, sex, and body size. Here, we have established certain morphometric data encompassing 8 parameters and 5 indexes to analyze the morphology of the pelvic bones obtained from 88 specimens (45 dugongs). We will present three main findings: (1) the pelvic bone in mature male subjects is larger than it is in female subjects, (2) a high rate of accuracy can be established for sex identification using morphometric data obtained from the pelvic bone, and (3) the pelvic bone has the highest degree of correlation with body length, followed by body weight and age. Notably, the important data on the pelvic bone of the dugong acquired in this study can be reliable and extremely useful in sex identification and body size estimation.
Topics: Algorithms; Animals; Body Size; Dugong; Female; Male; Pelvic Bones; Principal Component Analysis; Reproducibility of Results; Sex Determination Analysis; Sex Factors
PubMed: 33168870
DOI: 10.1038/s41598-020-76545-w -
Injury Dec 2023Civilian gunshot fractures of the pelvic ring represent a unique challenge for orthopaedic surgeons due to a high incidence of complicating associated injuries.... (Review)
Review
INTRODUCTION
Civilian gunshot fractures of the pelvic ring represent a unique challenge for orthopaedic surgeons due to a high incidence of complicating associated injuries. Internationally accepted guidelines for these injuries are not available. The aim of this review is to summarize the available literature and to provide concise management recommendations.
METHODS
Literature search was performed using PubMed. The review focuses on civilian gunshot fractures of the pelvic ring and includes the acetabulum and hip joint only where it was deemed necessary for the understanding of the management of these patients.
RESULTS
The management of civilian transpelvic gunshot fractures is complicated by potentially life-threatening associated injuries, the risk of contamination with bowel content and retained bullets in joints. The infection risk is higher compared to extremity gunshot fractures. There is no clear evidence for the use of antibiotics available. The studies focusing on civilian pelvic ring gunshot fractures reported no case of orthopaedic fracture fixation in their series. Routine wash-out and debridement of fractures is not warranted based on the literature but conflicting recommendations for surgical interventions exist.
CONCLUSION
There is limited evidence available for civilian transpelvic gunshot fractures. The high frequency of associated injuries requires a thorough clinical examination and multidisciplinary management. We recommend routine antibiotic prophylaxis for all transpelvic gunshots. For fractures with a high risk of infection, a minimum of 24 h broad-spectrum antibiotics is recommended. The indication for orthopaedic fixation of civilian transpelvic gunshot fractures is based on the assessment of the stability of the fracture and is rarely necessary. Although conflicting recommendations exist, routine wash-out and debridement is not recommended based on the literature. Bullets buried in bone without contact to synovial fluid do not warrant removal, unless they have traversed large bowel and are accessible without undue morbidity. Furthermore, bullets should be routinely removed if they are retained in the hip joint, if mechanical irritation of soft tissues by projectiles is expected or if the bullet traversed large bowel before entering the hip joint.
Topics: Humans; Fractures, Bone; Fracture Fixation; Pelvic Bones; Pelvis; Wounds, Gunshot; Anti-Bacterial Agents; Retrospective Studies
PubMed: 37827874
DOI: 10.1016/j.injury.2023.111086 -
Journal of Orthopaedic Trauma Feb 2022The purpose of this study was to assess patient outcomes using Patient-Reported Outcomes Measurements Information System (PROMIS) scores after closed reduction and...
OBJECTIVES
The purpose of this study was to assess patient outcomes using Patient-Reported Outcomes Measurements Information System (PROMIS) scores after closed reduction and percutaneous fixation (CRPF) of the posterior pelvic ring and determine whether quality of reduction affects the outcomes.
DESIGN
This is a retrospective cohort study.
SETTING
The study involved a Level I trauma center.
PATIENTS
The study included 46 adult patients with operatively treated pelvic ring injuries (63% OTA/AO 61-B) who underwent CRPF between 2014 and 2018 at a single institution.
INTERVENTION
The intervention involved closed reduction and percutaneous posterior pelvic ring fixation.
MAIN OUTCOME MEASUREMENTS
The main outcome measurements were postoperative patient PROMIS scores, including physical function, pain interference, anxiety, and depression, and radiographic measurements of postoperative displacement and pelvic deformity.
RESULTS
After CRPF, PROMIS scores of physical function, pain interference, and anxiety were significantly improved at the time of final follow-up when compared with the first postoperative visit. The amount of malreduction or pelvic deformity did not significantly affect outcome scores; however, results were limited by small sample size.
CONCLUSIONS
CRPF of posterior pelvic ring injuries results in good functional and radiographic outcomes. Degree of malreduction may not affect outcomes as much as previously believed.
LEVEL OF EVIDENCE
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Topics: Adult; Fracture Fixation, Internal; Fractures, Bone; Humans; Patient Reported Outcome Measures; Pelvic Bones; Retrospective Studies; Treatment Outcome
PubMed: 35061646
DOI: 10.1097/BOT.0000000000002321 -
Injury Feb 2022Fractures of the pelvic ring and acetabulum generally result after high energy trauma. Pelvic fractures, especially, are considered complex injuries from a therapeutic...
Fractures of the pelvic ring and acetabulum generally result after high energy trauma. Pelvic fractures, especially, are considered complex injuries from a therapeutic point of view, in relation to the frequent coexistence of skeletal and / or parenchymal lesions affecting other areas, and the abundant bleeding invariably associated with the latter. The systematic study of these injuries, starting from the 1950s, has led to a significant prognostic improvement, while generally remaining a non-negligible degree of disability. The knowledge of the characteristics of the lesions and of the classification systems, as well as an accurate assessment of the anatomo-functional repercussions, represent therefore the fundamental prerequisites for the correct assessment of physical damage. Herein, we aim to examine whether the medico-legal assessment parameters of physical damage being used in Italy and Europe are appropriate and consistent with the complexity of similar injuries.
Topics: Acetabulum; Fractures, Bone; Hip Fractures; Humans; Pelvic Bones; Pelvis; Spinal Fractures
PubMed: 34865817
DOI: 10.1016/j.injury.2021.11.063