Early vs. late definitive fixation of pelvic ring fractures in resuscitated polytraumatized patients: a systematic review and meta-analysis

Aim The aim of this systematic review is to compare the short-term clinical outcomes between early (EDF) and late definitive fixation (LDF) in polytraumatized patients with pelvic ring fractures (PRF). Method The following databases: Embase, Medline and Cochrane Library were searched until June 2022. Studies comparing EDF and LDF for PRF in polytrauma patients defined as ISS >15 were included. The methodological quality of studies was assessed using the Newcastle Ottawa Scale. Results Out of 869 studies screened, 10 were included in the meta-analysis with a total of 2918 patients. The most common time point used to define EDF was within 24 hours of hospital admission and LDF (>24hr). The most common reasons for LDF were surgeon’s choice, availability of pelvic surgeon and transfer from other hospitals. Our meta-analysis revealed that EDF was associated with a reduced length of hospital stay (WMD=-3.52 days; 95% CI: [-5.43 to -1.62], p<0.0003) and lower incidence of ARDS (RR=0.48; 95% CI: [0.20 to 1.18], p=0.04). No significant association was found in mortality, length of ICU stays, multi-organ failure, sepsis and surgical site infection between EDF and LDF. Conclusions These findings suggest that early definitive fixation may be a safe and viable option with no increased risk of complications and mortality. However, the adequacy of resuscitation and the estimate of physiologic reserve should be balanced with the risks of operative fixation in all patients. Further prospective validation studies are warranted to test the predictive ability of the various proposed trauma care models and stratify patients for EDF.

Improved outcome after early fixation of acetabular fractures

IntroductionThere 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 methodsThe 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.ResultsEleven 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.ConclusionsFixation 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.

3D - Navigated percutaneous screw fixation of pelvic ring injuries – a pilot study

PurposeConventional 2D fluoroscopy-based screw fixation of pelvic ring fractures has high screw misplacement rates and can be technically challenging. Implementation of 3D image guidance is presumed to simplify screw placement and improve procedural safety. The objective of this study was to evaluate the accuracy of 3D navigation in percutaneous screw fixation of pelvic ring fractures.MethodsA consecutive case series including all patients undergoing 3D-guided screw fixation of pelvic ring fractures between 2019 and 2022 was conducted. Primary study endpoints were screw misplacement, neurological complications, and surgical site infections. Data were analysed using descriptive statistics.ResultsA total of 90 consecutive patients (180 screws) were included, with 120 transsacral-transiliac screws (TSTI) and 60 sacral-iliac (SI) screws used for posterior fixation, 5 retrograde transpubic screws placed for anterior fixation, and 23 antegrade screws placed into the superior rami. For two patients (2.7%), screw misplacements were observed. No neurological complications occurred due to screw misplacement.ConclusionsThe result of the current study shows that 3D navigation provides excellent screw placement accuracy, with minimal screw misplacements and no neurological complications due to screw misplacement.

Background: Percutaneous screw fixation has increasingly been used for pelvic ring fracture fixation. In older adult patients, especially in patients with a fragility fracture of the pelvis (FFP), minimally invasive techniques followed by early ambulation have been promoted in order to regain pre-injury levels of mobility and independence. The purpose of this study was to evaluate patient-centered outcomes, including post-operative pain relief, functional performance, and satisfaction, in older adults with pelvic ring fractures treated with percutaneous screw fixation and to assess injury characteristics, complications, and return-to-home rates. Methods: In this retrospective cohort study, patients 50 years and older who had their pelvic fracture treated in the Amsterdam UMC location AMC between January 2019 and December 2022 were identified. After a minimum follow-up period of 6 months, a questionnaire was conducted by phone to evaluate the pain, current living situation, and mobility of the patients. Results: A total of 51 patients were included in this study with a median age of 74 years (IQR 62-82), and the vast majority were female (n = 40, 78%). Over half of the pelvic fractures were caused by low-energy trauma (n = 29, 57%). Unilateral or bilateral sacral fractures with unilateral anterior ring fractures were the most common fracture pattern. The interoperative complication rate was 4%, and the in-hospital complication rate was 23%. Forty-five patients were reached to complete the questionnaire. Forty patients (91%) returned to an acceptable level of mobility after treatment, and almost all (n = 44, 98%) were pleased with the results of the surgery. Conclusions: Percutaneous screw fixation of pelvic fractures in older adult patients is a safe and effective operating technique. Most patients preserve their pre-morbid functionality and are able to return to their previous place of residence after admission. Furthermore, patients are almost unanimously very pleased with the results of the surgery despite some residual pain complaints.

Although the benefits of acute stabilization of long bone fractures are recognized, the role of early fixation of unstable pelvis and acetabular fractures is not well-defined. The purpose of this study was to review complications and hospital course of patients treated surgically for pelvis and acetabulum fractures. We hypothesized that early definitive fixation would reduce morbidity and decrease length of stay. Six hundred forty-five patients were treated surgically at a level I trauma center for unstable fractures of the pelvic ring (n = 251), acetabulum (n = 359), or both (n = 40). Mean age was 40.5 years, and mean Injury Severity Score (ISS) was 25.6 (range 9-66). They were retrospectively reviewed to determine complications including acute respiratory distress syndrome (ARDS), pneumonia, deep vein thrombosis, pulmonary embolism, multiple organ failure (MOF), infections, and reperations. Definitive fixation was within 24 hours of injury in 233 patients (early, mean 13.4 hours) and >24 hours in 412 (late, mean 99.2 hours). Twenty-nine patients (12.4%) had complications after early fixation versus 81 (19.7%) after late, p = 0.006. Length of stay and intensive care unit days were 10.7 days versus 11.6 days (p = 0.26) and 8.1 days versus 9.9 days (p = 0.03) for early and late groups, respectively. With ISS >18 (n = 165 early [ISS 32.7]; n = 253 late [ISS 33.1]), early fixation resulted in fewer pulmonary complications (12.7% versus 25%, p = 0.0002), less ARDS (4.8% versus 12.6%, p = 0.019), and less MOF (1.8% versus 4.3%, p = 0.40). Rates of complications, pulmonary complications, deep vein thrombosis, and MOF were no different for patients with pelvis versus acetabulum fractures. In patients receiving ≥ 10U packed red blood cells (n = 41 early, n = 56 late) early fixation led to fewer pulmonary complications (24% versus 55%, p = 0.002), less ARDS (12% versus 25%, p = 0.09), and MOF (7.3% versus 14%, p = 0.23). Two hundred ten patients had some chest injury (32.6%). Chest injury with Abbreviated Injury Scores ≥ 3 was present in 46 (19.7%) of early and 78 (18.9%) of late patients (p = 0.44) and was associated with pulmonary complications in 26.1% versus 35.9%; ARDS in 15.2% versus 23.1%; and MOF in 6.5% versus 6.4%, respectively (all p > 0.20). However, chest injury with Abbreviated Injury Scores ≥ 3 was independently associated with more complications including ARDS (20.2% versus 3.3%, p < 0.0001), other pulmonary complications (32.3% versus 10.4%, p < 0.0001), and MOF (6.5% versus 1.2%, p = 0.0016), regardless of timing of fixation. Early fixation of unstable pelvis and acetabular fractures in multiply injured patients reduces morbidity and length of intensive care unit stay, which may decrease treatment costs. Further study to ascertain the effects of associated systemic injuries and the utility of physiologic and laboratory parameters during resuscitation may delineate recommendations for optimal surgical timing in specific patient groups.

To assess practices related to ordering computed tomography (CT) scans routinely after posterior pelvic ring fixation and revision surgery rates. A 20-question cross-sectional survey. Fellowship-trained orthopaedic traumatologists. (1) Percentage of surgeons ordering a routing postoperative CT after posterior pelvic ring fixation, (2) Revision surgery rates based on routine CT scan results. Responses were received from 57 surgeons. Practices varied regarding postoperative CT scans, with 20 surgeons (35%, group A) routinely ordering them and 37 surgeons (65%, group B) not ordering them on all patients. Group A were younger and with less years of experience than those in Group B. Most group A surgeons report a revision surgery rate of <1% based on results of the postoperative CT. Group A report routine postoperative scans were obtained to assess reduction, instrumentation placement, and for educational purposes. Group B did not obtain routine postoperative CTs because of the following: unlikely to change postoperative treatment course, adequate reduction and instrumentation placement assessed intraoperatively and by postoperative radiographs, and increased radiation exposure and cost to patients. Group B did report obtaining postop CT scans on select patients, with postoperative neurological deficit being the most common indication. The routine use of postoperative CTs following posterior fixation of pelvic ring fractures is a controversial topic. Although we recognize the role for postoperative CT scans in select patients, our study questions the clinical utility of these scans in all patients and in conclusion do not recommend this protocol.

Purpose: Damage control laparotomy has contributed to improved survival rates for severe abdominal injuries. A large part of severe abdominal injury occurs with a concomitant pelvic bone fracture. The safety and effectiveness of internal fixation of pelvic bone fracture(s) has not been established. The aim of the present study was to evaluate infection risk in the pelvic surgical site in patients who underwent emergent abdominal surgery. Methods: This single-center retrospective observational study was based on data collected from a prospectively maintained registry between January 2015 and June 2019. Patients who underwent laparotomy and pelvic internal fixation were included. Individuals <18 and ≥80 years of age, those with no microbiological investigations, and those who underwent one-stage abdominal surgery were excluded. Comprehensive statistical comparative analysis was not performed due to the small number of enrolled patients. Results: A total of six patients met the inclusion criteria, and the most common injury mechanism was anterior-posterior compression (67%). The average duration of open abdomen was 98 hours (range, 44-198), and the time interval between abdominal closure and pelvic surgery was 98 hours. One patient (16.7%) died due to multi-organ dysfunction syndrome. Micro-organisms were identified in the abdominal surgical site in five patients (83%), with no micro-organisms in pelvic surgical sites. There was no unplanned implant removal. Conclusions: Internal fixation of pelvic bone fracture(s) could be performed in the state of open abdomen, and the advantages of early fixation may countervail the risks for cross contamination.

Due to the general increase in life expectancy of the population, the number of elderly and senile people suffering from osteoporosis is increasing in the world. Pelvic bone fractures that occur against the background of osteoporotic changes in the bones of the skeleton are distinguished by a number of characteristic features and are associated with a high mortality rate. If in the young population the main cause of these fractures are high-energy injuries resulting from road accidents and falls from a great height, then in elderly patients with concomitant osteoporosis, pelvic fractures can occur as a result of a fall from their own height. Fragility of bone tissue, the presence of a large number of chronic diseases and impaired adaptive capacity of the body in elderly patients complicates surgical fixation of pelvic ring fractures using various metal structures, which forces clinicians to adhere to conservative treatment tactics.Aims: to study the medium-term and long-term results of conservative treatment of pelvic bone injuries in patients over 65 years of age.Materials and methods. During the period from 2021 to 2024, a total of 30 patients (mean age 72±6.21 years) over 65 years old with pelvic bone fractures were treated at the A.K. Yeramishantsev City Clinical Hospital. The distribution of pelvic bone fractures according to the AO/OTA classification was as follows: type A in 6 (20%) patients, type B in 18 (60%), acetabular fracture in 6 (20%) patients.Results and conclusions. The mid-term treatment results after 6 months were assessed in 30 (100%) patients (in 6 they were excellent, in 16 – good, in 6 – satisfactory, in 2 – poor). The remote treatment results after 12 months were assessed in 24 (80%) patients (in 6 of them they were excellent, in 12 – good, in 4 – satisfactory, in 2 – poor). After 2 years, 16 (53%) patients were assessed (4 had excellent results, 8 had good results, 2 had satisfactory results, and 2 had poor results). 26 (86%) patients restored their previous activity level. Mortality was 0%. The analysis of pelvic fracture treatment results showed that in elderly patients with a comorbid history, it is preferable to adhere to conservative treatment tactics.

Simple parameters to identify patients treatable with early definitive fixation: A nationwide study

IntroductionThe timing of definitive fracture care in polytrauma patients remains a complex topic, especially in the presence of concomitant intracranial injuries, which often dictate surgical priorities. The International MultidisciPlinAry Consensus panel on polyTrauma (IMPACT) recently proposed recommendations on the timing of surgical interventions in polytrauma patients with competing priorities and identified some gaps in evidence. The aim of this study is to provide a systematic review of the scientific evidence on the timing of fracture fixation in patients with traumatic brain injuries (TBI).Material & methodsA systematic review on MEDLINE and EMBASE was performed, including original articles published between 2000 and 2024, comparing the outcomes of early (≤ 24 h) versus late (> 24 h) definitive fracture fixation in polytrauma patients with TBI. Demographic data, overall injury severity, and TBI severity of the respective cohorts were taken into consideration for qualitative analysis. Additionally, complication rates and outcomes were assessed.ResultsA total of 9782 studies were identified. After applying the inclusion and exclusion criteria, 7 studies were finally included. Overall, significant heterogeneity was observed in the selection criteria, with some studies focusing on more severe and others on milder TBI, using different criteria. Overall, most studies provide evidence that early fracture fixation in patients with mild TBI might be beneficial for patients’ outcomes.ConclusionsEarly definitive fracture fixation within 24 h should be attempted in polytrauma patients with concomitant mild TBI under specific conditions, which were previously defined by the IMPACT group. Furthermore, current evidence suggests that this approach is both safe and beneficial in a carefully selected patient population. In cases of moderate and severe TBI, decision-making is usually more difficult and complex, often requiring it to be individualized. However, we identified several gaps in the existing literature, particularly with regard to the heterogeneity of the available studies in terms of inclusion criteria, injury morphologies and investigated outcome parameters. Prospective or detailed registry studies are required to obtain further insight into this relevant topic.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00068-025-02981-w.

BackgroundScrew fixation of pelvic ring fractures is a common, but demanding procedure and navigation techniques were introduced to increase the precision of screw placement. The purpose of this case series was the evaluation of screw misplacement rate and functional outcome of percutaneous screw fixation of pelvic ring disruptions using a 2D navigation system.MethodsBetween August 2004 and December 2007, 44 of 442 patients with pelvic injuries were included for closed reduction and percutaneous screw fixation of disrupted pelvic ring lesions using an optoelectronic 2D-fluoroscopic based navigation system. Operating and fluoroscopy time were measured, as well as peri- and postoperative complications documented. Screw position was assessed by postoperative CT scans. Quality of live was evaluated by SF 36-questionnaire in 40 of 44 patients at mean follow up 15.5 ± 1.2 month.Results56 iliosacral- and 29 ramus pubic-screws were inserted (mean operation time per screw 62 ± 4 minutes, mean fluoroscopy time per screw 123 ± 12 seconds). In post-operative CT-scans the screw position was assessed and graded as follows: I. secure positioning, completely in the cancellous bone (80%); II. secure positioning, but contacting cortical bone structures (14%); III. malplaced positioning, penetrating the cortical bone (6%). The malplacements predominantly occurred in bilateral overlapping screw fixation. No wound infection or iatrogenic neurovascular damage were observed. Four re-operations were performed, two of them due to implant-misplacement and two of them due to implant-failure.Conclusion2D-fluoroscopic navigation is a safe tool providing high accuracy of percutaneous screw placement for pelvic ring fractures, but in cases of a bilateral iliosacral screw fixation an increased risk for screw misplacement was observed. If additional ramus pubic screw fixations are performed, the retrograde inserted screws have to pass the iliopubic eminence to prevent an axial screw loosening.

Evaluation of the functional outcome after unstable pelvic ring fractures stabilized with internal fixation. Between January 1, 1990, and September 1, 1997, 37 patients were treated with internal fixation for unstable pelvic fracture. Demographic data, type of accident, Hospital Trauma Index-Injury Severity Score, and fracture type according to Tile classification were scored. One patient died the day after the accident from neurologic injury. A Short Form-36 health questionnaire and a form regarding functional result after pelvic trauma, adapted from Majeed et al., were returned by 31 of 36 patients (86%). Twenty-eight patients (78%) were seen for physical and radiologic examination. Twenty-six men and 11 women, with an average age of 34.7 years (range, 15-66 years) were included. The mean Injury Severity Score reached 30.4 (range, 16-66). According to the Tile classification, there were 16 type B fractures and 21 type C fractures. Seven patients were treated with open reduction and internal fixation of the pubic arch, 10 patients were treated with a combination of anterior open reduction and internal fixation with additional external fixation to increase the stability of the posterior ring. Nineteen patients underwent internal fixation of both anterior and posterior arch. In the remaining case, percutaneous posterior screw fixation was combined with anterior external fixation, because of estimated infectious risk. The average follow-up time was 35.6 months. Patients scored 78.6 of 100 on the Majeed score. Remarkable was the reported change in sexual intercourse in 12 patients (40%). Only 12 patients (40%) did not have complaints when sitting. On the SF-36 scales physical and social functioning, role limitations due to physical problems and vitality were limited compared with the averages for the Dutch population. Patients treated with combined anterior and posterior internal fixation scored significantly better on both the Majeed score and on the categories physical functioning, pain, general health and social functioning compared with patients with similar fractures treated with a combination of anterior internal fixation with external fixation. At the physical examination, 11 of 28 patients (39%) did not have any abnormality. Nineteen patients (68%) were back at their original job, which was physically demanding in 9 cases. There was a suspicion of nonunion of the posterior arch in two patients, which could be confirmed with a computed tomographic scan. In general, limitations in functioning are reported, even after long-term follow-up. In partially unstable fractures, solitary anterior fixation gives good results. In completely unstable fractures, patients treated with combined internal fixation anterior as well as posterior scored a better outcome compared with combined internal and external fixation. Therefore, this technique is recommended as treatment of first choice in completely unstable fractures.

Screw misplacement in percutaneous posterior pelvic iliosacral screwing with and without navigation: A prospective clinical study of 174 screws in 127 patients