Pelvic Ring Fractures Research Articles

Coronavirus disease 2019 pandemic, restriction, and orthopedic trauma: Retrospective observational study.

In 2019, the Coronavirus disease 2019 (Covid-19) was reported in Wuhan, China. Governments in various countries had taken many safeguards. This study investigated the incidence of orthopedic trauma in a rural region epidemiologically and guided source distribution and medical professionals to sustain healthcare systems.Between December 2019 and August 2020, 1651 patients admitted to orthopedics and traumatology clinics with trauma were evaluated in this study. Patients were grouped into 3 groups: pre-covid, restriction, and permitted groups. Age, sex, and fracture types of patients were recorded.The number of patients in the pre-covid period was 629 (38.1%), those were 334 (20.2%) in the restriction period, and 688 (41.7%) patients were admitted in the permitted period. A total of 1203 (72.9%) patients with upper extremity fractures, 383 (23.2%) patients with lower extremity fractures, and 65 (3.9%) patients with axial skeleton and pelvic ring fractures were included in the study. The lowest rates were found in the restriction period when all fractures were evaluated according to the admission periods. There were significant differences between admission dates and the fractures (P < .001).In this study, a decrease in orthopedic trauma rates was observed by half in the restriction period compared with the other 2 periods. Public health precautions had led to a reduction in the incidence of orthopedic trauma in all age groups.

Definitive Management Option of Pelvic Ring Injury

Pelvic ring injury is a rare condition with the incidence of hip fracture about 3% to 8% of all fractures. However, the majority of pelvic fracture patients have a high morbidity rate that could threaten their survival. The majority cause of hip fracture is high energy blunt trauma and is related to polytrauma incident. The main goals of management for pelvic ring injury are to restore the form and stability of the pelvic. The main goal is to prevent nonunion and malunion, which lead to chronic pain and disability. This review is focused on the strengths and weaknesses of the management option, approach and complication for pelvic ring fracture surgery. Complications of pelvic ring fracture surgery are bleeding, nerve damage, DVT, pulmonary embolism, soft tissue injury, sepsis, and malunion of the pelvis and nonunion. Management for pelvic ring fracture surgery is used based on the location and configuration of the fracture, implant availability, surgeon’s preference, and experience.

Anatomical evaluation of the transpubic screw corridor based on a 3D statistical model of the pelvic ring

Retrograde transpubic screw fixation is a common procedure for the treatment of anterior pelvic ring fractures. With its sparing surgical approach and significant pain relief after screw fixations allowing early mobilisation, it has gained importance especially in the treatment of insufficiency fractures in elderly patients. However, positioning of transpubic screw osteosynthesis is not always possible due to narrowness and curvature of the screw corridor. The aim of the present study was to evaluate availability and length of the screw corridor using a 3D statistical model of the pelvic ring consisting out of 150 uninjured pelves. Virtual bore probes with a diameter of 7.5 mm were analysed as to accessibility, length and grey value distribution in Hounsfield Unit (HU). A transpubic corridor with a diameter of ≥ 7.5 mm was available in 185 of 300 investigated superior pubic rami with mean screw length of 131.7 mm. Accessibility of the screw corridor was higher in males than in females. However, screw length showed no systematic differences between the sexes or ethnicities. Analysis of the grey value distribution demonstrated the strongest bone to be located at the lateral ilium and the supraacetabular region.

Management Of Sacral And Sacroiliac Joint Fractures By Percutaneous Screws

Pelvic ring fractures are serious injuries which have been functionally determined by reduction quality; the objective of this research is to assess the effect of percutaneous fixation of the screw in the treatment of sacred fractures and sacroiliac joint damage. The research included 20 patients with sacral fractures and sacroilia joint injuries, with an average age of 32. Every single xray anteroposterior (AP), inlet and outlet views in the pelvis were radiologically evaluated for all patients. At the conclusion of the follow-up period, the outcomes were evaluated both clinically and radiologically. Overall Majeed outcomes were (clinically) judged to be acceptable among 16 (80%) patients; eight (40%) were excellent and eight (40%) were good and only 4 (20%) were unsatisfactory; 3 (15%) were fair and 1 (5%) were bad; Percutaneous sacroiliac pelvic fracture fixation has less damage, less bleeding, fast recovery, safe and effective minimally invasive operation technique. Percutaneous iliosacral vibrators are very demanding methods of placing highly scalable malpositions that are potentially associated with the risk of neurological damage or inadequate stability.

Circumferential Pelvic Antishock Sheeting.

Pelvic ring fractures range from low-energy falls in the elderly to high-energy mechanisms in young patients. These injuries can be a significant cause of morbidity and mortality and are frequently associated with additional injuries. Hemorrhage and resultant hemodynamic instability are often associated with high-energy injuries and require prompt management. Circumferential pelvic antishock sheeting is an effective and readily available tool for reducing pelvic volume at the accident scene or in the emergency department, while still allowing access to the abdomen and lower extremities for ongoing resuscitation. This article, and the associated instructional video, reviews the indications and proper technique for placing a pelvic sheet.

Analysis of trans-sacral corridors in stabilization of fractures of the pelvic ring.

Percutaneous screw fixation combined with pelvic reduction is a surgical technique used to stabilize fractures of the posterior pelvic ring. This is the standard surgical treatment of unstable posterior pelvic ring injuries. The primary goal of this treatment is an anatomic reduction and stable fixation. This has been shown to reduce pain and improve the patients' long-term well-being. The aim of this analysis was to determine the possible screw lengths and the positioning of the screws in the S1 and S2 sacral segments. A population of 697 pelvises from the Stryker Orthopaedic Modeling and Analytics database were analyzed. The dimensions of the S1 and S2 screw corridors were determined and after assessing for sacral dysmorphism, the correct screw placement was chosen to determine the necessary screw length for surgical treatment. The measurements of the screw lengths show a Gaussian distribution for the analyzed population. The percentage of dysmorphic pelvises for the S1 screw corridor was 31.3% and for the S2 corridor 8%. Average screw length for S1 was 163.8 ± 16.2 mm and for the S2 137.3 ± 9.5 mm. The results show that the S1/S2 axis cannot be used for a trans-sacral screw placement in every patient. The study shows that intraosseous screw corridors are present in 68.7% of the patients in the S1 position and in 92% at the S2 level where an intended implant can be placed fully intraosseous.

Modified pedicle screw-rod versus anterior subcutaneous internal pelvic fixation for unstable anterior pelvic ring fracture: a retrospective study and finite element analysis

ObjectivesThis study compared the stability and clinical outcomes of modified pedicle screw-rod fixation (MPSRF) and anterior subcutaneous internal pelvic fixation (INFIX) for the treatment of anterior pelvic ring fractures using the Tornetta and Matta grading system and finite element analyses (FEA).MethodsIn a retrospective review of a consecutive patient series, 63 patients with Orthopaedic Trauma Association (OTA)/Arbeitsgemeinschaft für Osteosynthesefragen (AO) type B or C pelvic ring fractures were treated by MPRSF (n = 30) or INFIX (n = 33). The main outcome measures were the Majeed score, incidence of complications, and adverse outcomes, and fixation stability as evaluated by finite element analysis.ResultsSixty-three patients were included in the study, with an average age of 34.4 and 36.2 in modified group and conventional group, respectively. Two groups did not differ in terms of the injury severity score, OTA classification, cause of injury, and time to pelvic surgery. However, the MPSRF group had a rate of higher satisfactory results according to the Tornetta and Matta grading system than the conventional group (73.33% vs 63.63%) as well as a higher Majeed score (81.5 ± 10.4 vs 76.3 ± 11.2), and these differences were statistically significant at 6 months post-surgery. FEA showed that MPSRF was stiffer and more stable than INFIX and had a lower risk of implant failure.ConclusionsBoth MPSRF and INFIX provide acceptable biomechanical stability for the treatment of unstable anterior pelvic ring fractures. However, MPSRF provides better fixation stability and a lower risk of implant failure, and can thus lead to better clinical outcomes. Therefore, MPSRF should be more widely applied to anterior pelvic ring fractures

Clinical characteristics, injury pattern and management of pediatric pelvic fracture: An observational retrospective study from a level I trauma center

BackgroundPediatric pelvic fractures (PPF) are uncommon among children requiring hospitalization after blunt trauma. The present study explored our experience for the prevalence, patients demographics, clinical characteristics, injury pattern and management of pediatric pelvic fractures in a level I trauma center.MethodsThis is a retrospective review of prospectively collected data obtained from trauma registry database for all pediatrics trauma patients of age ≤18 years. Data were analyzed according to different aspects relevant to the clinical applications such as Torode classification for pelvic ring fracture (Type I–IV), open versus closed triradiate cartilage, and surgical versus non-surgical management.ResultsDuring the study period (3 and half years), a total of 119 PPF cases were admitted at the trauma center (11% of total pediatric admissions); the majority had pelvic ring fractures (91.6%) and 8.4% had an acetabular fracture. The mean age of patients was 11.5 ± 5.7, and the majority were males (78.2%). One hundred and four fractures were classified as type I (5.8%), type II (13.5%), type III (68.3%) and type IV (12.5%). Patients in the surgical group were more likely to have higher pelvis AIS (p = 0.001), type IV fractures, acetabular fractures and closed triradiate cartilage as compared to the conservative group. Type III fractures and open triradiate cartilage were significantly higher in the conservative group (p < 0.05). Patients with closed triradiate cartilage frequently sustained spine, head injuries, acetabular fracture and had higher mean ISS and pelvis AIS (p < 0.01) than the open group. However, the rate of in-hospital complications and mortality were comparable among different groups. The overall mortality rate was 2.5%.ConclusionPPF are uncommon and mainly caused by high-impact trauma associated with multisystem injuries. The majority of PPF are stable, despite the underlying high-energy mechanism. Management of PPF depends on the severity of fracture as patients with higher grade fractures require surgical intervention. Furthermore, larger prospective study is needed to understand the age-related pattern and management of PPF.

Relapses of urethral strictures associated with a pelvic ring fracture and osteosynthesis: the features of treatment and prevention

Introduction. Pelvic ring fracture with complex bone fragments displacement is associated with the urethral distraction injury in about 10% of cases. Emergency care for these patients includes the provision of trauma management and urinary diversion followed by delayed urethroplasty.Purpose of the study. To determine the effect of extramedullary osteosynthesis in a pelvic ring fracture on the outcome of treatment in patients with post-traumatic urethral strictures.Materials and methods. The study included 17 patients with post-traumatic urethral strictures associated with pelvic ring fractures (Types B, C). The average age of the patients was 35.8 ± 10.2 (19 - 61) yrs. All patients underwent submerged osteosynthesis and cystostomy drainage as an emergency. Localization of strictures: 10 (58.8%) - membranous, 7 (41.2%) - bulbo-membranous. Length of strictures: 1.47 ± 0.5 (0.5 - 2.5) cm. Post-traumatic period: 6.6 ± 1.3 (4 - 10) mo.Results. All patients underwent anastomotic urethroplasty. No early postoperative complications were identified. Spontaneous urination was restored by 14 - 15 days in all patients. Early urethral stricture relapses were revealed in 9 (52.9%) patients during 3-mo follow-up. These patients underwent removal of the metal structures fixing the pelvic bones. Repeated urethroplasty was performed a month later. Subsequent relapses of urethral stricture were not detected in any of 17 cases with a median follow-up of 28 (12 - 128) mo.Conclusion. Surgical treatment of urethral strictures associated with a pelvic ring fracture and osteosynthesis is advisable after removal of the metal structures fixing the pelvic bones. This is since the excessed retropubic screws protrusion (&gt; 0.2 - 0.3 mm) is associated with a large area of periurethral fibrous inflammation and causes high relapse risks of stricture disease (52.9%) in the case of urethral surgery preceding the removal of metal structures.

Three-dimensional morphometry of the first two sacral segments and its impact on safe transiliac-transsacral screw placement

IntroductionPercutaneous screw fixation of the posterior pelvic ring is a popular technique to treat unstable pelvic ring lesions. This technique is practicable in both, the high-energy pelvic ring fractures, mostly in the young population as well as the osteoporotic fractures in the elderly. Risk of the transiliac-transsacral screw positioning is that the critical area of nerve root exit has to be passed twice. For secure screw placement, without causing iatrogenic neurovascular injuries, the knowledge of distances to the narrowest areas is essential. Purpose of this anatomical study was to examine the optimal intraosseous screw placement for the first two sacral segments. Material/methodsImages of uninjured pelves from 50 patients (64-line CT scanner) were evaluated. Then virtual transiliac-transsacral srews were positioned into the first two sacral segments. The distance from the screws’ entrance points at the ilium's alar bone to the narrowest portion of the whole pedicle as well as the height and width in this area were measured. Descriptive statistics were used and gender related differences were evaluated using student T-test. ResultsFor the first sacral segment the distance to the narrowest zone amounted in mean 62.75 mm, respectively 63.31 mm, depending on the selected way of measurement. For the second segment the mean distance to the neuroforamina was on average 50.61 mm, respectively 51.54 mm. The average height in S1 measured 25.88 mm and the average width 25.49 mm. The average height for S2 was 17.54 mm and the average width 17.61 mm. We could not find any statistically significant gender correlation for the measured distances. ConclusionResults of this anatomical study may help in performing a safe surgical procedure.

Complications and outcomes in 69 consecutive patients with floating hip

BackgroundFloating hip is a rare and potentially serious injury. The objective of this study was to evaluate our management strategy for patients with floating hip. HypothesisA standardized strategy with specialised multidisciplinary management is associated with a low mortality rate. MethodsConsecutive patients who had surgery to treat floating hip between January 2010 and December 2019 were included in this single-centre retrospective study. Epidemiological, clinical, and radiological data were collected and analysed. Patients were managed according to a standardised strategy adapted to the haemodynamic status and type of floating hip (type A, femoral and pelvic ring fractures; type B, femoral and acetabular fractures; and type C, femoral, acetabular, and pelvic ring fractures). The clinical outcome at last follow-up was determined by a telephone interview, based on the Majeed and Oxford scores, sports resumption, and work resumption. To assess the radiological outcomes, we applied Matta's criteria for the acetabulum and Tornetta's criteria for the pelvic ring. ResultsWe included 69 patients with a mean age of 38.5 years. Among them, 39 (57%) had haemodynamic instability requiring embolisation (n=15, 22%) or multiple blood transfusions (n=24, 35%). Type A injuries predominated (n=57, 83%). The need for multiple blood transfusions was significantly associated with type C floating hip, underlining the risk of heavy bleeding with this injury. Two (3%) patients died. When management was complete, the reduction was anatomical or satisfactory for 76% (13/17) of the acetabula according to Matta's criteria (maximum residual displacement <3mm) and for 85% (56/66) of the pelvic rings according to Tornetta's criteria (maximum residual displacement <10mm). One or more complications occurred in 45 (65%) patients. After a mean follow-up of 5 years, the mean Oxford Hip Score in patients with acetabular fractures was 35.5 and the mean Majeed score in patients with pelvic ring fractures was 71.5. Only 30% of patients were able to resume physical activities at the former level and to return to their former professional activities. ConclusionType C floating hip, which combines fractures of the pelvic ring and acetabulum, carries a high risk of bleeding. Special attention should be directed to the reduction of pelvic ring fractures, to avoid malunion. Acetabular fractures that are complex in the Letournel classification carry a risk of imperfect reduction. The results of this study confirm the severity of these rare injuries and the need for specialised multidisciplinary management according to a standardised strategy that is appropriate for the haemodynamic status and type of floating hip (A, B, or C). Level of evidenceIV; retrospective study.

Evaluation and management of low-energy pelvic ring fractures in elderly patients: a narrative review

The incidence of pelvic ring fractures has shown a steady increase in elderly patients that has been caused by a rapidly aging population and increased life expectancy. Many of these injuries result from a low-energy mechanism such as a fall from standing height. Classification systems such as the Young and Burgess and Tile classifications commonly are used to describe these fractures. One of the major distinctions to be made is whether the fracture pattern is stable or unstable in order to determine treatment. The goal of treatment is to restore patients back to their preinjury level of function. Mortality rate has previously been shown to be high in these injuries (20% at 30 days).

Minimally invasive triangular lumboiliac and iliosacral fixation of posterior pelvic ring injuries with vertical instability: Technical note

To date, no strong consensus exists on the best way to treat posterior pelvic ring injuries when there is no neurological deficit. Various fixation methods have been described; more recently, constructs that combine lumboiliac and iliosacral fixation have been introduced. This type of fixation is mainly indicated in cases of spinopelvic dissociation with large displacement of fracture fragments in the sagittal plane. However, these techniques are associated with postoperative complications, particularly infections and severe skin complications. This led us to propose a minimally invasive lumboiliac and iliosacral fixation technique for posterior pelvic ring injuries. The procedure is done with the patient prone. It consists of pedicle screw insertion into L4 or L5 and screw fixation of the ilium with fluoroscopy guidance; intraoperative distraction can be done depending on the amount of displacement. An iliosacral screw is then inserted percutaneously to allow reduction in the transverse plane and yield a triangular construct. In the five patients that we have operated using this technique, the mean preoperative vertical displacement was 11.9±6.9mm (SD) (min 1.3, max 19.7) versus 3.7±3.2mm (min 0.3, max 6.7) postoperatively and the mean preoperative frontal displacement was 7.5±3.7mm (min 4.2, max 12.4) versus 2.5±2.0mm (min 0.3, max 4.3) postoperatively. Minimally invasive iliosacral and lumboiliac fixation is an option for treating posterior pelvic ring fractures free of neurological deficit and especially spinopelvic dissociation.

Whole Body PMHS Response in Injurious Experimental Accelerative Loading Events.

Previous studies involving whole-body post-mortem human surrogates (PHMS) have generated biomechanical response specifications for physically simulated accelerative loading intended to reproduce seat and floor velocity histories occurring in under-body blast (UBB) events (e.g.,. References 10, 11, 21 These previous studies employed loading conditions that only rarely produced injuries to the foot/ankle and pelvis, which are body regions of interest for injury assessment in staged UBB testing using anthropomorphic test devices. To investigate more injurious whole-body conditions, three series of tests were conducted with PMHS that were equipped with military personal protective equipment and seated in an upright posture. These tests used higher velocity and shorter duration floor and seat inputs than were previously used with the goal of producing pelvis and foot/ankle fractures. A total of nine PMHS that were approximately midsize in stature and mass were equally allocated across three loading conditions, including a 15.5m/s, 2.5ms time-to-peak (TTP) floor velocity pulse with a 10m/s, 7.5ms TTP seat pulse; a 13m/s, 2.5ms TTP floor pulse with a 9.0m/s, 5ms TTP seat pulse; and a 10m/s, 2.5ms TTP floor pulse with a 6.5m/s, 7.5ms TTP seat pulse. In the first two conditions, the seat was padded with a ~ 120-mm-thick foam cushion to elongate the pulse experienced by the PMHS. Of the nine PMHS tests, five resulted in pelvic ring fractures, five resulted in a total of eight foot/ankle fractures (i.e.,two unilateral and three bilateral fractures), and one produced a femur fracture. Test results were used to develop corridors describing the variability in kinematics and in forces applied to the feet, forces applied to the pelvis and buttocks in rigid seat tests, and in forces applied to the seat foam in padded seat tests. These corridors and the body-region specific injury/no-injury response data can be used to assess the performance and predictive capability of anthropomorphic test devices and computational models used as human surrogates in simulated UBB testing.

Matta\u2019s criteria may be useful for evaluating and predicting the reduction quality of simultaneous acetabular and ipsilateral pelvic ring fractures

BackgroundAlthough the incidence, types, and radiological outcomes of simultaneous ipsilateral pelvic ring and acetabular fractures have been reported, there have been no reports on factors that may affect the quality of acetabular fracture reduction. Here, we evaluate the radiological outcomes of patients treated for simultaneous ipsilateral pelvic and acetabular fractures and analyze the factors that affect the quality of acetabular fracture reduction.MethodsWe conducted a retrospective review of patients treated for simultaneous ipsilateral pelvic ring and acetabular fractures between 2016 and 2020. Factors that may predict inadequate reduction of the acetabular fracture were analyzed.ResultsData from 27 hips of 26 patients were collected. AO B2.2 and anterior columnar fractures were the most common types of pelvic ring and acetabular fractures, respectively. Univariate analysis revealed that Matta’s criteria for pelvic ring fracture may be useful for predicting fair to poor quality of acetabular fracture reduction on X-rays. Furthermore, associated fractures identified by Letournel’s classification system on computed tomography may be predictive of greater step-offs.ConclusionsAssociated fractures identified via Letournel’s classification may contribute to inadequate reduction of acetabular fractures. Matta’s criteria for pelvic ring fractures may also be useful for predicting the risk of inadequate reduction of the acetabulum on X-ray scans. These findings may be assessed intraoperatively by fluoroscopy before beginning osteosynthesis for acetabular fractures.

The role of anterior supra-acetabular external fixator as definitive treatment for anterior ring fixation in unstable pelvic fractures.

Management of anterior ring injuries is still a matter of discussion, and there are only few studies reporting anterior external fixator as definitive treatment for unstable pelvic injuries. This study aimed to describe the clinical and radiological outcomes of a consecutive series of mechanically unstable pelvic injuries that were treated with definitive anterior supra-acetabular external fixator for the anterior ring, and to identify risk factors for failure. We included a consecutive series of patients with unstable pelvic ring fractures who underwent anterior supra-acetabular external fixation for definitive treatment, between January 2012 and January 2020. All demographics, associated injuries and procedures, injury mechanism, and complications were analysed. Pelvic fracture was classified based on Orthopaedic Trauma Association/Tile AO (OTA/AO) and Young-Burgess classifications. Complications associated with the external fixator were revised. All patients were functionally evaluated at final follow-up and asked to report their clinical outcomes using the Majeed score. A total of 47 patients were included, of which 25 were females. The median age was 44years (interquartile range 23-59). Median follow-up duration was 14months (interquartile range 6-31). The most frequent aetiology was motor vehicle accident (35), followed by fall from height (8). All fractures required posterior pelvic ring fixation. The median time during which patients had external fixation in situ was 11weeks (interquartile range 9-13). All patients achieved healing of pelvic fracture at median time of 10weeks (interquartile range 8-12). At final follow-up, the median displacement of the anterior pelvis was 6mm (interquartile range 0-11). Superficial infection was the most common complication (n = 7). No washout procedures were needed. No major complication was reported. No patient required reoperation for anterior ring fracture. The median Majeed score was 88 points (range 60-95; interquartile range 80-90) at final follow-up. Our findings suggest that the use of supra-acetabular external fixator is safe and effective for definitive treatment of the anterior ring in unstable pelvic fractures. It is a method with high proportion of excellent results, regardless of the type of fracture. The rate of complications is low, and it does not compromise functional results.

Comparing the responsiveness of a generic and a musculoskeletal specific functional outcome measure in orthopaedic patients with operative fixation of pelvic ring, acetabulum, or tibia fractures: a comparison between single injury and multiply injured patients.

Objectives:This study compares the responsiveness, or the ability to detect clinical change in a disease, between the generic Short Form-36 (SF-36) and musculoskeletal specific Short Musculoskeletal Functional Assessment (SMFA) patient-reported outcome measures (PROMs) in the orthopaedic trauma population. Stratified analysis was performed to compare whether responsiveness differs between patients with single or multiple orthopaedic injuries.Design:Prospective case series.Setting:Level 1 Trauma Center.Patients:A total of 659 patients with orthopaedic trauma injuries to the pelvis, acetabulum, or tibia were included for analysis. There were 485 patients with a single isolated injury and 174 patients with multiple orthopaedic injuries.Intervention:None.Main Outcome Measurements:Responsiveness was calculated through the standard response mean (SRM), the proportion meeting a minimal clinically important difference, and floor and ceiling effects.Results:Between baseline and 6 months the magnitude of the SRM for SF-36 was consistently greater than that of SMFA in patients with single (P < .01) and multiple injuries (P < .01). Between 6 and 12 months, there were no differences in SRM across all cohorts. The proportion of patients who achieved minimal clinically important difference was consistently higher when assessed with SF-36 compared with SMFA between baseline and 6 months (81.8% vs 68.1%, P < .0001) and between 6 and 12 months (63.3% vs 55.4%, P = .01).A ceiling effect was only observed at baseline for the SMFA with 16.6% of patients achieving the maximal level of functioning detectable. No floor effects were seen in either PROM.Conclusion:This study demonstrates that SF-36 has superior responsiveness versus SMFA in both polytrauma and isolated injury patients and supports the collection of SF-36 as the primary PROM in prospective orthopaedic trauma studies irrespective of whether the patient has an isolated injury or multiple injuries.

Utility of 3-Dimensional Intraoperative Imaging in Pelvic and Acetabular Fractures: A Network Meta-Analysis.

Successful surgical management of pelvic ring and acetabular fractures requires technical expertise to achieve an accurate reduction and stable fixation. The use of 3-dimensional (3D) intraoperative imaging (3DIOI) as an assessment tool has led to improved reduction and placement of implants. The purpose of this study was to assess the utility of using 3DIOI in the management of acetabular and pelvic fractures on the basis of outcomes reported in the literature. A literature search was performed using PubMed, the Cochrane Database of Systematic Reviews (CDSR), and Google Scholar using key terms. A network meta-analysis conducted using the frequentist approach allowed for statistical analysis of reported outcomes regarding screw position (in mm), fracture reduction (in mm), and complications. A total of 9 studies were included in this analysis. When compared with conventional radiography, the mean radiation dose (in cGy·cm2) was significantly higher in 3DIOI (mean difference, 82.72; 95% confidence interval [CI], 21.83 to 143.61; p = 0.007). Use of 3DIOI yielded a 93% lower risk of developing medical complications (odds ratio [OR], 0.07; 95% CI, 0.02 to 0.35; p = 0.014). Use of 3DIOI yielded higher odds of achieving accurate screw placement (OR, 4.21; 95% CI, 1.44 to 12.32; p = 0.008) and perfect reduction (OR, 2.60; 95% CI, 1.19 to 5.68; p = 0.016). In ranking the imaging modalities, 12 of the 13 parameters analyzed were in favor of 3DIOI over conventional fluoroscopy and 2D navigation imaging. Current literature supports the use of 3DIOI because of the decreased rates of misplaced implants, malreduced fractures, complications, and subsequent revision operations. The use of 3DIOI allows for improved visualization of pelvic anatomy when repairing pelvic and acetabular fractures, and helps surgeons to achieve favorable surgical outcomes. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evoked potential as an adjuvant predictive tool for neurological deficit in acetabular and pelvic ring injuries: A meta-analysis

ObjectivesTo identify the value of the evoked potential as an adjuvant predictive tool in pelvic ring and acetabulum fractures focusing on the neurological deficit. Material and methodsAdhering to PRISMA guidelines, we performed a systematic review with a priori design to identify randomized controlled trials, retrospective and prospective cohort studies, and case-control studies of interventions in acetabular and pelvic ring injuries. The search strategy included the use of Title/Abstract related to: (“somatosensory” or “evoked potential” or “electrophysiology”) and (“randomized controlled trials” or “clinical studies” or “controlled clinical trial” or “systematic literature review” or “meta-analysis” or “review” or “overview”) and (“complications”). From 01/1985 to 12/2019, we searched MEDLINE, PubMed, EMBASE, and Cochrane, Centre for Reviews and Dissemination, reference lists and journals. The PRISMA checklist was adopted to evaluate reporting quality. Two reviewers independently selected studies and extracted data. Statistical analysis was conducted to assess the probability of evoked potential tests performed on random samples, with the assumption of normal distribution of the populations from which they were derived and knowledge of the parametric variance. ResultsFive articles fulfilled eligibility criteria. ConclusionEvoked potential tests can quickly and accurately detect imminent neurological impairment during surgery of acetabular and pelvic ring injuries. This results in significantly better surgical outcomes, although in some cases the irreversible nature of the injury cannot be prevented.

Distinct fracture characteristics influence decision making and patient management in fragility fractures of the pelvis – an alternative approach for fracture evaluation

Abstract Objective Pelvic ring fractures in the elderly with osteoporotic bone are often caused by a minor trauma. A separate classification for these fragility fractures of the pelvis (FFP) has been proposed by Rommens. However, at our institution the management algorithm is rather based on patient profile, clinical course and the ability to mobilize than on the fracture category. We aimed to identify fracture characteristics that might better reflect clinical decision making and show an association with outcome. Methods Four fracture characteristics were investigated as potential variables: 1. Extent of the dorsal pelvic ring fracture (absent, unilateral, bilateral); 2. Extent of the ventral pelvic ring fracture (absent, unilateral, bilateral); 3. Ventral comminution/dislocation; 4. Presence of a horizontal sacral fracture. These four characteristics were assessed retrospectively in a series of 548 patients with a CT scan proven FFP. The association of the fracture morphology with the decision to perform surgery, failure of conservative treatment and the length of hospital stay (LOS) was determined. Results Three of the four evaluated characteristics showed an independent and significant association with clinical decision making and patient management. In particular the extent of the dorsal fractures was identified as an independent risk factor for the decision to perform surgery with a 7.3-fold increase per category (p &amp;lt; 0.001). The same was observed for the presence of ventral comminution/dislocation (OR = 2.4; p = 0.002). The extent of ventral fractures (OR = 1.5; p = 0.047) was an independent risk factor for a longer LOS in conservatively treated patients. Conclusion Three evaluated morphologic aspects of FFPs showed a clear and independent relation to current clinical decision making and patient management at our institution. Importantly, the ventral fracture component has been shown to have major impact on treatment decision and outcome, which has been underestimated in the current FFP classification system. These four easily distinguishable fracture characteristics have the potential to form the basis of an alternative classification system that matches clinical reality and captures prognostic aspects.