Pelvic Ring Injuries Research Articles

Prevalence of pelvic CT angiography (CTA) and angiographic embolization in geriatric patients with pelvic ring fractures presenting to two level I trauma centers

ObjectivesHemorrhage in osteoporotic pelvic ring fractures is a rare, but serious complication. Most bleeding comes from the bone or venous plexuses, but arterial injury does occur. The purpose of this study was to characterize a large geriatric pelvic fracture cohort and determine the prevalence of pelvic CT angiography (CTA) and subsequent need for arterial embolization. MethodsA cohort of geriatric pelvic fracture patients at two level 1 trauma centers was reviewed. Many epidemiologic and patient factors were collected for cohort characterization. The primary outcome was if patients underwent a CTA of the pelvis and subsequently underwent arterial embolization. ResultsThere were 457 patients included and mean age was 83.1 years (range 65–100). Most patients had a low energy mechanism (91.4 %). In-hospital mortality was recorded for 30 cases (6.6 %). Of these deaths, two received a pelvic CTA and two had an embolization procedure. Pelvic CTA was performed on 33 patients (7.2 %). Fourteen patients (3.0 %) had an arterial embolization procedure. A high energy mechanism of injury was associated with receiving a pelvic CTA (p = 0.0067). Mechanism of injury was not associated with undergoing an embolization procedure (p = 0.685). DiscussionIn the geriatric population, even patients with stable pelvic fractures can present with life-threatening arterial bleeding. A non-insignificant percentage of patients will require CTA for suspected bleeding (7.2 %) and embolization to treat confirmed arterial bleeding (3.0 %). ConclusionsBleeding events in geriatric pelvic ring injuries is a previously under researched area of orthopedic trauma. Further research is needed to elucidate the exact pathomechanisms of arterial injury and what patients or injury patterns are most significantly associated. Specifically, larger cohort sizes and evaluating our existing cohort with different injury classification systems may yield useful results.

Increasing the Threshold to Perform Preperitoneal Pelvic Packing Decreases Morbidity Without Affecting Mortality.

To determine the effectiveness of an updated protocol that increased the transfusion threshold to perform preperitoneal pelvic packing in patients with pelvic ring injuries and hemodynamic instability (HDI). Retrospective review. Urban level 1 trauma center. Severely injured (injury severity score > 15) patients with pelvic ring injuries treated before and after increasing the threshold to perform preperitoneal pelvic packing from 2 to 4 units of red blood cells (RBCs). HDI was defined as a systolic blood pressure <90 mm Hg. Mortality from hemorrhage, anterior pelvic space infections, and venous thromboembolisms before and after increasing preperitoneal pelvic packing threshold. One hundred sixty-six patients were included: 93 treated under the historical protocol and 73 treated under the updated protocol. HDI was present in 46.2% (n = 43) of the historical protocol group and 49.3% (n = 36) of the updated protocol group (P = 0.69). The median age of patients with HDI was 35.0 years (interquartile range 26.0-52.0), 74.7% (n = 59) were men, and the median injury severity score was 41.0 (interquartile range 29.0-50.0). Patients with HDI in the updated protocol group had a lower heart rate on presentation (105.0 vs. 120.0; P = 0.004), required less units of RBCs over the first 24 hours (6.0 vs. 8.0, P = 0.03), and did not differ in age, injury severity score, systolic blood pressure on arrival, base deficit or lactate on arrival, resuscitative endovascular balloon occlusion of the aorta, resuscitative thoracotomy, angioembolization, or anterior pelvis open reduction internal fixation (P > 0.05). The number of PPPs performed decreased under the new protocol (8.3% vs. 65.1%, P < 0.0001), and there were fewer anterior pelvic infections (0.0% vs. 13.9%, P = 0.02), fewer VTEs (8.3% vs. 30.2%; P = 0.02), and no difference in deaths from acute hemorrhagic shock (5.6% vs. 7.0%, P = 1.00). Increasing the transfusion threshold from 2 to 4 units of red blood cells to perform pelvic packing in severely injured patients with pelvic ring injuries decreased anterior pelvic space infections and venous thromboembolisms without affecting deaths from acute hemorrhage. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Do we need another screw? Sacroiliac screw fixation in open-book pelvic ring injuries (APC type II).

To compare anterior plate fixation (SP fixation) both alone and in combination with an additional posterior sacroiliac screw (SP+SIS fixation) as a treatment for pelvic ring injuries with widening of the pubic symphysis and disruption to the anterior sacroiliac ligaments. To find studies with pelvic ring injuries (APC II; B2.3d) and SP or SP+SIS fixation, a systematic literature review was conducted by searching four databases. A protocol was published a priori at Open Science Framework (https://doi.org/10.17605/OSF.IO/3YHAV). Exclusion criteria included perineal injuries, chronic instability of the symphysis, complete sacroiliac separation, and pediatric patients (age <18 years). Primary outcomes of interest were defined as implant failure, health-related quality of life, and revision rate. Altogether, 1861 studies were screened, and 40 studies qualified for full-text analysis. In total, 14 studies (two surveys, six biomechanical studies, and six retrospective clinical studies) were included. The surveys revealed that surgeons who had more recently begun practicing were more likely to use posterior fixation (SP+ISS). The biomechanical studies were heterogenous and did not yield a uniform pattern. In clinical studies, 117 patients (45%) received SP fixation, and 142 patients (55%) received SP+SIS fixation. Complications occurred in 31 SP patients (30%) and in five SP+SIS patients (3.5%). A high risk of bias was uncovered, and reporting was found to be incomplete. SP+SIS may have the potential to improve outcomes, but the evidence remains too inconclusive to draw reliable recommendations.

Standardization and Reproducibility of Dynamic Stress Testing for Occult Pelvic Ring Instability.

Examination under anesthesia (EUA) (stress fluoroscopy) is commonly done after pelvic ring injury to identify occult instability because unstable disruptions may displace causing morbidity. The force applied during EUA for these injuries has not been standardized. The purpose of this study was to examine the forces used during the EUA by experienced orthopaedic trauma pelvic surgeons. Orthopaedic traumatologists performed simulated EUA on a cadaver at two North American pelvis and acetabular courses using internal rotation (IR), external rotation, and push-pull maneuvers while wearing a handheld dynamometer to measure force. All surgeons used a comparable method, and each performed EUA multiple times. Maximum forces were measured in Newton (N). Eighteen surgeons participated. Four had been practicing for <5 years, six for 5 to 10 years, six for 11 to 20 years, and two for >20 years. Surgeons applied a force ranging from 40.4 to 374.9 N during IR, 72.9 to 338.4 N during external rotation, and 25 to 323 N during push-pull, with notable variability seen between surgeons. Three surgeons (18%) had >50-N variability on serial trials of a single EUA maneuver (IR). This is the first study evaluating the forces applied during pelvic EUA used to assess ring stability. Notable variability existed among surgeons performing EUA and in serial examinations by the same surgeon. Additional study is needed to standardize the displacement measured and threshold for instability that guides management.

Pediatric-Specific Lesions in Unstable Pelvic Ring Fractures of Skeletally Immature Children: Impact on Diagnosis and Management Decisions.

Surgical fixation of pediatric pelvic ring injuries is gaining popularity to avoid the poor long-term outcomes of pelvic asymmetry. The surgical techniques and fixation choices depend on the individual injuries affecting the anterior and posterior pelvic ring areas. The immature bony pelvis of young children has anatomic differences including soft bones, elastic ligaments, and the presence of growth centers. Understanding the unique pediatric lesions with unstable pelvic fractures is essential for treatment decisions. Anterior lesions include pubic symphysis disruption through the pubic apophysis, single ramus fractures, pubic rami fractures through the triradiate cartilage, and/or the ischiopubic synchondrosis; ischiopubic ramus infolding injury; or the unstable superior and inferior quadrant lesions. Posterior pelvic lesions include iliac wing infolding and sacroiliac joint dislocation or transiliac (crescent) fracture/dislocations through the iliac apophysis growth plate. Pubic symphysis and sacroiliac disruptions are physeal injuries in children, and they have excellent healing potential. External fixation is an ideal choice for anterior ring fixation including bony and pubic symphysis injuries. Posterior lesions are mostly sacroiliac joint disruptions with iliac apophysis separation that can serve as a landmark for vertical displacement correction. Posterior lesions can be treated by percutaneous iliosacral screw fixation or open reduction techniques.

Emergency treatment of pelvic ring injuries: state of the art.

High energy pelvic injuries sustain significant mortality rates, due to acute exsanguination and severe associated injuries. Managing the hemodynamically unstable trauma patient with a bleeding pelvic fracture still forms a major challenge in acute trauma care. Various approaches have been applied through the last decades. At present the concept of Damage Control Resuscitation (DCR) is universally accepted and applied in major trauma centers internationally. DCR combines hemostatic blood transfusions to restore blood volume and physiologic stability, reduced crystalloid fluid administration, permissive hypotension, and immediate hemorrhage control by operative or angiographic means. Different detailed algorithms and orders of hemostatic procedures exist, without clear consensus or guidelines, depending on local traditions and institutional setups. Fracture reduction and immediate stabilization with a binder constitute the basis for angiography and embolization (AE) or pelvic packing (PP) in the hemodynamically unstable patient. AE is time consuming and may not be available 24/7, whereas PP offers a quick and technically easy procedure well suited for the patient in extremis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has also been described as a valuable adjunct in hemostatic non-responders, but merely constitute a bridge to surgical or angiographic hemostasis and its definitive role in DCR is not yet clearly established. A swift algorithmic approach to the hemodynamically unstable pelvic injury patient is required to achieve optimum results. The present paper summarizes the available literature on the acute management of the bleeding pelvic trauma patient, with emphasis on initial assessment and damage control resuscitation including surgical and angiographic hemostatic procedures. Furthermore, initial treatment of open fractures and associated injuries to the nervous and genitourinary system is outlined.

Influence of age on pelvic inlet and outlet radiographic views

Background. Unstable fractures of the posterior pelvic ring represent a pressing concern in trauma surgery. Minimally invasive osteosynthesis techniques have gained widespread acceptance in contemporary practice. Accurate radiographic visualization is a critical component for the precise and successful placement of iliosacral and transsacral screws. Obtaining and accurately interpreting X-ray images can pose challenges in specific clinical situations, particularly those involving age-related skeletal changes. The aim of the study is to assess the influence of the patient’s age on the measures of pelvic radiographic inlet and outlet views angles for performing a sacral fracture fixation using cannulated screws. Methods. A retrospective analysis of CT data was conducted on 106 patients with posterior pelvic ring injuries requiring cannulated screw fixation. Preoperative CT scans were reconstructed into sagittal projections. We performed construction and measurement of the true inlet angle, super-inlet angle, pelvic outlet angle, sacral concavity angle, promontory angle, S1 and S2 outlet view angles. Statistical correlation between sacral tilt angle and the patient’s age was assessed. Results. A two-step cluster analysis divided the patient cohort into two groups with significant differences in pelvic outlet angles and age (N1 = 64, N2 = 42). Statistically significant differences were found between the two clusters in all the studied parameters: median values of true pelvic inlet angles were 27.2° [23.2-32.2] and 18.2° [11.4-26.6] respectively (p0.001); super-inlet angles were 42.5° [39.3-47.8] and 36.2° [28.7-42.8] respectively (p0.001); promontory angles were 128.1° [123.3-133.2] and 122.1° [115.6-129.3] respectively (p = 0.003); pelvic outlet angles were 62.6° [58.4-69.6] and 50.3° [45.9-53.5] respectively (p0.001); S1 outlet angles were 51.8° [48.9-56.5] and 46.8° [43.1-50.2] respectively (p0.001); S2 outlet angles were 40.8° [37.3-44.6] and 35.7° [30.9-38.6] respectively (p0.001); the mean of the sacral concavity angles was 174.8°±10.5 and 152.1°±38.2 respectively (p0.001); and the main age was 41.6±18.7 and 69.2±16.1 years respectively (p0.001). A statistically significant inverse correlation between age and pelvic tilt angle (ρ = 0.534; p0.001) was found. A novel diagnostic method for identifying sacral dysmorphism using angle measurement within the S1 bone corridor is presented. The sacrum was considered dysmorphic if the angle was equal to or less than 5°. Conclusions. As the patient’s age increases by one year, pelvic outlet angle decreases by 26°. If pelvic inlet angles are equal to or less than 14.45°, the difficulties in visualizing S1 and S2 outlet views during surgery are to be expected. The median of angles difference before and after anterior sacral tilt correction using a coccyx pad was 9.4° with interquartile range from 7.8° to 11°. Significant anatomical variations in posterior pelvic ring structure were observed among the study cohort. Preoperative CT sagittal reconstructions allow appropriate planning of intraoperative visualization considering expected intraoperative radiographic inlet and outlet views.

Treatment Outcomes in Vertical Shear Pelvic Fractures: A Comparative Study.

Background Vertical shear (VS) pelvic ring injuries present a unique challenge due to their inherent vertical and rotational instability and the risk of massive bleeding. VS injuries may result from either bony or ligamentous injury. The goal in the treatment of VS fractures of the pelvis is to achieve and maintain an accurate reduction of the displaced hemipelvis. Aim of the study This study aimed to compare the results of the treatment of VS fractures pelvis by using iliosacral (IS) screws versus lumbopelvic fixation (LPF). Methodology This retrospective study was carried out on 40 patients with VS fracture pelvis injuries at El Hadara University Hospital, Alexandria, Egypt, from January 2020 to December 2020. Twenty of them were treated by an IS screw, and the other 20 were treated by LPF. Then, both groups were followed up for six months with regard to union rate, metal failure, and clinical outcomes. Results The EQ-5D showed a significant improvement in LPF more than the IS screw group in the five items of the score. Moreover, the total EQ-5D index showed a significant increase in the LPF group more than the IS screw group (p < 0.05). The incidence of neurological complication was found in four cases in the IS screw group, while no cases were found in the LPF group. The infection was found in six patients in the IS screw group and only three cases in the LPF group. The malunion was found in two cases in the IS screw groupand no cases in the LPF group. The neurological change and the incidence of infection were significantly higher in the IS screw group than in the LPF group (p < 0.05). Conclusion Our results demonstrate reliable maintenance of reduction and acceptable complication rates with a minimally invasive LPF for VS fractured pelvis. The benefits of minimally invasive LPF may be offset by increased elective reoperations for the removal of instrumentation.

Effects of Obesity on Systemic Complications After Operative Pelvic Ring Fractures.

To determine the effect of obesity on systemic complications after operative pelvic ring injuries. Retrospective cohort study. Single level 1 trauma center. All patients at a level 1 trauma center who underwent operative fixation of a pelvic ring injury from 2015 to 2022 were included. Patients were grouped based on body mass index (BMI) into 4 categories (normal = BMI <25, overweight = BMI 25-30, obese = BMI 30-40, and morbidly obese BMI >40). Systemic complications including acute respiratory distress syndrome, pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism, ileus, acute kidney injury (AKI), myocardial infarction, and mortality were recorded. Patients who developed a complication were compared with those who did not regarding demographic and clinical parameters to determine risk factors for each complication. A total of 1056 patients underwent pelvic ring fixation including 388 normal BMI, 267 overweight, 289 obese, and 112 morbidly obese patients. The average age of all patients was 36.9 years, with a range from 16 to 85 years. Overall, 631 patients (59.8%) were male. The overall complication and mortality rates were 23.2% and 1.4%, respectively. BMI was a significant independent risk factor for all-cause complication with an odds ratio of 1.67 for overweight, 2.30 for obese, and 2.45 for morbidly obese patients. The risk of DVT and AKI was also significantly increased with every weight class above normal with ORs of 5.06 and 3.02, respectively, for morbidly obese patients (BMI >40). This study demonstrated that among patients undergoing pelvic ring fixation, higher BMI was associated with increased risks of overall complication, specifically DVT and AKI. As the prevalence of obesity continues to increase in the population, surgeons should be cognizant that these patients may be at higher risk of certain postoperative complications during the initial trauma admission. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Insertion sites of iliosacral screws on the posterior ilium: Implications for posterior pelvic fixation

ObjectivesLateral compression type II pelvic ring injuries can be treated with fixation through open or percutaneous approaches depending on the injury pattern and available osseous fixation pathways. The start site of iliosacral screws to stabilize these injuries should be on the unstable posterior iliac fragment; however, our understanding of start sites for iliosacral screws has not been developed. The purpose of this study is to provide an analysis of iliosacral screw start sites on the posterior ilium to help guide treatment of pelvic ring injuries. MethodsOne-hundred and seventeen consecutive patients at an academic level I trauma center with pelvic ring injuries who underwent surgical treatment with iliosacral screws were included in the final analysis. The start sites of iliosacral screws with confirmed intraosseous placement on a postoperative computed tomography were mapped on the posterior ilium and analyzed according to the sacral segment and type of iliosacral screw. ResultsOne-hundred and seventeen patients were included in the final analysis. Of the total of 272 iliosacral screw insertion sites analyzed, 145 (53%) were sacroiliac-style screws and 127 (47%) were transsacral screws. The insertion sites for sacroiliac-style screws and transsacral screws at different sacral segment levels can vary but have predictable regions on the posterior ilium relative to reliable osseous landmarks. ConclusionsIliosacral screws start sites on the posterior ilium have reliable regions that can be used to plan posterior fixation of pelvic ring injuries.

Intraoperative slide rail CT assistance in percutaneous sacroiliac joint screws for the treatment of pelvic posterior ring injury

To compare the clinical efficacy of intraoperative slide rail CT combined with C-arm X-ray assistance and just C-arm for percutaneous screw in the treatment of pelvic posterior ring injury. A retrospective analysis was performed on the patient data of 76 patients with posterior pelvic ring injury admitted to the Department of Orthopedic Trauma from December 2018 to February 2022. Among them, 39 patients in the CT group were treated with C-arm combined with slide rail CT-assisted inline fixation including 23 males and 16 females with an average age of (44.98±7.33) years old;and the other 37 patients in the C-arm group were treated with intraline fixation treatment under only C-arm fluoroscopy including 24 males and 13 females with an average age of (44.37±10.82) years old. Among them, 42 patients with anterior ring fractures were treated with percutaneous inferior iliac spines with internal fixation (INFIX) or suprapubic support screws to fix the anterior pelvic ring. Postoperative follow-up time, operation time, complications of the two groups were compared. Results of Matta reduction criteria, Majed efficacy evaluation, the CT grading and the rate of secondary surgical revision were compared. The nailing time of (32.63±7.33) min in CT group was shorter than that of (52.95±10.64) min in C-arm group (t=-9.739, P<0.05). The follow-up time between CT group (11.97±1.86) months and C-arm group (12.03±1.71) months were not statistically significant(P>0.05). The postoperative complication rates between two groups were not statistically significant (χ2=0.159, P>0.05). Results of Matta reduction criteria (Z=2.79, P<0.05), Majeed efficacy evaluation(Z=2.79, P<0.05), CT grading (Z=2.83, P<0.05) in CT group were better than those in C-arm group(P<0.05); the secondary surgical revision rate in the CT group was significantly lower than that in the C-arm group (χ2=5.641, P<0.05). Compared with traditional C-arm fluoroscopy, intraoperative slide rail CT combined with C-arm assisted percutaneous sacroiliac joint screw placement surgery has the characteristics of short operation time, high accuracy and safety, and significant decrease in postoperative secondary revision rate, and is one of the effective methods for re-establishing the stability of the posterior ring of pelvic fracture.

The clinical relevance of fixation failure after pubic symphysis plating for anterior pelvic ring injuries: an observational cohort study with long-term follow-up

BackgroundOpen reduction and plate fixation is a standard procedure for treating traumatic symphyseal disruptions, but has a high incidence of implant failure. Several studies have attempted to identify predictors for implant failure and discussed its impact on functional outcome presenting conflicting results. Therefore, this study aimed to identify predictors of implant failure and to investigate the impact of implant failure on pain and functional outcome.MethodsIn a single-center, retrospective, observational non-controlled cohort study in a level-1 trauma center from January 1, 2006, to December 31, 2017, 42 patients with a plate fixation of a traumatic symphyseal disruption aged ≥ 18 years with a minimum follow-up of 12 months were included. The following parameters were examined in terms of effect on occurrence of implant failure: age, body mass index (BMI), injury severity score (ISS), polytrauma, time to definitive treatment, postoperative weight-bearing, the occurrence of a surgical site infection, fracture severity, type of posterior injury, anterior and posterior fixation. A total of 25/42 patients consented to attend the follow- up examination, where pain was assessed using the Numerical Rating Scale and functional outcome using the Majeed Pelvic Score.ResultsSixteen patients had an anterior implant failure (16/42; 37%). None of the parameters studied were predictive for implant failure. The median follow-up time was six years and 8/25 patients had implant failure. There was no difference in the Numerical Rating Scale, but the work-adjusted Majeed Pelvic Score showed a better outcome for patients with implant failure.Conclusionimplant failure after symphyseal disruptions is not predictable, but appears to be clinically irrelevant. Therefore, an additional sacroiliac screw to prevent implant failure should be critically discussed and plate removal should be avoided in asymptomatic patients.

Factors Associated With Infection in Patients With Combined Pelvic Ring and Bladder Injuries.

To identify the infection rate in patients with combined pelvic ring and bladder injuries. Secondary aims included identifying treatment and injury factors associated with infection. Retrospective review. Single Level I Tertiary Academic Center. All patients over a 12-year period with combined pelvic ring and bladder injuries were evaluated. Exclusion criteria were nonoperative management of the pelvic ring, isolated posterior fixation, and follow-up <90 days. Primary outcome measured was deep infection of the anterior pelvis requiring surgical irrigation and debridement. In total, 106 patients with anterior stabilization of the pelvis in the setting of a bladder injury were included. Seven patients (6.6%) developed a deep infection and required surgical debridement within 90 days. Patients undergoing open reduction and internal fixation with plating of the anterior pelvis and acute concomitant bladder repair had an infection rate of 2.2% (1/43). Patients undergoing closed reduction and anterior fixation with either external fixation or percutaneous rami screw after bladder repair had an infection rate of 17.6% (3/17). There was a higher infection rate among patients with combined intraperitoneal (IP) and extraperitoneal (EP) bladder injuries (23%) when compared with those with isolated EP (3.8%) or IP (9.1%) bladder injuries (P = 0.029). Acute open reduction and internal fixation of the anterior pelvis in patients with combined pelvic ring and bladder injuries has a low infection rate. Patients with combined IP and EP bladder injuries are at increased risk of infection compared with those with isolated IP and EP injuries. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Numerical study of pedicle screw construction and locking compression plate fixation in posterior pelvic ring injuries: Analyzed by finite element method.

The aim of this study was to compare the biomechanical performance of pedicle screw construction and locking compression plate fixation in posterior pelvic ring injuries analyzed by finite element method. A 3-dimensional finite element model of the spine-pelvis-femur complex with ligaments was reconstructed from computed tomography images. An unstable posterior pelvic ring injury was created, which was fixed with a pedicle screw construction or locking compression plate. A follower load of 400 N was applied to the upper surface of the vertebrae to simulate the upper body weight, while the ends of the proximal femurs were fixed. The construct stiffness, the maximum vertical displacement, the maximum posterior displacement, the maximum right displacement, and the overall maximum displacement of the sacrum, and stress distributions of the implants and pelvises were assessed. The construct stiffness of the pedicle screw model (435.14 N/mm) was 2 times that of the plate model (217.01 N/mm). The maximum vertical displacement, the maximum posterior displacement, the maximum right displacement, and the overall maximum displacement of the sacrum in the pedicle screw model were smaller than those in the plate model (0.919, 1.299, 0.259, and 1.413 mm in the pedicle screw model, and 1.843, 2.300, 1.053, and 2.895 mm in the plate model, respectively). The peak stresses of the implant and pelvis in the pedicle screw model decreased by 80.4% and 25% when compared with the plate model (44.57 and 34.48 MPa in the pedicle screw model, and 227.47 and 45.97 MPa in the plate model, respectively). The study suggested that the pedicle screw construction could provide better fixation stability than the locking compression plate and serves as the recommended fixation method for the treatment of posterior pelvic ring injuries.

Hidden blood loss and the influential factors after minimally invasive treatment of posterior pelvic ring injury with sacroiliac screw

BackgroundTo analyze the perioperative bleeding and hidden blood loss (HBL) of sacroiliac screw minimally invasive treatment of pelvic posterior ring injury and explore the influential factors of HBL after operation for providing reference for clinical treatment.MethodA retrospective analysis was conducted on data from 369 patients with posterior pelvic ring injuries treated with sacroiliac screws internal fixation at our hospital from January 2015 to January 2022. The research was registered in the Chinese Clinical Trial Registry in July 2022 (ChiCTR2200061866). The total blood loss (TBL) and HBL of patients were counted, and the factors such as gender, age, and surgical duration were statistically analyzed. The influential factors of HBL were analyzed by multiple linear regression.ResultsThe TBL was 417.96 ± 98.05 ml, of which the visible blood loss (VBL) was 37.00 ± 9.0 ml and the HBL was 380.96 ± 68.8 ml. The HBL accounted for 91.14 ± 7.36% of the TBL. Gender, surgical duration, fixed position, and fixed depth had significant effects on the HBL (P < 0.05).ConclusionsThe HBL was the main cause of anemia after minimally invasive treatment of posterior pelvic ring injury with a sacroiliac screw. Gender, surgical duration, fixed position, and fixed depth were closely related to the occurrence of HBL. In clinical treatment, we should consider these influential factors and take effective measures to reduce the impact of HBL on patients.

Incidence, Diversity, and Quality of Publications in Orthopaedic Trauma Literature

Introduction: Modern medicine increasingly relies on evidence-based care, using academic journals as vehicles for information dissemination. Increasing rates of publication have led to an overwhelming volume of literature. This study evaluates the proportion of dedicated orthopaedic trauma literature, the frequency of different topic domains, and the quality of currently published information. Methods: Top orthopaedic journals were selected by impact factor and scientific articles published between 2016 –2019 were evaluated. All articles were categorized by subspecialty and pre-defined topic domains and level of evidence was recorded. Results: 3,697 articles were published in Journal of Orthopaedic Trauma (JOT), Clinical Orthopaedics and Related Research (CORR), the Journal of Bone and Joint Surgery (JBJS), and Bone and Joint Journal (BJJ). 32% of articles were dedicated to orthopaedic trauma topics. Joint Arthroplasty was the most published subspecialty in general journals (35.37%, P&lt;0.002). Hip fractures were the most prevalent trauma topic domain in all four journals (15.5%, P&lt;0.002). Pelvic ring injuries were the second most prevalent topic in orthopaedic trauma journals, versus distal radius fractures in non-trauma journals (P&lt;0.05). 48.4% of published literature was level III evidence, with no differences between trauma and non-trauma publications (P&gt;0.05). Conclusion: Orthopaedic trauma is well represented within the orthopaedic literature with a diverse distribution of topics over the four-year period, second only to Joint Arthroplasty which was by far the most common topic in general orthopaedic journals. Level of Evidence in trauma literature parallel other orthopaedic subspecialties, but there is an overall low proportion of level I and II studies in the orthopaedic literature. Level of Evidence: Level II

A Comparative Study of Functional Outcomes in Unstable Pelvic Ring Fractures Treated With Internal Fixator (INFIX) With and Without Sacroiliac Joint Screw Fixation.

Introduction Despite constituting only 3-8% of orthopedic trauma cases, pelvic injuries are associated with high mortality rates, emphasizing the critical need for stable fixation rather than merely anatomical alignment. The use of an anterior, subcutaneous, internal pelvic fixator (INFIX), a novel technique, has shown promise in treating these injuries. Posterior pelvic ring injuries are challenging because they require a significant level of surgical training and technical expertise, and each treatment method has disadvantages. The aim of this study is to compare the clinical and biomechanical outcomes of INFIX with and without sacroiliac screw fixation for unstable pelvic fractures. Methods and methodology Retrospectively, we selected 20 patients with unstable pelvic ring injuries who had come to a high-volume tertiary care hospital and medical college in the state of Maharashtra, India. All the patients were operated on with INFIX; 10 with a sacroiliac joint screw and 10 without a sacroiliac joint screw. We followed up with the patients for six months and evaluated them according to the Majeed score. Results Functional outcomesdiffered little between INFIX patients operated on with and without a sacroiliac joint screw. However, morbidity, hospital stay, the need for ICU, radiation exposure, and technical ease of surgery were improved in INFIX patients without the sacroiliac screw procedure. We noted an average Majeed score of 78 in the INFIX-alone group and 77.2 in the group that received INFIX with a sacroiliac joint screw. Six months after the surgery, the patients showed signs of a stable bony union, had achieved a full range of motion, and reported no problems in their day-to-day work. Conclusion Although this was a short-term study, we conclude that INFIX without a sacroiliac joint screw showed a comparable functional outcome compared to INFIX with a sacroiliac joint screw. Patients with INFIX alone showed better results; they had reduced surgical time, reduced radiation exposure, and less evidence of neurological harm to the L5-S1 nerve root. The procedure was less complicated and easier for surgeons to learn. Its simplicity and speed were especially beneficial for obese patients.

Critical distance of the sacroiliac joint for open reduction using screw fixation for traumatic sacroiliac joint diastasis: a retrospective study

BackgroundOsteosynthesis for sacroiliac joint (SIJ) diastasis using an iliosacral screw (ISS) and a trans-iliac-trans-sacral screw (TITSS) can be performed using a closed or an open method. However, no clear indication for open reduction has been established.MethodsData on patients with unilateral traumatic SIJ diastasis who underwent ISS and TITSS fixation were retrospectively collected and separated into groups according to the reduction method: closed reduction group (C group) and open reduction group (O group). Demographic data and perioperative image assessments were compared between the groups. The critical distance of the SIJ was identified to elucidate the indication for open reduction of the diastatic SIJ.ResultsFifty-six patients met the inclusion criteria over a 3-year period. There was no significant difference in the reduction quality of pelvic ring injuries between the groups, according to Matta’s and Lefaivre’s criteria. The improvement in the SIJ distance was significantly greater in the O group than in the C group in the axial plane on multiplanar computed tomography (p = 0.021). This model predicted that a difference of > 3.71 mm between the injured and healthy SIJ was a recommended indication for open reduction, with an area under the curve of 0.791 (95% confidence interval 0.627–0.955, p = 0.004).ConclusionsOpen reduction for SIJ diastasis might achieve better reduction quality than does closed reduction in the axial plane in selected cases. When the difference between the injured and healthy SIJ was wider than 3.71 mm, open reduction was recommended for satisfactory radiological outcomes.

Biomechanical comparative study on external fixators of new configurations in the treatment of Tile C pelvic injury

To compare the biomechanical properties of several anterior pelvic ring external fixators with two new configurations in the treatment of Tile C pelvic fractures, in order to evaluate the effectiveness of the new configurations and provide a reference for their clinical application. A finite element model of a Tile C pelvic ring injury (unilateral longitudinal sacral fracture and ipsilateral pubic fracture) was constructed. The pelvis was fixed with iliac crest external fixator (IC), anterior inferior iliac spine external fixator (AIIS), combination of IC and AIIS, combination of anterior superior iliac spine external fixator (ASIS) and AIIS, and S1 sacroiliac screw in 5 types of models. The stability indices of the anterior and posterior pelvic rings under vertical longitudinal load, left–right compression load and anterior–posterior shear load were quantified and compared. In the simulated bipedal standing position, the results of the vertical displacement of the midpoint on the upper surface of the sacrum are consistent with the displacement of the posterior rotation angle, and the order from largest to smallest is IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. The longitudinal displacement of IC is greater than that of the other models. The displacements of ASIS + AIIS and IC + AIIS are similar and the latter is smaller. In the simulated semi-recumbent position, the vertical displacement and posterior rotation angle displacement of the midpoint on the upper surface of the sacrum are also consistent, ranking from large to small: IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. Under the simulated left–right compression load state, the lateral displacements of the highest point of the lateral sacral fracture end are consistent with the highest point of the lateral pubic fracture end, and the order from large to small is S1 screw, IC, AIIS, ASIS + AIIS and IC + AIIS, among which the displacements of S1 screw and IC are larger, and the displacements of ASIS + AIIS and IC + AIIS are similar and smaller than those of other models. The displacements of IC + AIIS are smaller than those of ASIS + AIIS. Under the simulated anterior–posterior shear load condition, the posterior displacements of the highest point of the lateral sacral fracture end and the highest point of the lateral pubic fracture end are also consistent, ranking from large to small: IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. Among them, the displacements of IC and AIIS are larger. The displacements of ASIS + AIIS and IC + AIIS are similar and the latter are smaller. For the unstable pelvic injury represented by Tile C pelvic fracture, the biomechanical various stabilities of the combination of IC and AIIS are superior to those of the external fixators of conventional configurations. The biomechanical stabilities of the combination of ASIS and AIIS are also better than those of the external fixators of conventional configurations, and slightly worse than those of the combination of IC and AIIS. Compared with sacroiliac screw and conventional external fixators, the lateral stabilities of IC + AIIS and ASIS + AIIS are particularly prominent.

Minimally Invasive Treatment of Pelvic Fractures with Titanium Elastic Nailing: An Innovative Technology.

Minimally invasive treatment has become the most popular and effective treatment for pelvic fractures. This study aimed to evaluate the safety and efficacy of a new technique, titanium elastic nailing (TEN), for the minimally invasive treatment of pelvic fractures. Twenty-four patients with pelvic fractures were referred to us between January 2020 to January 2022, including sixteen males and 8 females. Pelvic fractures were temporarily fixed by pelvic fixation belt accompanied by traction from the lower limb bone. Anterior pelvic ring injuries (superior ramus of pubis) and ilium fractures were treated with closed reduction and intramedullary fixation with minimally invasive TEN. Intraoperative C-arm, including pelvic anteroposterior, pelvic outlet, inlet and ilium oblique views, and O-arm fluoroscopy (intraoperative CT) were employed to assess fractures reduction and determine the location of the elastic titanium nail within the bone channel. By adopting closed reduction and minimally invasive incision techniques, pelvic fractures could be safely fixed by placing an elastic titanium nail in the osseous medullary cavity channels of the pelvis. Postoperative investigation indicated that the wounds of all patients were healed in the first stage without any occurrence of complications, such as injuries to the nerves, blood vessels, and important tissue structures. Patients are essential quickly after the operation and could perform the functional exercise in the early stages of the recovery. TEN can be used for minimally invasive treatment of pelvic fractures. This novel technique has no obvious complications and is worthwhile in clinical practice.