Posterior Pelvic Ring Fractures Research Articles

Conservative versus operative treatment of FFP II fractures in a geriatric cohort: a prospective randomized pilot trial

A clear recommendation regarding treatment strategy of fragility fractures of the pelvic ring is missing. The most typical fracture pattern is a lateral compression type injury with non-displaced fractures of the anterior pubic rami and a unilateral os sacrum fracture (FFP II). We hypothesized that operative treatment would be superior to conservative treatment. From October 2017 to April 2020, a randomized prospective non-blinded trial with n = 39 patients was carried out. Two arms with 17 operative versus 22 conservative cases were created. Inclusion criteria were a posterior pelvic ring fracture FFP type II, age over 60 years and acute fracture (< 3 weeks). Barthel index, pain level (VAS), quality of life (EQ-5D-3L), and Tinetti–Gait Test were determined on admission, at discharge, and after 3, 6, 12 and 24 months. Median follow-up was 12.9 months. The Barthel index (= 0.325), VAS (p = 0.711), quality of life (p = 0.824), and Tinetti–Gait Test (p = 0.913) showed no significant differences between the two groups after 12 months. Two patients switched from the conservative to the operative arm due to persistent immobilization and pain. The one-year mortality rate showed no significant difference (p = 0.175). Our hypothesis that surgical treatment is superior was refuted. No significant benefit was shown in terms of quality of life, mortality and pain levels. The results suggest a more differentiated treatment approach in the future, with initial conservative treatment preferred. A larger multi-center trial is required to confirm these findings.Trial registration: The study was retrospectively registered with the German Clinical Trials Registry (DRKS00013703) on 10/12/2018.

Operative versus conservative treatment in pelvic ring fractures with sacral involvement

BackgroundTo evaluate the performance in activities of daily living (ADL), level of pain, mortality and rate of complications in patients with a pelvic ring fracture with sacral involvement who were treated conservatively compared to a surgically treated patient collective using percutaneous iliosacral screw fixation. HypothesisConservative treatment does not result in inferior clinical outcome compared to operative treatment. Patients and methodsA retrospective study of 112 conservatively (n=46) or operatively (n=66) treated patients with an isolated posterior or a combined posterior and anterior pelvic ring fracture was performed. The analysis included: age, sex, mechanism of injury, fracture type according to AO/OTA classification, energy of trauma sustained (no-, low-, high-energy trauma), type of treatment (operative or conservative), complications as well as duration of in-hospital stay. To assess clinical and activity outcome, the visual analog scale for pain (VAS), Barthel Scale, American Society of Anaesthesiologists (ASA) scores as well as mortality were assessed. The mean follow-up was 29.3±14.6 months. Furthermore, a geriatric subgroup (n=68, age≥60, low-energy trauma only) was analyzed. ResultsThe majority of the patients were female (79%) and suffered from low-energy trauma (n=64, 58%). There were no significant differences in the operative and the conservative groups and subgroups concerning VAS, Barthel scores and ASA scores. The survival analyses showed a significantly lower survival rate in the conservative group (41.8±3.6 months) compared to the operative group (55.9±2 months, p=0.002). Similar findings were encountered in the geriatric subgroup analysis. ConclusionThis study demonstrates equivalent clinical outcome in conservatively and surgically treated patients using a percutaneous iliosacral screw fixation at a mid-term follow-up. However, operatively treated patients showed decreased mortality. This needs to be carefully considered in clinical decision-making but must be further explored using a prospective randomized study approach. Level of evidenceIII.

Epidemiology and socioeconomic consequences of work-related pelvic and acetabular fractures recorded in the German Social Accident Insurance

IntroductionPelvic and acetabular fractures can result from work-related accidents and frequently require lengthy medical treatments. Consequently, high medical costs as well as delayed or absent return to work can be the consequence. Therefore, we aimed to study the socioeconomic consequences of work-related pelvic and acetabular fractures. Materials and methodsThis retrospective study investigated work-related pelvic and acetabular fractures recorded in the German Social Accident Insurance in 2011 and 2017, in terms of age, sex, type of accident, duration of incapacity to work, reductions in earning capacity, costs for outpatient and inpatient treatment and costs for pension and severance pay. ResultsAmong a total of 606 injuries in 2011 and 619 injuries in 2017, male patients and patients between 40 and 65 years were predominantly affected. Acetabular fractures caused higher rates of long absence from work of 6–12 months (2011: 24.7% vs. 9.5–16.9%; 2017: 26.1% vs. 6.1–11.0%) and >12 months (2011: 15.8% vs. 9.8–10.2%; 2017: 13.3% vs. 1.9–8.2%) as well as more cases with a reduction in earning capacity of at least 20% (2011: 61 vs. ≤27 cases; 2017: 39 vs. ≤12 cases) compared to pelvic ring fractures. The total costs for pelvic ring and acetabular fractures in the German social accident insurances amounted € 18,726,630 and € 9637,189 in the periods 2011–2020 and 2017–2020, respectively. The average costs per case for treatment and rehabilitation until 2020 was € 19,079 for injuries from 2011 and € 13,629 for injuries from 2017. Acetabular fractures were found to be the most cost-intensive injuries compared to anterior, posterior or complex pelvic ring fractures. ConclusionsWork-related pelvic and especially acetabular fractures have a considerable socioeconomic impact in the German Social Accident Insurance. Measures to prevent work-related accidents and to improve treatment of pelvic injuries can help to reduce their socioeconomic burden.

Clinical implications of additional posterior fractures in combined anterior-posterior pelvic ring fractures in elderly patients

ObjectivesHistorically, pelvic ring fractures (PRF) are considered to occur predominantly in the anterior ring and therfore to be mechanically stable. Combined anterior and posterior (A + P) PRF are expected to be less mechanically stable and therefore to be associated with higher levels of pain and reduced mobility compared to isolated anterior fractures. The current study investigates the clinical relevance of combined A + P PRF in elderly patients. MethodsA prospective multicentre cohort study was conducted in patients >70 years of age with anterior PRF after low-energy trauma diagnosed on conventional radiographs. All patients underwent an additional CT-scan. Patients were divided into two groups; isolated anterior or combined A + P fractures. Patients were treated conservatively with adequate analgesia for at least one week. If patients could not be mobilised after conservative treatment, surgical fixation was performed. Numerical Rating Scale (NRS) pain scores, dependence on walking aids and Activities of Daily Living scores (ADL) were measured at 2–4 weeks, and 3, 6 and 12 months after fracture. Results102 patients (age 81.1 ± 7.6 years) were included. Isolated anterior fractures were diagnosed in 25 (24.5%) and A + P fractures in 77 (75.5%) patients. Baseline characteristics did not differ between the two groups. Most patients were successfully treated conservatively and 5 (4.9%) underwent percutaneous trans-iliac, trans-sacral screw fixation after failure of conservative treatment. At 2–4 weeks post trauma, patients with A + P fractures had similar median pain scores (3 (range 0–8) vs. 5 (0–10), p = 0.19) and ADL scores (85 (25–100) vs. 78.6 (5–100), p = 0.67), but were more dependent on walking aids (92.8% vs. 72.2%; p = 0.02) compared to patients with isolated anterior fractures. There were no significant differences at 3 months. At one year follow-up the median NRS pain and ADL scores for both fracture groups were 0 and 100, respectively. Mortality was 10.8%, and additional loss to follow-up was 17.6%. ConclusionsThe vast majority of elderly patients with PRF have combined A + P fractures. The clinical implications of additional posterior pelvic ring fractures in elderly patients appears to be limited.

Posterior pelvic ring involvement detected with CT taken within a week of admission in acute fragility fractures of the pelvis (FFP) does not predict failure of conservative treatment: a retrospective cohort study

BackgroundAcute low energy pubic rami fractures in the elderly receive primarily conservative treatment. There is debate to what extent posterior ring involvement, which is detected superiorly by CT compared to X-ray, has an impact on outcome and may require modified treatment. We want to demonstrate if posterior ring involvement has an influence on different types of outcome in primarily conservatively treated acute FFP, questioning the usefulness of early CT. Additionally we analysed the early fracture pattern in cases where conservative treatment failed with need for secondary surgery.MethodsA retrospective cohort study of 155 consecutive patients, recruited between 2009 and 2016, aged over 65 years diagnosed with an acute LE-PFr on X-ray at the emergency department of a single, level-one trauma centre and receiving an early CT. A set of outcome parameters was compared between patients with an isolated pubic rami fracture (CTia) and patients who had a combined posterior pelvic ring fracture (CTcp).ResultsThere were 155 patients of whom 85.2% were female with a mean age of 83 years. 76.8% of patients living at home returned home and 15.5% moved to a nursing home. Mortality rate during hospitalisation was 6.4% and 14.8% at one year post-trauma. Secondary fracture displacement occurred in 22.6%. Secondary surgery was performed in 6 cases (3.9%). Median hospitalisation length of stay was 21 days (range 0 to 112 days). There was no significant association between the subgroups and change in residential status (p = 0.65), complications during hospitalisation (p = 0.75), mortality rate during admission (p = 0.75) and at 1 year (p = 0.88), readmission within 30 days (p = 0.46) and need for secondary surgery (p = 0.2). There was a significant increased median length of stay (p = 0.011) and rate of secondary displacement (p = 0.015) in subgroup CTcp. Secondary displacement had no impact on in-hospital complications (p = 0.7) nor mortality rate during admission (p = 0.79) or at 1 year (0.77). Early CT in patients who underwent secondary surgery showed stable B2.1 lesions in 4 of 6 cases.ConclusionsOur data suggest that early CT in patients with conservatively treated acute LE-PFr in order to detect posterior lesions, has limited value in predicting failure of conservative treatment.

Minimally invasive bilateral fixed angle locking fixation of the dorsal pelvic ring: clinical proof of concept and preliminary treatment results

PurposeDorsal pelvic ring fractures may result from high energy trauma in younger patients or from osteoporosis as fragility fractures in elderly patients. To date, no strong consensus exists on the best surgical technique to treat posterior pelvic ring injuries. The aim of this study was to evaluate the surgical performance of a new implant for angle-stable fixation of the posterior pelvic ring and patient outcome.MethodsIn a prospective pilot study, 27 patients (age: 39–87 years) with posterior pelvic ring fractures classified according to the AO classification (n = 5) or to the fragility fractures of the pelvis (FFP) classification (n = 22) were treated using the new implant. During a follow-up period of 1 year, surgical parameters of the implantation technique, complication rate, morbidity, mortality, preservation of patient mobility, and social independence were evaluated.ResultsNo implant misplacement or failure was observed. Two patients developed symptomatic spinal canal stenosis at L4/L5 following mobilization. MRI diagnosis proved the implant was not responsible for the symptoms. In one case, an additional plate stabilization of a pubic ramus fracture was necessary 6 months later. There was no inpatient mortality. One patient died due to her underlying oncological disease within the first 3 months. The main outcome parameters were pain, mobility, preservation of independent living and employment.ConclusionOperative instrumentation of dorsal pelvic ring fractures should be stable enough to allow for immediate weight bearing. The new locking nail implant offers percutaneous reduction and fixation options and may decrease the generally observed rate of complications.Trail registrationGerman Clinical Trials Register ID: DRKS00023797, date of registration: 07.12.2020.

Le traitement conservateur des fractures du sacrum par insuffisance osseuse est-il toujours d’actualité ? Étude clinique observationnelle à propos de 46 patients

BackgroundAccording to current forecasts, our society will grow older and older, so that the proportion of 6 % of the German population from 2017 who were 80 years or older will increase further. The frequency of falls in this patient population lead to a further increase of sacral insufficiency fractures. HypothesisThe aim of this study is to evaluate the multimodal interdisciplinary conservative therapy regime for sacral insufficiency fractures in geriatric patients, especially on the basis of mobility and the need for assistance. Patients and methodsA cohort of patients, who were treated as inpatients at the Waldkrankenhaus St. Marien in Erlangen with ICD-10 for sacral fractures S32.1 as the main diagnosis, was retrospectively examined. Only newly diagnosed sacral insufficiency fractures were taken into account. Patients were divided into groups based on the factors hospital stay, fracture location on the sacrum, and location of concomitant pelvic ring injury. The Barthel Index, the Tinetti's Mobility Test and the Timed Up&Go Test were recorded. ResultsForty-six patients met the inclusion criteria. Using the conservative therapy, improvements were achieved in all patients in terms of need for care, mobility without aids and risk of falling, also patients with an anterior and posterior pelvic ring fracture. Regard a score improvement in the Barthel Index and Tinetti Mobility Test, patients with bilateral sacral insufficiency fracture (n=17, 37.0 %) did not differ significantly from patients with unilateral sacral insufficiency fracture (n=22, 47.8 %). ConclusionIn geriatric patients, decisions about therapy should always be made on an individual and interdisciplinary basis. The conservative therapy regimen continues to play an important role in this. The collected tests – consisting of Barthel Index, Tinetti Mobility Test and Timed Up&Go Test – are well suited for further reproducible, objective studies with a larger patient collective. Level of evidenceIV.

Is the conservative treatment of sacral insufficiency fractures still up to date? Retrospective clinical observational study in 46 patients

BackgroundAccording to current forecasts, our society will grow older and older, so that the proportion of 6% of the German population from 2017 who were 80 years or older will increase further. The frequency of falls in this patient population lead to a further increase of sacral insufficiency fractures. HypothesisThe aim of this study is to evaluate the multimodal interdisciplinary conservative therapy regime for sacral insufficiency fractures in geriatric patients, especially on the basis of mobility and the need for assistance. Patients and MethodsA cohort of patients, who were treated as inpatients at the Waldkrankenhaus St. Marien in Erlangen with ICD-10 for sacral fractures S32.1 as the main diagnosis, was retrospectively examined. Only newly diagnosed sacral insufficiency fractures were taken into account. Patients were divided into groups based on the factors hospital stay, fracture location on the sacrum, and location of concomitant pelvic ring injury. The Barthel Index, the Tinetti's Mobility Test and the Timed Up&Go Test were recorded. Results46 patients met the inclusion criteria. Using the conservative therapy, improvements were achieved in all patients in terms of need for care, mobility without aids and risk of falling, also patients with an anterior and posterior pelvic ring fracture. Regard a score improvement in the Barthel Index and Tinetti Mobility Test, patients with bilateral sacral insufficiency fracture (n=17, 37.0%) did not differ significantly from patients with unilateral sacral insufficiency fracture (n=22, 47.8%). ConclusionIn geriatric patients, decisions about therapy should always be made on an individual and interdisciplinary basis. The conservative therapy regimen continues to play an important role in this. The collected tests–consisting of Barthel Index, Tinetti Mobility Test and Timed Up&Go Test–are well suited for further reproducible, objective studies with a larger patient collective. Level of evidenceIV.

Percutaneous iliosacral screw insertion with only outlet and inlet fluoroscopic view for unstable pelvic ring injuries: Clinical and radiological outcomes.

Percutaneous iliosacral screw fixation in posterior pelvic ring fractures is challenging and commonly performed under fluoroscopy or navigation techniques. This study aimed to assess the safety and efficacy of percutaneous iliosacral screw implantation under fluoroscopy guidance with only inlet and outlet views. This retrospective study included 58 consecutive unstable posterior pelvic injury patients (36 sacral fractures and 22 sacroiliac joint disruptions) treated with percutaneous iliosacral screws between January 2015 and November 2019. Acceptable inlet radiographs show the anterior cortex of the S1 body superimposed on the S2 body. Acceptable outlet radiographs show the superior pubic symphysis at the level of the S2 foramen and visualize the S1 and S2 sacral foramina. In our technique, the screw was inserted at the inferior half of the outlet view and the posterior half of the inlet view. The time needed for screw insertion and the radiation exposure time was recorded. Intra and postoperative complications were documented. Postoperative computed tomography (CT) scans assessed screw position. In total, 69 iliosacral screws were inserted in 58 patients. In postoperative CT scans, the screw position was assessed, 89.8% were in a secure position, and 10.2% had malposition. The mean operation time per screw was 21.18 min and the mean fluoroscopy time per screw was 112 s. There was no evidence of wound infection or iatrogenic neurovascular injury. No reoperation was performed. Percutaneous iliosacral screws can be placed using the only outlet and inlet fluoroscopic views with comparable radiological and clinical outcomes to the conventional method.

Minimally Invasive Percutaneous TightRope® System Fixation for an Unstable Posterior Pelvic Ring: Clinical Follow‐up and Biomechanical Studies

ObjectiveTo evaluate the mechanical stability and clinical efficacy of minimally invasive percutaneous TightRope® systems applied via gun‐shaped reduction forceps for unstable posterior pelvic ring fractures.Materials and methodsThis study consists of two parts: a clinical retrospective study and a randomized controlled biomechanical test. For the clinical study, a retrospective analysis of posterior pelvic ring fractures was performed between June 2015 and May 2020. Eighteen patients underwent surgery using two TightRope® systems to fix a broken posterior pelvic ring because of unstable AO type C1 and C2 pelvic ring fractures. The patients were followed up for at least 2 years, and all patients were evaluated using the Majeed scoring system and vertical displacement. In the biomechanical tests, six embalmed adult pelvic specimens were used. The fractures were subjected to TightRope®, IS screw, and TBP fixation in a randomized block design. The specimens were placed in a biomechanical testing machine in a standing neutral posture. A cyclic vertical load of up to 500 N was applied, and the displacement of the specimens was recorded by the testing machine. The ultimate load in each group of specimens was recorded. The displacement and ultimate load were compared and analyzed by statistical methods.ResultsAt a mean follow‐up of 38.89 ± 8.72 months, the functional Majeed score was excellent in 14 patients and good in four patients. The final radiological examinations showed that the outcome was excellent in 14 patients and good in four patients. In these patients, no serious clinical complications were found. Weight‐bearing was delayed in four patients. In biomechanical tests, the displacement of the specimens fixed with TightRope® was significantly lower than that of the specimens fixed with TBP (P < 0.05) when the load ranged from 300 to 500 N. The displacement in the IS screw group was significantly lower than that in either the TBP or TightRope® group (P < 0.05) when the load ranged from 0 to 500 N. The ultimate load in the IS screw group (1798 ± 83.53 N) was significantly greater than that in the TBP group (1352 ± 74.41 N) (t = 9.78, P < 0.0001) and the TightRope® group (1347 ± 54.28 N) (t = 11.11, P < 0.0001). However, no significant difference was observed between the TightRope® and TBP groups (t = 0.13, P = 0.90).ConclusionPercutaneous posterior TightRope® system shows strong stability in mechanical experiments and shows good results in clinical follow‐up while this system has certain advantages in lower surgical requirements and lower risk of related nerve and vascular structural damage.

Spinal nerve compression after malunion of vertical sacrum fractures.

Introduction and importanceUnstable pelvic ring injuries often occur in high energy traumas. Vertical sacrum fracture is an associated injury. This report describes a late spinal nerve compression that occurred following surgical reduction and fixation of pelvic ring injuries caused by traumatic L5-S1 disc herniation and malposition of the sacral fracture.Case presentationA 61-year-old female presented with radiculopathy in her right leg after surgical reduction and fixation of a sacral and pelvic fracture. Physical examination revealed numbness and weakness of the right leg. Radiographic studies showed spinal compression caused by a fracture spike from the malunion of the sacrum and protruding disc from the L5/S1 level. The fracture spikes were removed by laminectomy and discectomy after which the patient's condition had improved and she had no recurrent symptoms at the one-year follow-up.Clinical discussionMalunion of a posterior pelvic ring fracture and a herniated adjacent intervertebral disc can cause sacral nerve root compression. This complication can be managed and satisfactory results achieved by surgical intervention.ConclusionTraumatic L5-S1 disc herniation and malposition following surgical reduction and fixation of a sacrum fracture can be avoided. Posterior decompression by laminectomy and discectomy is an effective alternative treatment for patients with this condition.

Inverse association between sarcopenia and displacement in the early phase of fragility fractures of the pelvis

ObjectivesFragility fractures of the pelvis (FFP) commonly occur in the frail elderly. Displacement in the posterior pelvic ring is recognized as the key sign of instability. This study aims to elucidate the relationship between computer tomography (CT)-based frailty markers and displacement of the posterior pelvic ring within 7 days after injury. MethodsThis retrospective study included 49 patients (42 females, 7 males) with FFP (type I 10, type II 24, type III 12, type IV 3). On a CT slice at the level of the third lumbar vertebra, skeletal muscle area, skeletal muscle radiation attenuation, and skeletal muscle index (SMI) were calculated as sarcopenia markers. Osteopenia was measured with trabecular region of interest attenuation technique on the same CT slice. ResultsThere was no difference in the demographics between non-displaced and displaced FFP. CT-based data showed that patients with FFP had osteopenia. However, no difference was found between non-displaced and displaced FFP. SMI was higher in FFP types III/IV than non-displaced FFP when CT-based data on sarcopenia were compared among all patients. Female patients with FFP demonstrated similar results. Logistic regression analysis using the demographics and CT-based markers on sarcopenia and osteopenia revealed that SMI was a potential determinant of displacement of the posterior pelvic ring fractures. ConclusionsThere was inverse association between sarcopenia and displacement of the posterior pelvic ring in the early phase of FFP. Relatively preserved muscle may develop displacement in the elderly with osteopenia.

Displaced posterior pelvic ring fractures treated with an unlocking closed reduction technique: Prognostic factors associated with closed reduction failure, reduction quality, and fixation failure

PurposesThis study aimed to evaluate the clinical effect of the unlocking closed reduction technique (UCRT) for the displaced posterior pelvic ring fractures and to analyze the factors associated with failure of closed reduction and fixation. Patients and methodsData from patients admitted with displaced posterior pelvic ring fractures initially treated with the URCT from July 2017 to January 2020 were extracted. Clinical and radiological factors including fracture classification, interval days from injury to surgery, number of screws, and type of fixation for the posterior pelvic ring were analyzed to evaluate their correlation with closed reduction failure, reduction quality, and fixation failure. Then a logistic regression model was used for statistical analysis to eliminate confusion factors. ResultsNinety-seven patients with displaced posterior pelvic ring fractures were followed for a mean of 1.7 years after surgery. Successful closed reduction and percutaneous fixation were achieved for 89 patients (91.8%), of which 82 patients (92.1%) achieved an excellent or good reduction. Closed reduction failure which converted to open reduction was recorded for eight patients (8.2%). AO/OTA type C3 fracture (p = 0.036) and osteoporosis (p = 0.012) were significant factors for closed reduction failure. Excellent was recorded for 76 patients (78.4%) and acute (1-21 days) interval days from injury to surgery was an associated factor for reduction quality. For AO/OTA type C1 fractures, no more than two short screws (unilateral iliosacral screws) or a single long screw (transiliac-transsacral screws) were independent prognostic factors of fixation failure (p = 0.026). ConclusionsDisplaced posterior pelvic ring fractures treated with the UCRT are associated with excellent/ good radiological results. However, in patients with AO/OTA type C3 pelvic fracture and osteoporosis, the backup plan of open reduction should be routinely prepared. The patient should be brought to the operating room within three weeks to get a good reduction result. Two long screws or one long screw combined with two short screws are required to create a strong construct for AO/OTA type C1 pelvic fractures.

Percutaneous Robot-Assisted versus Freehand S2 Iliosacral Screw Fixation in Unstable Posterior Pelvic Ring Fracture.

ObjectivesTo assess the efficiency, safety, and accuracy of S2 (IS) screw fixation using a robot‐assisted method compared with a freehand method.MethodsThis is a retrospective clinical study. We analyzed the patients treated with S2 IS screw fixation for unstable pelvic fractures from January 2016 to January 2019 in our institution. Sixty‐three patients (17 men and 46 women) aged between 21 and 55 years (with an average age of 39.22 ± 9.28) were included in this study. According to the Tile classification, there were 26 (41.3%) type B fractures and 37 (58.7%) type C fractures. All patients were divided into robot‐assisted (RA) group (38 patients) or the traditional freehand (FH) group (25 patients). In RA group, the S2 IS screws were implanted with a robot‐assisted technique. And S2 IS screws were implanted with a traditional freehand technique in FH group. The screw‐related complications were recorded during and after the surgery. The position of all screws and fracture reduction was assessed by postoperative CT scans according to the Gras classification. The number of guide wire attempts and the radiation exposure for S2 screw implantation during operation were also recorded. Finally, the Matta standard was used to evaluate the fracture reduction of the IS joint.ResultsA total of 89 IS screws were implanted into S2 iliosacral joint. Fifty‐four screws were placed by RA (38 patients) and 35 screws were by FH (25 patients). There was no difference between the two groups with respect to demographic data. There was no screw‐related complications or revision surgery in any group. In terms of screw placement, the excellent and good rate was 100% in the RA group, better than that in the FH group where it was only 85.7% (P < 0.001). The fluoroscopy time was 8.06 ± 3.54 s in RA group, which was much less than that in the FH group (27.37 ± 8.82 s, P < 0.001). The guide wire attempts in the RA group (0.685 ± 0.820) were much less than those in the FH group (5.77 ± 3.34) (P < 0.001). Both the fluoroscopy time per screw and the number of guide wire attempts in the RA group were much less than those in the FH group (P < 0.001). The overall postoperative excellent and good rate of Matta standard in RA and FH groups were 86.8% (34/4) and 90.0% (23/25), respectively (P = 0.750), and there was no statistical difference.ConclusionThe robot‐assisted surgery is an accurate and minimally invasive technique. S2 IS screw implantation assisted by TiRobot to treat the posterior pelvic ring fractures, have a high success rate than the freehand technique. Percutaneous RA S2 IS screw fixation for unstable posterior pelvic ring injuries is safe and clinically feasible and has great clinical application value.

Comparison of lumbopelvic fixation and iliosacral screw fixation for the treatment of bilateral sacral fractures

BackgroundBilateral sacral fractures result in traumatic disruption of the posterior pelvic ring. Treatment for unstable posterior pelvic ring fractures should aim for fracture reduction and rigid fixation to facilitate early mobilization. Iliosacral screw fixation (ISF) and lumbopelvic fixation (LPF) were recommended for the treatment of these injuries. No algorithm or gold standard exists for surgery of these fractures.PurposeThe purpose of this study was to evaluate the differences between ISF and LPF in bilateral sacral fractures regarding intraoperative procedures, complications and postoperative mobilization. The secondary aim was to determine whether demographics influence surgical treatment.MethodsOver a 4-year period (2016–2019), 188 consecutive patients with pelvic ring injuries were treated at one academic level 1 trauma center and retrospectively identified. Fractures were classified according to the AO/OTA classification system. Seventy-seven patients were treated with LPF or ISF in combination with internal fixation of pubic rami fractures and could be included in this study. Comparisons were made between demographic and perioperative data. Infection, hematoma and hardware malpositioning were used as complication variables. Mobilization with unrestricted weight bearing was used as outcome variable. Follow-up was at least 6 months postoperatively.ResultsOperative stabilization of bilateral posterior pelvic ring injuries was performed in 77 patients. Therefore, 29 patients (females 59%) underwent LPF whereas 48 patients (females 83%) had bilateral ISF. The ISF group was older (76 yrs.) compared to the LPF group (62 yrs.) (p = 0.001), but no differences regarding BMI or comorbidities were detected. Time for surgery was reduced for patients who were treated with ISF compared to lumbopelvic fixation (73 min vs. 165 min; respectively, p < 0.001). But this did not result in reduced fluoroscopic time or radiation exposure. Overall complication rate was not different between the groups. Patients with LPF had a greater length of stay (p = 0.008) but were all weight bearing as tolerated when discharged (p < 0.001).ConclusionBilateral posterior pelvic ring injuries of the sacrum can be sufficiently treated by LPF or ISF. LPF allows immediate weight bearing which may benefit younger patients and patients with an elevated risk for pneumonia or other pulmonary complications. Treatment with ISF reduces operative time, length of stay and postoperative wound infection. Elderly patients may be better suited for treatment with ISF if there is concern that the patient may not tolerate the increased operative time.

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.

Iliac Bone Corridors to Host the Transiliac Internal Fixator-An Experimental CT Based Analysis.

Background: The transiliac internal fixator (TIFI) is a novel minimally invasive surgical procedure to stabilize posterior pelvic ring fractures. Two bone corridors with different lengths, widths, and angulations are suitable to host screws in the posterior iliac wing. While the length and the width have been described previously, the angulation has not been determined yet. Methods: We created a computer tomography-based 3D-model of 40 patients (20 women, 20 men). The possible bone corridors to host the ilium screws for the TIFIcc (cranio-caudal) and the TIFIdv (dorso-ventral) procedure were identified. After reaching the optimal position, the angles in relation to the sagittal and axial plane were measured. The anterior pelvic plane was chosen as the reference plane. Results: The mean angle of the TIFIcc screws related to the axial plane was 63.4° (±1.8°) and to the sagittal plane was 12.3° (±1.5°). The mean angle of the TIFIdv screws related to the axial plane was 16.1° (±1.2°) and to the sagittal plane was 20.1° (±2.0°). In each group, a high constancy was apparent irrespective of the age or physical dimension of the patient, although a significant gender-dependent difference was observed”. Conclusions: Due to a high inter-individual constancy in length, width, and angulation, bone corridors in the posterior iliac wing are reliable to host screws for posterior pelvic ring fixation irrespective of each individual patient’s anatomy.

The S2-Alar-Iliac Screw for Pelvic Trauma.

Percutaneous sacro-iliac screw osteosynthesis is considered to be standard of care for most posterior pelvic ring fractures. However, special situations require alternative strategies for sufficient stabilization. In these cases, stabilization can often be achieved using posterior instrumentation e.g. using SIPS-screws (spina-iliaca-posterior-superior screws). However, this often leads to implant-related aggravation of the sometimes already critical soft tissue conditions after pelvic trauma. S2-Ala-Ilium screws (S2AI screws) are a suitable alternative. The starting point lies medial of the posterior superior iliac spine below the iliac level. It is almost in line with a potential spinal instrumentation and therefore usually causes fewer soft tissue problems. Although this technique has been widely used in spinal surgery in recent years, its use in orthopaedic traumatology is largely unknown. The possibilities but also the limitations of this technique for the treatment of injuries to the pelvis are illustrated by this retrospective case series.

Part 1: Outcome of Posterior Pelvic Ring Injuries and Associated Prognostic Factors - A Five-Year Retrospective Study of One Hundred and Sixty Five Operated Cases with Closed Reduction and Percutaneous Fixation.

The aim of this study was to evaluate: 1. the outcome of pelvic ring fractures treated by closed reduction and percutaneous fixation, 2. the prognostic factors associated with a poor quality reduction, 3. the prognostic factors associated with ilio-sacral screws misplacement and 4. the prognostic factors associated with nonunion. Data from medical charts for all patients admitted with unstable posterior pelvic ring injuries from 2009 to 2013 were extracted. A total of 165 patients with a mean age of 40years were included. One hundred and five patients were reviewed at a mean of 32months of follow-up. The prognostic factors analyzed were clinical and radiological factors. Tile B and Tile C pelvic ring fractures were compared and analyzed separately. Then specific statistical analysis was performed using a logistic regression model to eliminate confusion factors. An excellent or good clinical result was achieved for 94 patients (90%). An excellent or good reduction was achieved for 141 patients (85%). Nonunion rate, smoking patients, bad reductions, age of patients and ISS score were significantly higher in Tile C group. To eliminate confusion factors we used a multivariate analysis logistic regression model. Only unstable vertical bilateral posterior injuries (Tile C2 and C3) were independent prognostic factors for unsatisfactory reduction (p= 0.001; OR = 4.72; CI 95% [2.08-16.72]). Screw misplacement was recorded for 30 patients (16%) and sacral dysmorphia was an associated prognostic factor (p= 0.0001; OR = 15.6; CI95% [3.41-98.11]). Nonunion was recorded for ten patients (6%) and smoking was an associated prognostic factor (p= 0.01, OR = 5.12; CI95% [1.1-24.1]). Posterior pelvic ring fractures treated by closed reduction and percutaneous fixation are associated with excellent/good clinical results if excellent/good reduction and bone healing are achieved without screw misplacement. Bilateral unstable vertical posterior pelvic ring injuries, and sacral dysmorphia are risk factors for bad quality reduction and screw misplacement respectively.

Robot-assisted treatment of unstable pelvic fractures with a percutaneous iliac lumbar double rod fixation combined with a percutaneous pelvic anterior ring INFIX fixation

ObjectiveTo investigate the clinical effect of robot-assisted treatment of unstable pelvic fractures through a percutaneous iliac lumbar double rod fixation combined with a percutaneous pelvic anterior ring INFIX (internal fixator) fixation.MethodsThis was a retrospective analysis of 17 cases of unstable anterior and posterior pelvic ring fractures treated between April 2016 and October 2018 by the third Ti-robot system produced in China. The posterior ring was supported with an iliac lumbar double rod fixation and the anterior ring with an INFIX fixation. Operation time and peri-operative bleeding were recorded. The reduction of pelvic fracture displacement was evaluated by Matta score, the post-operative results were evaluated according to Majeed score, and the complications were recorded.ResultsTwelve males and five females, aged 21–71 years (mean 40.1 ± 3.8 years) were followed up for three to 12 months, (median 6.7 months). Tile typing showed seven B1 type, two B2 type, and eight C1 type cases. Operation time was 90–160 minutes (mean 112.9 ± 16.8 minutes), bleeding was 80–150 mL (mean 105.9 ± 20.6 mL). X-ray three to five days after operation was evaluated by Matta score as excellent in 15 and good in two cases. Majeed score at last follow-up was 85–98 points, excellent in 17 cases. Two cases of lower extremity deep vein thrombosis received an inferior vena cava filter. The filters were removed after two weeks. One case showed incision fat liquefaction healing and the wound healed three weeks after surgery.ConclusionOrthopedic robot-assisted treatment of unstable pelvic fractures by a percutaneous iliac lumbar double rod fixation and a percutaneous pelvic anterior ring INFIX fixator was minimally invasive and feasible. A prospective study is needed.