Pubic Ramus Research Articles

Total Operating Room Time and Total Surgical Procedure Time in Treating Pelvic Ring Fractures with Calcium Phosphate: A Guide for Surgery Scheduling

Introduction: The purpose of this study is to look at total surgery time and to calculate surgical procedure time as well as surgery set up time. Methods: Over an eighteen-month period, 6/2018 -12/2019, we retrospectively reviewed the results of 45 cases of pelvic injuries consisting of fragility fractures. Data consisting of Total OR Time (TOT), Total Surgical Time (TST) and Total Set Up Time (TOT – TST = Total Set Up Time) was recorded at surgery. This information comprises the rationale of this report. Results: Classification of the fracture types were 28 Type Ia, 1 Type Ib, 1 Type IIa, 7 Type IIb, and 8 IVb. Total Operating Room time for Type Ia was one hour. Types IIb which include an ipsilateral sacral alae fracture was again found to take 60 minutes. The Total Set Up Time for Type Ia was 30 minutes. The Total Surgery Time for Type Ia was 30 minutes. The combined Total Operating Room Time for Type IIb fractures, which include the ipsilateral sacral fracture, was 1 hour. Total Surgery Time was less than 1 hour. The 8 bilateral sacral fragility fractures Type IVb was 47 minutes. The times as reported demonstrate procedures representative of the minimally invasive treatment of pubic rami fractures. Discussion: The purpose of this report was to look at the surgical time required to complete a new surgical technique to treat Fragility Fractures of the pelvis. Calcium Phosphate treatment for these fractures provides a delivery system that accommodates comminuted fracture patterns, minimally invasive, and supplies a supportive endothermic material adding stability to the fracture site. Conclusion: Calcium Phosphate treatment is minimally invasive and easily performed. All fracture Types are amendable for this treatment. The times as reported demonstrate procedures representative of the minimally invasive treatment of pubic rami fractures.

Anterior Pelvic Ring Fracture Pattern Predicts Subsequent Displacement in Lateral Compression Sacral Fractures.

To determine if anterior pelvic fracture pattern in lateral compression (LC) sacral fractures correlates with subsequent displacement on examination under anesthesia (EUA) or follow-up in both nonoperative and operative cases. Retrospective cohort study. Level 1 trauma center. Two hundred twenty-seven skeletally mature patients with traumatic LC (OTA/AO 61B1.1, 61B2.1-2, and 61B3.1-2) pelvic ring injuries treated nonoperatively, with EUA, or with pelvic fixation were included. The study intervention included retrospective review of patients' charts and radiographs. Displacement on EUA or follow-up radiographs (both operative and nonoperative) correlated with anterior pelvic ring fracture pattern. Independent of sacral fracture pattern (complete or incomplete), risk of subsequent displacement on EUA or at follow-up after both nonoperative and operative treatments correlated strongly with ipsilateral superior and inferior pubic rami fractures that were either comminuted (95.6%, P < 0.001) or oblique (100%, P < 0.001). Patients with transverse or lack of inferior pubic ramus fracture did not displace (0%, P < 0.001). Out of 21 LC injuries treated with posterior-only fixation, displacement at follow-up occurred in all 11 patients (100%) with comminuted and/or oblique superior and inferior pubic rami fractures. Nakatani zone I and II rami fractures correlated most with risk of subsequent displacement. Unstable anterior fracture patterns are characterized as comminuted and/or oblique fractures of ipsilateral superior and inferior pubic rami. EUA should be strongly considered in these patients to disclose occult instability, for both complete and incomplete sacral fracture patterns. Additionally, these unstable anterior fracture patterns are poor candidates for posterior-only fixation and supplemental anterior fixation should be considered. Irrespective of sacral fracture pattern (complete or incomplete), nonoperative management is successful in patients with transverse or lack of inferior pubic ramus fractures. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

337 AN INVESTIGATION OF UNDER-TREATMENT OF KNOWN OSTEOPOROSIS IN PATIENTS WITH SUBSEQUENT HIP FRACTURE

Abstract Background Hip fractures have long been associated with significant morbidity and mortality and threat to independent living. A major, treatable risk factor for the development of a hip fracture is osteoporosis. The objective of this study was to investigate what proportion of patients with a prior osteoporosis diagnosis admitted to acute hospitals with a new hip fracture are receiving suboptimal osteoporosis treatment. We further aimed to investigate if any demographic variables or features from clinical history and exam were associated with undertreatment. Methods Using the Irish Hip Fracture Database (IHFD), we prospectively examined patients over the age of 60 who were admitted to an acute trauma centre with a diagnosis of hip fracture, between January 2019 and December 2021. Patients were excluded if they had a pubic rami fracture or other non-hip fracture, or if they were under the age of 60. History of osteoporosis was either diagnosed by DEXA imaging or by previous fragility fracture. We also collected data on demographic and clinical variables that may be associated with being more likely to be treated with osteoporosis medications, such as age, sex, New Mobility Score, Abbreviated Mental Test Score and the American Society of Anesthesiologists grade. Results Initial data collection showed 246 patients who met our inclusion criteria, with only 97 patients (39.4%) on appropriate treatment for osteoporosis. We then applied a binary logistic regression model to our predictor variables in estimating the likelihood of a patient to be prescribed “appropriate” osteoporosis medication as previously described, however none of the selected variables were shown to have any significant value in predicting the likelihood of being undertreated with appropriate medication for osteoporosis. Conclusion This study demonstrated that 60% of patients admitted with hip fracture who had a known diagnosis of osteoporosis were undertreated for same. Treatment inertia in prescribing medications for osteoporosis must be tackled to try and remedy this.

Entry Point Variation in the Osseous Fixation Pathway of the Anterior Column of the Pelvis-A Three-Dimensional Analysis.

Fractures of the superior pubic ramus can be treated with screw insertion into the osseous fixation pathway (OFP) of the anterior column (AC). The entry point determines whether the screw exits the OFP prematurely. This can be harmful when it enters the hip joint or damages soft tissues inside the lesser pelvis. The exact entry point varies between patients and can be difficult to ascertain on fluoroscopy during surgery. The aim of this study was to determine variation in the location of the entry point. A retrospective single center study was performed at a level 1 trauma center in the Netherlands. Nineteen adult patients were included with an undisplaced fracture of the superior pubic ramus on computer tomography (CT)-scan. Virtual three-dimensional (3D) models of the pelvises were created. Multiple screws were placed per AC and the models were superimposed. A total of 157 screws were placed, of which 109 did not exit the OFP prematurely. A universally reproducible entry point could not be identified. A typical crescent shaped region of entry points did exist and was located more laterally in females when compared to males. Three-dimensional virtual surgery planning can be helpful to identify the ideal entry points in each case.

Navigation Template Design and the Anatomic Measurement for Anterograde Transpubic Screws.

For pelvic ring fractures, screw fixation became a popular technique for its good biomechanical performance. The safe insertion of anterograde the transpubic screw is important for patients with anterior pelvic ring fractures. This paper is to research the anatomical parameters of the anterograde transpubic screw corridor and evaluate the safety of anterograde transpubic screw placement assisted by the assembled navigation template. Fifty subjects with normal pelvic, 25 men and 25 women, age from 20 to 60 were enrolled, and their ilium were 3D reconstructed. The ilium was divided into zone I, zone II and zone III. Zone I and zone III was defined as medial and lateral to the obturator foramen, respectively. Zone II is located between zones I and III. The corridor A is formed by zone I and zone II and corridor B is formed by zone I, zone II and zone III. The diameter and length of the inner circle, the distance from the center of the inner circle to the posterior superior and to the inferior iliac spine of corridor A and corridor B were measured, respectively. Nine patients with pelvic fractures underwent anterograde transpubic screw and transverse sacroiliac screw placement assisted by the assembled navigation template and were retrospectively analyzed. Operation time, blood loss, incision length and fluoroscopy times were recorded. Grading score and Matta score were evaluated after surgery. In the 50 subjects, the diameter of corridor A was 11.16 ± 2.13 mm, and that of corridor B was 8.54 ± 1.52 mm. The length of corridor A was 86.39 ± 9.35 mm, and that of corridor B was 117.05 ± 5.91 mm. The surface distance from the screw entry point to the posterior superior iliac spine in corridor A was 109.31 ± 11.06 mm, and that in corridor B was 127.86 ± 8.23 mm. The surface distance from the screw entry point to the posterior inferior iliac spine in corridor A was 91.16 ± 10.34 mm, and that in corridor B was 106.92 ± 7.91 mm. A total of 18 sacroiliac transverse screws and 11 anterograde transpubic screws were inserted assisted by assembled navigation templates for nine patients. The average operation time was 108.75 ± 25.71 min, the blood loss was 141.11 ± 50.21 ml, the incision length was 14 ± 4.62 cm, and the intraoperative fluoroscopy was 17.89 ± 4.01 times. Transpubic screw corridor can be obtained by 3D reconstruction. For the majority of patients, the anterograde pubic ramus corridor accommodated a 6.5 mm diameter screw. It is safe to use anterograde transpubic screw placement assisted by an assembled navigation template.

Emerging Options Using Osteobiologics Treatment for FFP Type IA Comminuted Stable Fragility Fractures Involving the Pubic Rami

Introduction: For many elderly patients who sustain a pubic rami fracture after a fall, the traditional treatment of extended bed rest and restricted mobility is often not practical. A classification for pubic rami fractures has been developed to recommend treatment. There is a technique to augment the biologic fracture environment using Calcium Phosphate through a minimally invasive procedure. In this study FFP Type Ia fractures were treated using Calcium phosphate. Methods: Our study, from January 1, 2018, to December 31, 2019, identified eighty-eight patients with FFP Type Ia fractures, who were treated with Calcium Phosphate. There were 9 males and 79 females, average ages were 78 and 86 respectively. Admission workup included pelvic x-rays as well as a CT scan. All received Calcium Phosphate for fracture fixation. They were followed in the outpatient clinic with pelvic radiographs at 3 weeks, 6 weeks, 6 months. 9 months and 1 year. Evidence of incorporation of the Calcium Phosphate in the fracture healing were documented. Results: There were no infections, no vascular, and no urological complications with this technique. All treated fractures went on to heal. Incorporation of the Calcium Phosphate was noted as early as 12 weeks. Residual presence of Calcium Phosphate was seen at 1 year and was consistent with the research literature. Conclusion: This new method of minimally invasive internal fixation using a bone biologic enhancement material provides an immediate improvement of post injury pain and an increase in immediate post treatment mobility. This treatment is applicable for all pelvic fragility fractures, including Type Ia who present with comminution. Risks with this treatment are low and benefits to the patient are high.

Novel Covert-Inferior Pelvic Approach with a Subpubic Plate for Anterior Pelvic Ring Fractures: Preliminary Results.

Anterior pelvic ring injuries can be treated via Pfannenstiel, modified Stoppa, or ilioinguinal approaches, but these require exposing the abdominal soft tissues and may damage pelvic organs. The scar on the abdominal wall is also unacceptable for some patients. The minimally invasive anterior pelvic ring internal fixator (INFIX) is not ideal for thin patients with easily irritated skin, and it is associated with complications such as femoral nerve palsy, vascular occlusion, and lateral femoral cutaneous nerve injury. In this study, we designed a new external pelvic approach for the treatment of an anterior pelvic ring fracture. We retrospectively reviewed 28 patients with 36 pubic ramus fractures that had been treated via the covert-inferior pelvic approach. All patients underwent a surgical procedure between August 2019 and January 2021. According to the Nakatani classification, there were 6 cases of type-I fracture, 25 cases of type-II fracture, and 5 cases of type-III fracture. Operative time, blood loss, and postoperative radiographic and computed tomographic (CT) findings were recorded. Patients were followed for fracture healing time, functional status, esthetic satisfaction, and complications. A total of 27 patients had follow-up for at least 12 months (range, 12 to 29 months). Postoperative radiographs and CT scans showed well-positioned plates and screws. The mean preoperative time was 9.4 ± 3.8 days, the mean operative time was 61.3 ± 22.67 minutes, the mean intraoperative blood loss was 63.6 ± 42.62 mL, the mean fracture healing time was 4.1 ± 1.6 months, and the mean Majeed score was 89.74 ± 8.07. There were no complications of nonunion, internal fixation failure, vascular injury, nerve palsy, or hernia. All of the patients were esthetically satisfied with the scar. The covert-inferior pelvic approach combined with a subpubic plate effectively fixed Nakatani type-I, II, and III fractures. The advantages of this method include rapid recovery after the surgical procedure, safety, simplicity, a short learning curve, no damage to abdominal soft tissue, no effect on pubic symphysis micromotion, and esthetic benefits. It may be another option for anterior pelvic ring fractures and can supplement other approaches. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

A biomechanical comparison of superior ramus plating versus intramedullary screw fixation for unstable lateral compression pelvic ring injuries,,,

IntroductionManagement of the anterior component of unstable lateral compression (LC) pelvic ring injuries remains controversial. Common internal fixation options include plating and superior pubic ramus screws. These constructs have been evaluated in anterior-posterior compression (APC) fracture patterns, but no study has compared the two for unstable LC patterns, which is the purpose of this study. MethodsA rotationally unstable LC pelvic ring injury was modeled in 10 fresh frozen cadaver specimens by creating a complete sacral fracture, disruption of posterior ligaments, and ipsilateral superior and inferior rami osteotomies. All specimens were repaired posteriorly with two fully threaded 7 mm cannulated transiliac-transsacral screws through the S1 and S2 corridors. The superior ramus was repaired with either a 3.5 mm pelvic reconstruction plate (n = 5) or a bicortical 5.5 mm cannulated retrograde superior ramus screw (n = 5). Specimens were loaded axially in single leg support for 1000 cycles at 400 N followed by an additional 3 cycles at 800 N. Displacement and angulation of the superior and inferior rami osteotomies were measured with a three-dimensional (3D) motion tracker. The two fixation methods were then compared with Mann-Whitney U-Tests. ResultsRetrograde superior ramus screw fixation had lower average displacement and angulation than plate fixation in all categories, with the motion at the inferior ramus at 800 N of loading showing a statistically significant difference in angulation. ConclusionAlthough management of the anterior ring in unstable LC injuries remains controversial, indications for fixation are becoming more defined over time. In this study, the 5.5 mm cannulated retrograde superior ramus screw significantly outperformed the 3.5 mm reconstruction plate in angulation of the inferior ramus fracture at 800 N. No other significance was found, however the ramus screw demonstrated lower average displacements and angulations in all categories for both the inferior and superior ramus fractures.

The lateral stress radiograph: an effective alternative to examination under anesthesia for identifying occult instability in minimally displaced lateral compression pelvic ring injuries.

The purpose of this study was to review the practice of utilizing lateral stress radiographs (LSRs) to identify occult instability (≥ 10mm of dynamic displacement on LSRs) of minimally displaced lateral compression type 1 (LC1) pelvic ring injuries and to evaluate for associations between instability and patient demographics, injury characteristics, and hospital course. A retrospective review of a prospective registry from 2018 to 2022 identified 151 patients with LC1 injuries. LSRs were obtained in 86.8% (131/151) of patients. Three (2.2%) patients were excluded for malrotation of LSRs, leaving 128 patients for analysis. The median maximum dynamic displacement on LSRs was 12.2mm (IQR: 5.9 to 17.3). Occult instability was present in 62.5% (80/128) of patients and was associated with older age (Median difference 11.0years, 95%CI 3.0 to 20.0), Nakatani type 1 rami fractures (73.7% vs. 47.9%, p = 0.001), and rami fracture comminution (Proportional difference 58.7%, 95%CI 42.8 to 71.3%), but not gender, high-energy mechanism, bilateral rami fractures, Denis classification, sacral fracture completeness, or sacral comminution. Patients with occult instability took longer to ambulate 15 feet and clear physical therapy (PT), were more likely to be unable to clear PT by hospital day 3 or by time of discharge, had longer hospital stays, and were more likely to require rehabilitation facilities. LSRs were obtained in a majority of patients. Occult instability was frequently present and associated with older age, comminuted distal pubic rami fractures, longer hospital stays, longer times to mobilize and clear PT, and an increased need for rehabilitation facilities.

GROIN PAIN - SOCCER

HISTORY:A 20 yo collegiate female soccer player presented with two weeks of insidious onset left groin pain. Pain was achy, without radiation, and intermittent. Pain with cutting and lateral ball dribbling/drills. No additional symptoms. She had decreased activity for a year due to the pandemic. Prior to preseason, she independently began a vigorous training program with hours of daily activity. She lost twenty pounds in two months and consuming about 1800 calories daily. Menses remained regular on oral contraceptives. PHYSICAL EXAMINATION: Inspection: Normal. Palpation: Nontender at all bony prominences and muscles of pelvis, hip, and lumbar spine. ROM: Full. Strength: Normal. Left groin pain with hip adduction and flexion. Neuro: Normal. Hip: Log roll, FABER, FADIR, Ober, Thomas, Ely’s, Scour all normal. Sacroiliac: normal including figure four, compression and thigh thrust. Lumbar : normal with negative straight leg raise. Single leg hop was nonpainful and nonantalgic gait with normal proprioception. DIFFERENTIAL DIAGNOSIS:1. Adductor Strain or Psoas Strain2. Pubic Rami Avulsion Fracture3. Sacral Ala Stress Fracture4. Femoral neck stress fracture5. Labral tear TEST AND RESULTS: AP Pelvis Xray: Sacroiliac joints, sacrum, lumbar spine, pelvis, and bilateral hips normal alignment without fracture. She completed one month of physical therapy with improvement initially, however, her pain then progressed to bilateral groin pain. MRI pelvis: symmetric transverse bilateral inferior pubic rami fractures. Nondisplaced with normal alignment. FINAL WORKING DIAGNOSIS:1)Bilateral Inferior Pubic Rami Transverse Stress Fractures2)Relative Energy Deficiency Syndrome TREATMENT AND OUTCOMES: Physical therapy and soccer were discontinued. Crutches provided. Calcium and vitamin D supplementation recommended. CBC, CMP, PTH, TSH, Ferritin, Vitamin D testing indicated iron deficiency anemia. Bone Density testing: normal. Referred to sports dietician•Repeat Pelvic AP xrays indicated interval progression of her stress fractures bilaterally, now radiographically present with evidence of callus formation at bilateral inferior pubic rami. No displacement. Plan: Slowly progress activity as tolerated over several months with repeat exam, lab work, and xrays to ensure healing and resolution.

An Acute Hip Injury Correlated With An Exacerbation Of Urinary Symptoms In A Dancer

HISTORY23-year-old female dancer sustained an acute right hip/groin injury during a rond-de-jambe movement (requiring a combination of hip abduction, extension and external rotation). She had a sensation of a pop at the time of injury, followed by difficulty with external rotation as she attempted to continue to dance. Subsequent days were characterized by bruising to the inner groin and progressive medial thigh discomfort. She concurrently experienced a significant worsening of pre-existing urinary dysfunction characterized by episodes of urge incontinence and a sensation of incomplete voiding. She then developed secondary lateral hip, sacroiliac and low back discomfort. PHYSICAL EXAMShe presented to our office 6 weeks after the initial injury. She had a normal gait and symmetric hip range of motion. Right hip exam with pain at end range of passive hip flexion, and pain also with resisted testing of hip adduction, internal rotation and external rotation. She had tenderness over the anterior hip flexor tendons and at the proximal medial thigh just inferior to the pubic ramus. She was not tender to the pubic ramus. Thomas test was negative bilaterally, but she had significant tightness of quadriceps bilaterally noted on Ely’s test. An internal exam separately completed by her urogynecologist identified tightness of the pelvic floor musculature. DIFFERENTIAL DIAGNOSIS adductor muscle strain, strain of deep hip rotator muscles (obturator externus, obturator internus), hip flexor tendonitis (as primary or secondary diagnosis), labral tear, pelvic floor muscle strain/tear/dysfunction, primary or secondary tightness of pelvic floor musculature, hormonal and/or bladder irritants affecting urinary function TESTS AND RESULTS 1. Xray pelvis/hip series: Well-formed acetabula, slight predisposition to CAM type FAI 2. Hip MRI: Shallow right acetabulum with mild uncovering of lateral femoral head, signs of possible labral tear, small partial intramuscular tear of the R obturator externus, strain of R iliopsoas muscle 3. Dynamic hip ultrasound - pending FINAL WORKING DIAGNOSIS 1.Obturator externus strain with comorbid strain of iliopsoas muscle 2.Pelvic floor dysfunction TREATMENT AND OUTCOMES 1. Dance specific PT for core and peri-pelvic stabilization 2. Pelvic floor physical therapy 3. Gradual return to dance

Pelvic ring injuries after road and mountain bike accidents.

The purpose of this study was to compare patients with traumatic pelvic ring injuries sustained in road and mountain bicycling accidents to evaluate for differences in injury types and hospital courses. A retrospective review of 60 patients presenting with pelvic ring injuries after road (n = 46) and mountain (n = 14) bicycling accidents was performed to compare patient/injury characteristics and hospital course. LC1 injuries were the most common pelvic ring injury (n = 31, 51.7%), 38.7% (n = 12) of which were considered unstable, followed by isolated iliac wing (n = 11, 18.3%), pubic rami (n = 6, 10.0%), and sacral fractures (n = 6, 10.0%). Hospital admission was required for 41 (68.3%) patients. The median hospital LOS was 4days (IQR 2-9) and 12 (20%) patients received operative treatment. Patients in road versus mountain bicycling accidents were more likely to be older tobacco users and were similar in sex, body mass index, and injury severity score. Road bicycling resulted in more LC1 injuries (58.7% vs 28.6%, p = 0.04), while mountain bicycling resulted in more iliac wing fractures (42.9% vs. 10.9%, p = 0.01). Road cycling injuries required more days in the hospital to clear PT (median difference 2, CI 0-4, p = 0.04) and had longer hospital stays (median difference 2, CI 0-6, p = 0.02) but had no difference in the rate of admission, operative intervention, or discharge to rehabilitation facilities. The majority of pelvic ring injuries from road and mountain bicycling accidents were LC1 injuries that were frequently unstable and often required hospital admission and operative fixation.

Extended Ischiopubic Fixation Using Porous Metal Augments in Cementless Acetabular Reconstruction during Revision Total Hip Arthroplasty.

ObjectivesThe aims of this study were to introduce the definition, indication, and surgical technique of extended ischiopubic fixation (EIF) and to investigate the early clinical, radiographic results and complications of hips revised with EIF.MethodsPatients who underwent revision THA utilizing the technique of EIF which was defined as securing the porous metal augment >5 mm deep into the ischium and/or pubic ramus to gain adequate mechanical support and fresh host bone for bony ingrowth in a single institution from February 2015 to February 2020 were retrospectively reviewed. After applying the inclusion and exclusion criteria, a total of 30 hips (28 patients) were eligible for the study and were enrolled. Four patients were lost to follow‐up postoperatively. The data of the remaining 24 patients (26 hips) were analyzed. The patients' clinical results were assessed using of the Harris Hip Score and any complications including postoperative periprosthetic joint infection, intraoperative fracture, postoperative periprosthetic fracture, dislocation, nerve palsy, hematoma or wound complication were documented. The radiographic results were assessed with the construct stability, the position of the center of rotation, and cup orientation.ResultsThe median age of these 25 patients was 62.00 (interquartile: 54.25–68.25) years, with a median body mass index (BMI) of 22.60 kg/m2 (interquartile: 21.49–25.12 kg/m2). A total of 12 (48%) patients were female. At a median duration of follow‐up of 49.16 months, 20 (80%) patients rated their satisfaction level as “very satisfied,” five (20%) were “satisfied.” The median HHS improved from 36.00 (interquartile range: 31.25–49.75) preoperatively to 81.00 (interquartile range: 74.75–88.25) at the most recent follow‐up (p < 0.001). No complications such as periprosthetic joint infection, intraoperative fracture, periprosthetic fracture, dislocation, nerve palsy, hematoma, or wound complication were identified. All constructs were considered to have obtained stable fixation. The median vertical and horizontal distance between the latest postoperative centers of rotation to the anatomic center of rotation improved from 13.62 and 8.68 mm preoperatively to 4.42 and 4.19 mm at final follow‐up (p < 0.001).ConclusionsEarly follow‐up of patients reconstructed with porous metal augments using the EIF technique demonstrated satisfactory clinical results with no particular complications, stable fixation, and restoration of the center of rotation.

Biomechanical study of anterior and posterior pelvic rings using pedicle screw fixation for Tile C1 pelvic fractures: Finite element analysis.

The purpose of this study was to analyse the biomechanical characteristics of pedicle screws with different placement methods and diameters in the treatment of Tile C1 pelvic fractures by finite element simulation technology and to compare them with the plate fixation model to verify the effectiveness of pedicle screw fixation. A three-dimensional digital model of a normal pelvis was obtained using computed tomography images. A finite element model of a normal pelvis containing major ligaments was built and validated (Model 1). Based on the verified normal pelvis finite element model, a Tile C1 pelvic fracture model was established (Model 2), and then a plate fixation model (Model 3) and a pedicle screw fixation model with different screw placement methods and diameters were established (Models 4-15). For all pelvic fracture fixation models, a vertical load of 500 N was applied on the upper surface of the sacrum to test the displacement and stress distribution of the pelvis in the standing state with both legs. The finite element simulation results showed the maximum displacement of Model 1 and Models 3-15 to be less than 1 mm. The overall maximum displacement of Models 4-15 was slightly larger than that of Model 3 (the maximum difference was 177.91×10-3 mm), but the maximum displacement of iliac bone and internal fixation in Models 4-15 was smaller than that of Model 3. The overall maximum stress (maximum stress of the ilium) and maximum stress of internal fixation in Models 4-15 were less than those in Model 3. The maximum displacement difference and maximum stress difference at the fracture of the pubic ramus between each fixed model were less than 0.01 mm and 1 MPa, respectively. The greater the diameter and number of pedicle screws were, the smaller the maximum displacement and stress of the pelvic fracture models were.The maximum displacement and stress of the pelvic fracture models of the screws placed on the injured side of the pubic region were smaller than the screws on the healthy side. Both the anterior and posterior pelvic rings are fixed with a pedicle screw rod system for treatment of Tile C1 pelvic fractures, which can obtain sufficient biomechanical stability and can be used as a suitable alternative to other implants.The greater the diameter and number of pedicle screws were, the greater the pelvic stability was, and the greater was the stability of the screws placed on the injured side of the pubic region than the screws on the healthy side.

Is the T-shaped acetabular fracture really likes a "T"? A study based on three-dimensional fracture mapping

ObjectivesTo explore the morphological pattern of T-shaped acetabular fractures (T-SAFs) by mapping the fracture line using 3D software. Material and methodsWe retrospectively reviewed 1298 consecutive patients with acetabular fractures, and a total of 56 T-SAF patients were enrolled. After the simulated reduction of each fracture in the software, the fracture lines of all patients were overlaid and plotted on a template. A frequency heat map was generated according to the differences in fracture line density distribution. According to the location of fracture lines, all cases were divided into three groups: posterior group, anterior group, extra-posterior group. In surgically treated patients, the surgical approach, fixation methods, and reduction quality were recorded or evaluated. ResultsThe transverse fracture line was sinuous without involving the acetabular roof, and the longitudinal fracture line sloped forward or backward along the edge of the acetabular fossa to split the obturator foramen. The anterior and posterior edges of the acetabular fossa, the transition zone of the acetabular roof and anterior wall, the transition zone of the superior pubic ramus and anterior wall, and the posterior wall near the greater sciatic notch were areas with high rates of fracture incidence. The posterior group included 26 patients (46.4%) and the distribution of fracture lines resembled a “T” or “Y”. The anterior group included 25 patients (44.6%) and the distribution of fracture lines resembled a “7″. The extra-posterior group included 5 patients (8.9%) and the fracture lines run through the ischial body. The surgical strategies vary among different groups of T-SAF patients. ConclusionOur findings shed light on the characteristics of fracture lines for T-SAFs and provide a reference for surgical treatment strategies.

Clinical Experience with the New EASY (Endoscopic Approach to the Symphysis) Preparation Technique for Injuries of the Anterior Pelvic Ring.

High-energy injuries of the anterior pelvic ring and especially disruptions of the pubic symphysis usually require surgical stabilization. There is a conflict between biomechanical stability and size in the surgical approach. We have previously presented a minimally invasive approach for symphyseal plating. Our current endoscopic surgical technique is presented step-by-step and is illustrated in a video. The results and courses of the first seven patients treated with the EASY preparation are presented. In all seven patients, the EASY preparation was successful. In four of the seven patients with an anterior pelvic ring injury, we performed a complete endoscopic plate osteosynthesis of the pubic symphysis. One patient gave consent only for endoscopic preparation, in one patient, we converted to open plate due to ventilation problems, and in one patient, the superior pubic rami fracture was stable. There were no surgical complications. The EASY is a feasible minimally invasive preparation technique to stabilize anterior pelvic ring injuries in the most biomechanically stable manner by performing plate osteosynthesis. However, further scientific monitoring is necessary to improve the technique and validate our data.

Pelvic ring injuries after alpine ski and snowboard accidents.

The purpose of this study was to analyze the patient/injury characteristics and associated hospital course of patients sustaining traumatic pelvic ring injuries after alpine ski and snowboard accidents at a level one trauma center in the Rocky Mountain region. Patient/injury characteristics were obtained from patients presenting with pelvic ring injuries after alpine ski (n = 55) and snowboard (n = 9) accidents. Characteristics and outcomes analyzed included mechanism of injury, pelvic ring classification (Young-Burgess and Tile), hospital admission, physical therapy (PT) clearance, ambulation, length of stay, inpatient morphine milligram equivalents (MME), and discharges to rehabilitation facility. Snowboarders were more often younger, male, tobacco/substance users, and more likely to be injured by a fall from height than skiers. There were no differences in injury classification or hospital course outcomes between alpine sports. Most common injuries included lateral compression type 1 (LC1) injuries (37.5%), isolated pubic ramus fractures (31.3%), and isolated iliac wing fractures (15.6%). LC1 injuries were unstable in 50% of cases and associated with increased admissions (proportional difference: 47.5%, CI: 23.8-64.5%, p = 0.0002), longer time to PT clearance (median difference(MD): 1.0day, CI: 0-2.0, p = 0.03), longer LOS (MD: 2.0, CI: 0-2.0, p = 0.02), and increased inpatient MMEs (MD: 197.9 MME, CI: 30.0-420.0, p = 0.02), as compared to other pelvic ring injuries. The majority of pelvic ring injuries from alpine ski and snowboard accidents were LC1 injuries, half of which were unstable, resulting in longer hospital stays, time to PT clearance/ambulation, and opioid use.

Quantification and visualization of anterior pelvis bone density to optimize screw fixation: A novel technique.

Plate fixation of anterior pelvic ring fractures is often a vital component when surgically treating unstable pelvis fractures. Certain plate and screw configurations can have premature implant loosening, potentially in part due to insufficient pullout strength in lower density bone. This study sought to define densities about the anterior pelvic ring using a novel computer-based technique. Thirty-three patients who received a computed tomography (CT) of the abdomen/pelvis for reasons other than pelvis fracture in a 1-month time period were included. Three statistically distinct density regions of the anterior pelvis were identified based on the three-dimensional (3D) density map. The densest regions included both the anterior and posterior aspects of the superior pubic ramus, along with the region of bone along the inferior cotyloid fossa. The intermediate density region included the caudal and medial pubic body. The least dense region included the anterior aspect of the inferior pubic ramus (IPR), the posterior pubic body, and the posterior/inferior IPR. This study presents specific quantification of anterior pelvis bone density based on a novel technique using opportunistic CT scans. Clinical Significance: Anterior surgical fixation of unstable pelvic ring injuries may benefit from targeting areas of higher density as described in this novel technique.

Superior Pubic Ramus Screw Placement During Complex Acetabular Revision: Acetabular Distraction for Treatment of Pelvic Discontinuity.

With the patient in the lateral decubitus position, the acetabulum is exposed from a standard posterior approach for a revision THA. The location of the superior pubic root is identified after making a recess within the anteroinferior capsule. In order to ensure that the appropriate trajectory is obtained, C-arm imaging (inlet view and orthogonal obturator outlet views) is utilized to safely predrill the screw trajectory into the superior pubic ramus. A Kirschner wire (K-wire) is then placed into the hole. With use of a metal-cutting burr on the back table, customized peripheral screw holes are placed and then the acetabular component is slid and impacted into place over the K-wire. After cup insertion, the K-wire is removed and the superior pubic ramus screw can be placed and confirmed on fluoroscopy. In general, chronic pelvic discontinuity requires surgical management with revision THA and has historically employed the use of a cup-cage construct, custom triflange implants, and/or jumbo acetabular cups with modular porous metal augments1-5. With these treatment options, it is typically necessary to insert "kickstand" screws, which function to prevent abduction failure of the acetabular cup4,5. However, in many cases of discontinuity, there may be severe ischial osteolysis, making ischial screw placement difficult or impossible. The superior pubic ramus, however, remains a reliable option that can be utilized for inferior screw fixation, even in cases of severe acetabular bone loss, and thus is especially beneficial in these difficult cases. The technique of acetabular distraction was developed because of limitations with alternative techniques. This procedure achieves cementless biologic fixation and eventual discontinuity healing as a result of lateral or peripheral acetabular distraction and resultant medial or central compression across the pelvic discontinuity. Acetabular distraction allows for intraoperative customization and cement unitization of the acetabular construct. This procedure requires the use of a "kickstand" screw or of inferior screw fixation in order to prevent abduction failure of the cup. These screws may be placed into either the ischium or superior pubic ramus. If the patient has substantial ischial osteolysis, ischial screw fixation may not be possible. If not placed in a systematic manner, pubic ramus screws can be technically challenging, and incorrect placement can result in neurovascular injury. The present video article demonstrates a reproducible technical method for safely placing a screw in the superior ramus to aid in optimal fixation of the acetabular component in cases of pelvic discontinuity. Thus far, short-term survivorship of acetabular distraction with use of a jumbo cup and kickstand screws has been about 95%. In the largest study to date assessing patients with chronic pelvic discontinuity who underwent revision THA with use of the acetabular distraction technique, only 1 of 32 patients required revision for aseptic loosening6. An additional 2 patients had evidence of radiographic loosening but did not undergo revision, and 3 had migration of the acetabular component into a more stable configuration. Radiographically, 22 of 32 patients in the study demonstrated healing of the discontinuity6. In another study assessing the survivorship of porous tantalum acetabular shells in revision THA to treat severe acetabular defects, patients with inferior screw fixation with superior pubic ramus or ischial screws had a significantly lower incidence of proximal translation of components compared with those without inferior screw fixation7. For reproducible, successful execution of this technique, it is important to confirm correct placement of the acetabular retractors at the correct anatomical locations to ensure adequate surgical visualization of the acetabulum for easy identification of the superior pubic root.It is also critical to check placement of the drill via fluoroscopy with an inlet and obturator outlet views prior to drilling.The drill should be advanced on the oscillate setting to avoid inadvertently perforating the cortical bone and damaging surrounding neurovascular structures. OR = operating roomf/u = follow-upvac = vacuum-assisted closureRSA = radiostereometric analysis.

Combined anterior and posterior ring fixation versus posterior ring fixation alone in the management of unstable Tile B and C pelvic ring injuries: A randomized controlled trial

PurposeCombined anterior and posterior ring (APR) fixation is classically performed in Tile B2 and C1 injuries to achieve superior biomechanical stability. However, the posterior ring (PR) is the main weight bearing portion that is responsible for weight transmission from the upper parts of the body to the lower limbs through the sacrum and the linea terminalis. It is hypothesized that isolated PR fixation can achieve comparable radiological and clinical outcomes to APR fixation. Therefore, we conducted this study to compare the two fixation principles in managing Tile B2 and C1 injuries. MethodsOur study included 20 patients with Tile B2 injuries and 20 patients with Tile C1 injuries. This study was a randomized control single-blinded study via computerized random numbers with a 1:1 allocation by using random block method. The study was performed at a level one trauma center. A total of 40 patients with Tile B2 and C1 injuries underwent combined APR or isolated PR fixation (Group A and B, respectively). Matta & Tornetta radiological principles and Majeed pelvic scoring system were used for the assessment of primary outcomes and postoperative complications. Secondary outcomes included operative time, amount of blood loss, intraoperative assessment of reduction, need of another operation, length of hospital stay, ability to weight bear postoperatively and pain control metrics. We used student t-test to compare the difference in means between two groups, and Chi-square test to compare proportions between two qualitative parameters. We set the confidence interval to 95% and the margin of error accepted to 5%. So, p ≤ 0.05 was considered statistically significant. ResultsThe mean follow-up duration was 18 months. The operative time (mean difference 0.575 h) and the intraoperative blood loss (mean difference 97.5 mL) were lower in Group B. Also, despite the higher frequency of rami displacement before union in the same group, there were no significant differences in terms of radiological outcome (excellent outcome with OR = 2.357), clinical outcome (excellent outcome with OR = 2.852) and postoperative complications assessment (OR = 1.556) at last follow-up. ConclusionThe authors concluded that isolated PR fixation could favorably manage Tile B2 and C1 pelvic ring injuries with Nakatani zone II pubic rami fractures and intact inguinal ligament. Its final radiological and clinical outcomes and postoperative complications were comparable to combined APR fixation, but with less morbidity (shorter operation time, lower amount of blood, and no records of postoperative wound infection).