Unstable Pelvic Ring Injuries Research Articles

Comparison of clinical and radiographic outcomes of bilateral versus unilateral ramus fixation in straddle fractures with posterior pelvic ring injury.

Superior and inferior ramus fractures, termed straddle fractures, are high-energy fractures often accompanied by unstable pelvic ring injuries. However, consensus is lacking regarding indications for surgical treatment or fixation methods. We aimed to compare clinical and radiological outcomes of unilateral ramus fixation (URF) and bilateral ramus fixation (BRF) for straddle fractures with unilateral posterior pelvic ring injuries. We enrolled 118 patients (73 males, 45 females; mean age, 47 years) diagnosed with straddle fractures between March 2015 and December 2021 with > 1 year of follow-up. Patients were divided into URF (n = 60) and BRF (n = 58) groups based on the anterior pelvic ring fixation method. Preoperative factors including body mass index, diabetes, smoking, injury mechanism, injury severity score, American Society of Anesthesiologists classification system, Tile classification, and Young and Burgess classification were compared. Intraoperative blood loss, operation time, postoperative bone union rate, complications, and the need for additional surgeries were analyzed. There were no statistically significant preoperative differences between the two groups. However, the URF group showed a significantly lower mean operative time and blood transfusion requirement (63min and 2 units, respectively) than the BRF group (104min and 3 units, respectively) (both p < 0.001). Postoperatively, bone union was achieved in 57 (95.0%) and 56 (96.6%) patients in the URF and BRF groups, respectively. Complications occurred in 17 (28.3%) and 14 (24.1%) patients in the URF and BRF groups, respectively, with additional surgeries needed in 3 (5.0%) patients in the URF group and 2 (3.4%) patients in the BRF group. Unilateral anterior fixation can provide sufficient stability and clinical effectiveness in the surgical treatment of straddle fractures in areas with posterior pelvic ring injuries. Compared with bilateral anterior fixation, unilateral fixation significantly reduces operation time and blood loss, making it a viable fixation method for straddle fractures.

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.

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.

Verticalization of patients and axial load on the lower limbs after surgical treatment of unstable injuries of the pelvic ring (brief review of the literature)

The article provides a theoretical review of scientific publications devoted to the rehabilitation of patients with unstable pelvic ring injuries; the features of pelvic ring damage are considered based on the specifics of the traumatic injury, the frequency of occurrence and the severity of the consequences. It is emphasized that prolonged pain syndrome due to pelvic ring injuries and the duration of the rehabilitation period negatively affect the physical and psycho-emotional state of a patient. At the same time, pelvic ring injuries are most relevant among the working population, and their consequences are quite serious, including disability and death. Consequently, the possibility of optimizing rehabilitation measures for patients with unstable injuries, aimed at restoring the functions of the musculoskeletal system in static conditions and while walking, is currently one of the urgent tasks of theoretical and practical traumatology. The possibilities of verticalization of patients and the use of axial load on the lower limbs in the postoperative period are considered as the main rehabilitation measures. It is noted that in the case of resolving the issue of axial load in case of unstable pelvic ring injury, the intensity of such load and the timing of the start of its use should be determined individually, depending on the physical condition of a patient, the characteristics of the injury and the presence of concomitant injuries. Treatment for unstable pelvic ring injuries most commonly is carried out in most cases through the use of various methods of surgical treatment and restoration of the pelvic anatomy. Based on the results of the theoretical study, it is necessary to state that, despite the obvious significance of postoperative treatment, the adequate organization of which largely determines its final result, it was revealed that the material for studying this issue is insufficient due to specific approaches to verticalization and axial load on the lower limbs, depending on type of pelvic ring injury, taking into account the individual characteristics of the injury in a particular patient.

Safe surgical corridor for iliosacral screw placement in unstable pelvic fractures: a computed-tomography-guided validation study of the “triangulation method”

BackgroundThe percutaneous iliosacral screw technique represents a global standard fixation method for unstable fractures of the posterior pelvic ring. However, the inaccurate positioning of iliosacral screws is associated with a significant risk of severe intra-operative complications. Therefore, this study aimed to investigate the relationship between the skin entry point of the transverse iliosacral screw of the first sacral vertebral body and the anterior superior iliac spine and the greater trochanter of the femur using computed-tomography-guided validation.MethodsOverall, 91 consecutive patients admitted to a tertiary referral center in China for posterior pelvic ring fixation via the “triangulation method” using computed-tomography-guided validation between January 1, 2020, and December 31, 2020, were included in this retrospective observational cohort study. Modeling and simulated iliosacral screw placement were performed using the Mimics software. The distance between the three points of interest was measured, and their relationship in a rectangular coordinate system was determined. Patients were categorized according to gender, body mass index, and femoral rotation angle to investigate the factors affecting the positional relationship between the three points.ResultsAn equilateral triangular relationship was observed between the positioning points of the transverse iliosacral screw, anterior iliac spine, and greater trochanter. Additionally, 95% of the entry points were within a circle radius centered 12 mm at the apex of an equilateral triangle comprising the anterior superior iliac spine and the greater trochanter as the base. The entry point in the femoral external rotation was more dorsal than that in the internal femoral rotation. Furthermore, the entry point in females was more rostral than that in males, and the entry point in overweight patients was more dorsal than that in normal-weight patients.ConclusionsThe skin entry point of the percutaneous iliosacral screw can be located by drawing an equilateral triangle from the anterior superior iliac spine and the greater trochanter as the base to the dorsum end of the patient’s head. In summary, this retrospective cohort study validated the safety and efficacy of the “triangulation methods” for percutaneous fixation of unstable posterior pelvic ring injuries.

Comparison of sacroiliac screw techniques for unstable sacroiliac joint disruptions: a finite element model analysis

Vertically unstable pelvic injuries associated with sacroiliac disruption are challenging. Although percutaneous iliosacral fixation using two screws at S1 vertebral body has been shown beneficial, the use of two transiliac screws at S1 has been proposed to increase the fixation strength of the construct. In the herein study, the finite element method (FEM) was performed to analyse the biomechanical behaviour of five different constructions using iliosacral screws only, transiliac screws only, and combining an iliosacral and a transiliac screw. A vertically unstable AO 61C1.2 type pelvic injury was produced for the evaluation of the posterior pelvic displacement and implant stress, and the anterior implant stress using FEM. The symphysis pubis was fixed with a 3.5-mm reconstruction plate in all cases. The model was axially loaded with 800N applied in the centre of S1 body, perpendicular to the ground (Y-axis), simulating the bipodal stance moment. There was a statistically significant reduction in both posterior displacement and implant stresses in the groups fixed with at least one transiliac screw compared to the groups fixed with iliosacral screws. In our FEM study, the construct using two transiliac screws in S1 is biomechanically superior for stabilizing the sacroiliac joint in vertically unstable pelvic ring injuries compared to the other configurations. Lateral displacement, posterior displacement, and von Mises stress were reduced with this construct. A good option can be the use of one iliosacral screw and one transiliac screw in S1.

Substitutional semi-rigid osteosynthesis technique for treatment of unstable pubic symphysis injuries: a biomechanical study

Background/PurposeThe surgical fixation of a symphyseal diastasis in partially or fully unstable pelvic ring injuries is an important element when stabilizing the anterior pelvic ring. Currently, open reduction and internal fixation (ORIF) by means of plating represents the gold standard treatment. Advances in percutaneous fixation techniques have shown improvements in blood loss, surgery time, and scar length. Therefore, this approach should also be adopted for treatment of symphyseal injuries. The technique could be important since failure rates, following ORIF at the symphysis, remain unacceptably high. The aim of this biomechanical study was to assess a semi-rigid fixation technique for treatment of such anterior pelvic ring injuries versus current gold standards of plate osteosynthesis.MethodsAn anterior pelvic ring injury type III APC according to the Young and Burgess classification was simulated in eighteen composite pelvises, assigned to three groups (n = 6) for fixation with either a single plate, two orthogonally positioned plates, or the semi-rigid technique using an endobutton suture implant. Biomechanical testing was performed in a simulated upright standing position under progressively increasing cyclic loading at 2 Hz until failure or over 150,000 cycles. Relative movements between the bone segments were captured by motion tracking.ResultsInitial quasi-static and dynamic stiffness, as well as dynamic stiffness after 100,000 cycles, was not significantly different among the fixation techniques (p ≥ 0.054).). The outcome measures for total displacement after 20,000, 40,000, 60,000, 80,000, and 100,000 cycles were associated with significantly higher values for the suture technique versus double plating (p = 0.025), without further significant differences among the techniques (p ≥ 0.349). Number of cycles to failure and load at failure were highest for double plating (150,000 ± 0/100.0 ± 0.0 N), followed by single plating (132,282 ± 20,465/91.1 ± 10.2 N), and the suture technique (116,088 ± 12,169/83.0 ± 6.1 N), with significantly lower values in the latter compared to the former (p = 0.002) and no further significant differences among the techniques (p ≥ 0.329).ConclusionFrom a biomechanical perspective, the semi-rigid technique for fixation of unstable pubic symphysis injuries demonstrated promising results with moderate to inferior behaviour compared to standard plating techniques regarding stiffness, cycles to failure and load at failure. This knowledge could lay the foundation for realization of further studies with larger sample sizes, focusing on the stabilization of the anterior pelvic ring.

A nerve-to-implant distance as a novel predictor for lateral femoral cutaneous nerve injuries after anterior subcutaneous pelvic internal fixation.

Although anterior subcutaneous pelvic internal fixation is a valuable tool for the reduction and fixation of unstable pelvic ring injuries, lateral femoral cutaneous nerve irritation by the implant is the most common complication. This study aimed to investigate the association between the nerve-to-implant distance and the postoperative lateral femoral cutaneous nerve symptom. Patients who underwent anterior subcutaneous pelvic internal fixation between 2016 and 2019 were retrospectively analyzed. Lateral femoral cutaneous nerve status was defined as follows: not identified, nerve-to-implant distance <13 mm, and ≥13 mm. The proportion of patients who experienced postoperative nerve disorders was compared using the nerve status. Nerve-to-implant distances were compared using the presence or absence of postoperative lateral femoral cutaneous nerve disorders. The predictive value of a nerve-to-implant distance of 13 mm for postoperative nerve disorders was assessed. Overall, 26 lateral femoral cutaneous nerves were included. Ten patients had postoperative nerve disorders, of which seven had an nerve-to-implant distance <13 mm, while the other three occurred in patients whose nerves were not identified. A nerve-to-implant distance ≥13 mm was significantly associated with a decreased risk of postoperative nerve disorder compared to a nerve-to-implant distance <13 mm (p = 0.017). A nerve-to-implant distance ≥13 mm had a perfect sensitivity (100%) and modest specificity (58.3%). Nerve-to-implant distance was ≥13 mm. Nerve disorders were frequently observed when the nerve-to-implant distance was <13 mm or the nerve was not identified intraoperatively. Efforts to identify the lateral femoral cutaneous nerve may be useful to avoid internal fixation-related nerve disorders.

Internal fixator vs external fixator in the management of unstable pelvic ring injuries: A prospective comparative cohort study.

Reconstruction of the pelvic ring anatomy in unstable anterior pelvic ring injuries is a significant step to reduce the mortality rate associated with these injuries efficiently. There is a debate on using either an anterior subcutaneous pelvis internal fixator (INFIX) or an anterior supra-acetabular external fixator (EXFIX) to manage an unstable anterior pelvic ring fracture. To compare the functional and radiological outcomes and complications of INFIX vs EXFIX in managing unstable pelvic ring injuries. A prospective cohort study included 54 patients with unstable pelvic ring fractures. The patients were divided into two groups; the INFIX group, in which 30 cases were fixed by INFIX, and the EXFIX group, in which 24 patients were treated by EXFIX. The average age in the EXFIX group was 31.17 years (16-57 years), while in the INFIX group, it was 34.5 years (17-53 years). The study included 20 (66.7%) males and 10 (33.3%) females in the INFIX group and 10 (41.7%) males and 14 (58.3%) females in the EXFIX group. The radiological outcomes were evaluated using Matta and Tornetta's score, and the functional outcomes using the Majeed score. The results revealed a statistically significant difference between both groups (P = 0.013) regarding radiological outcomes, according to Matta and Tornetta's score in favor of the INFIX group. Sitting, standing, and walking abilities were measured at a 3-mo follow-up visit using Majeed score modules. It was significantly better among the INFIX group than the EXFIX group in all three modules. At the final follow-up, both groups had no statistically significant difference according to the Majeed score; 92.35 in the INFIX group and 90.99 in the EXFIX group (P = 0.513). A lower surgical site infection rate was noticed in the INFIX group (P = 0.007). Anterior subcutaneous pelvis INFIX is associated with better radiological outcomes and a lower infection rate than anterior supra-acetabular EXFIX in managing patients with unstable anterior pelvic ring fractures.

Percutaneous screw fixation and external stabilization as definitive surgical intervention for a pelvic ring injury combined with an acetabular fracture in the acute phase of polytrauma in Korea: a case report

Unstable pelvic ring injuries are potentially life-threatening and associated with high mortality and complication rates in polytrauma patients. The most common cause of death in patients with pelvic ring injuries is massive bleeding. With resuscitation, external fixation can be performed as a temporary stabilization procedure for hemostasis in unstable pelvic fractures. Internal fixation following temporary external fixation of the pelvic ring yields superior and more reliable stabilization. However, a time-consuming extended approach to open reduction and internal fixation of the pelvic ring is frequently precluded by an unacceptable physiologic condition and/or concomitant injuries in patients with multiple injuries. Conservative treatment may lead to pelvic ring deformity, which is associated with various functional disabilities such as limb length discrepancy, gait disturbance, and sitting intolerance. Therefore, if the patient is not expected to be suitable for additional surgery due to a poor expected physiologic condition, definitive external fixation in combination with various percutaneous screw fixations to restore the pelvic ring should be considered in the acute phase. Herein, we report a case of unstable pelvic ring injury successfully treated with definitive external fixation and percutaneous screw fixation in the acute phase in a severely injured polytrauma patient.

Does sequential examination under anaesthesia provide a reliable method to determine a management plan for unstable lateral compression pelvic ring injuries? a prospective study.

To assess the reliability of sequential examination under anaesthesia (EUA) to determine pelvic instability and to evaluate radiological and functional outcomes in unstable lateral compression (LC) injuries. A prospective case series study was conducted from 2020 to 2022 at a university hospital on 43 cases with LC injuries that met the inclusion criteria. Sequential EUA was carried out in three steps. Posterior-only fixation or anterior-posterior fixation was done according to the algorithm. Each patient was followed up for at least 12months, both radiologically and functionally. Forty cases proved unstable and were fixed. None showed secondary displacement in the anterior-posterior fixation group. However, five cases (19.2%) of the posterior-only fixation group showed secondary displacement with a mean of 5.9mm. Four cases of them had tetra-ramic injuries. There is a high tendency for secondary displacement at 14.5mm or more preoperative displacement of the rami. Patients with secondary displacement showed comparable functional outcome scores to patients without secondary displacement. Posterior-only fixation showed shorter operative time, lesser radiological exposure, blood loss and iatrogenic nerve injury than anterior-posterior fixation. EUA is a reliable method to determine pelvic instability and management plan for LC fractures with unilateral anterior ring injury. Anterior-posterior fixation is needed if there is a tetra-ramic fracture or initial anterior ring displacement of 14.5mm or more, irrespective of EUA.

Standard practice in the treatment of unstable pelvic ring injuries: an international survey

PurposeUnstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe.MethodsA standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents).ResultsThe Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization).ConclusionThe Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences’ impact on outcomes needs to be further explored.

Quantification of the Safe Zone of the First to Third Sacral Segments for Transiliac-Transsacral Screw Fixation in Normal and Dysmorphic Sacra.

Transiliac-transsacral screw fixation is widely used to stabilize unstable posterior pelvic ring injuries. Preoperative radiographic assessment of the safe osseous corridor is necessary because the safe space of sacrum is narrower for transiliac-transsacral screw placement than for traditional iliosacral screw placement. However, the radiographic assessment has rarely been studied in the Taiwanese population. We retrospectively analyzed 100 patients with pelvic computed tomography images and divided them into normal and dysmorphic pelvis groups. To determine the safe osseous space, we recorded cross-section area, cross-sectional diameter of the safe zone (CS-szD), and safe zone width on axial view (Ax-szW) in the S1 to S3 segments. The prevalence of dysmorphic pelvis was 48% among all patients. In the S1 segment, no differences were found in the cross-section area and CS-szD been the two groups. However, the Ax-szW was significantly smaller in the dysmorphic pelvis group. In the S2 segment, the cross-section area, CS-szD, and Ax-szW were all significantly larger in the dysmorphic pelvis group. In the S3 segment, the cross-section area and CS-szD of the normal pelvis group were both significantly smaller. No differences were found in the Ax-szW between the two groups. Based on our findings in a Taiwanese population, S1 was the most suitable segment for transiliac-transsacral screw fixation in a normal pelvis, whereas S2, followed by S3, was most suitable in a dysmorphic pelvis. This study offers surgeons information on identifying the optimal sacral segment for transiliac-transsacral screw placement for each pelvic morphology. [Orthopedics. 2024;47(1):e13-e18.].

RADIOLOGICAL CLASSIFICATION OF THE PELVIS: A TOOL FOR TRAUMA SURGERY PLANNING

Variations in pelvic anatomy are a major risk factor for misplaced percutaneous sacroiliac screws used to treat unstable posterior pelvic ring injuries. A better understanding of pelvic morphology improves preoperative planning and therefore minimises the risk of malpositioned screws, neurological or vascular injuries, failed fixation or malreduction. Hence a classification system which identifies the clinically important anatomical variations of the sacrum would improve communication among pelvic surgeons and inform treatment strategy.300 Pelvic CT scans from skeletally mature trauma patients that did not have pre-existing posterior pelvic pathology were identified. Axial and coronal transosseous corridor widths at both S1 and S2 were recorded. Additionally, the S1 lateral mass angle were also calculated. Pelvises were classified based upon the sacroiliac joint (SIJ) height using the midpoint of the anterior cortex of L5 as a reference point. Four distinct types could be identified:Type-A – SIJ height is above the midpoint of the anterior cortex of the L5 vertebra.Type-B – SIJ height is between the midpoint and the lowest point of the anterior cortex of the L5 vertebra.Type-C – SIJ height is below the lowest point of the anterior cortex of the L5 vertebra.Type-D – a subgroup for those with a lumbosacral transitional vertebra, in particular a sacralised L5.Differences in transosseous corridor widths and lateral mass angles between classification types were assessed using two-way ANOVAs.Type-B was the most common pelvic type followed by Type-A, Type-C, and Type-D. Significant differences in the axial and coronal corridors was observed for all pelvic types at each level. Lateral mass angles increased from Types-A to C, but were smaller in Type-D.This classification system offers a guide to surgeons navigating variable pelvic anatomy and understanding how it is associated with the differences in transosseous sacral corridors. It can assist surgeons’ preoperative planning of screw position, choice of fixation or the need for technological assistance.

Diagnosis, surgical and conservative treatment of unstable sacral fractures (literature review)

Background. In the structure of severe combined trauma, injuries to the pelvic bones, especially the sacrum, are relatively rare but increase steadily with the scientific and technological progress and the urbanization. Despite the widespread use of modern diagnostic methods, such as computer and magnetic resonance imaging, and the ubiquity of X‑ray diagnostics, sacral fractures are diagnosed not in all patients or not in full. In 50 % of patients, sacral fractures are not diagnosed during the initial examination, including anteroposterior X‑ray examination. In addition, in 30 % of the patients, sacral fractures are recognized on a pelvic X‑ray film incorrectly, and the long‑term outcomes of their treatment are unsatisfactory from 30 to 60 % of the cases.Aim. To analyze scientific published sources on the issues of diagnosis, clinical picture, and treatment of patients with severe combined trauma and unstable sacral fractures.Materials and methods. The data of 232 domestic and foreign publications from 1971 to 2020. We present the epidemiology of combined trauma and unstable sacral fractures, consider various classifications, and describe the clinical course and tactics in conservative and surgical treatment of vertically unstable fractures in the posterior pelvic ring.Results. Many foreign publications describe both diagnostics and various methods of treatment for unstable pelvic ring injuries. The publications cover various aspects of diagnosis, clinical course, management tactics, extent and timing of surgery, and conservative treatment for sacral fractures. However, only a few publications in Russian discuss features of diagnostic search, the timing and extent of surgery, as well as the choice of the final tactics to treat patients with sacral fractures.Conclusions. It is necessary to study the problem of diagnosis and treatment of severe combined trauma and vertically unstable fractures of the posterior pelvic ring to develop optimal diagnostic algorithms and final treatment tactics aimed at reduction of the frequency of errors, complications, and deaths, and at improvement in the quality of life of such patients.

Surgical approach of T-type acetabular fractures does not affect quality of reduction on postoperative CT or the likelihood of postoperative complications

IntroductionT-type acetabular fractures are rare but challenging injuries. The purpose of this study was to evaluate for associations between chosen surgical approach for T-type acetabular fracture fixation, reduction quality, and complications. MethodsRetrospective, single institution study of T-type acetabular fractures who underwent surgical fixation. Surgical interventions included open reduction and internal fixation (ORIF) through an anterior intrapelvic approach (AIP) (modified Rives-Stoppa) and/or posterior (Kocher-Langenbeck [KL]), or percutaneous screw fixation. The primary outcome was reduction quality on routine postoperative computed tomography (CT) scan and postoperative complications. ResultsDuring the study period (March 2016 – October 2022), 22 patients presented with T-type acetabular fractures. Surgical approaches included AIP [31.8% (7/22)], percutaneous [27.3% (6/22)], AIP+KL [22.7% (5/22)], and KL [18.2% (4/22)]. On CT scans, 9.0% (2/22) had anatomic reductions, 27.2% (6/22) had fair reductions, and 63.6% (14/22) had poor reductions based on Matta Reduction Criteria. There was no observed difference in reduction quality between surgical approaches. Poor reductions (> 3 mm) were not associated with surgical approach, fracture classification, unstable pelvic ring injuries, posterior wall fractures, T-stem component, transverse component, preoperative articular displacement, preoperative femoral head protrusion, or surgeon experience. Complications occurred in 50.0% (11/22) of patients. No observed difference in complication rates was noted between the surgical approaches. ConclusionT-type acetabular fractures are challenging injuries with few patients achieving anatomic reduction on postoperative CT scans and half of patients developing complications.

Minimally Invasive 360° Fusion Using a Combination of INFIX and Minimally Invasive Spinopelvic Fixation by Intraoperative Computed Tomography Navigation for Unstable Pelvic Ring Fracture: A Technical Note

Fluoroscopy is often used in the surgery of unstable pelvic ring fractures, and improved safety in implant placement is an issue. An anterior subcutaneous pelvic fixator (INFIX) combined with a percutaneous screw has been reported to be a minimally invasive and effective surgical technique for unstable pelvic ring injuries. However, although percutaneous screw fixation is minimally invasive, its indications for fracture fixation and fractures with large fragment displacements in the vertical plane remain controversial. Therefore, this technical note aims to describe a new technique for unstable pelvic ring fractures. We describe a 360° fusion of the pelvic ring to treat unstable pelvic ring fractures, including vertical shear pelvic ring fractures, using an intraoperative CT navigation system. Seven patients were treated with 360° fusion for type C pelvic ring fractures. In surgery, after reducing the fracture with external fixation, intraoperative CT navigation is used to perform a 360° fusion with INFIX and minimally invasive surgical spinopelvic fixation (MIS-SPF). We will introduce a typical case and explain the procedure. A 360° fixation was performed, and no perioperative complications were noted. The mean blood loss was 253.2 ± 141.0 mL, and the mean operative time was 224.3 ± 67.4min. In a typical case, bone union was obtained 1 year after surgery, and we removed all implants. MIS-SPF has a strong fixation force and helps reduce fractures' horizontal and vertical planes. In addition, 360° fusion with intraoperative CT navigation may help treat unstable pelvic ring fractures.

Surgical treatment of chronic vertically unstable pelvic ring injuries

BACKGROUND: The initial severity of patients with vertically unstable pelvic injuries often does not allow to perform timely reconstructive surgical intervention. Thus, the number of chronic injuries increases. Treatment of patients with long-term pelvic ring damage (after 3 weeks from injury) with significant vertical displacement (over 20 mm) is a problem of its own.&#x0D; AIM: To analyze the immediate and long-term results obtained in patients with unresectable and chronic vertical unstable pelvic ring injuries.&#x0D; MATERIALS AND METHODS: The results for 58 patients treated at the Priorov National Medical Research Center with chronic vertically unstable damage to the pelvic ring in the period from 2017 to 2022 were analyzed. Clinical and radiological diagnostic methods, as well as the Majeed questionnaire, were used to assess the treatment results.&#x0D; RESULTS: The follow-up period for the patients ranged from 1 to 3 years (2.1 years on average). All patients after surgical treatment showed pain syndrome regression in the posterior pelvic area, decreased pain in sitting and standing positions, which improved their quality of life. All patients were able to move independently, to self-care after the treatment. Excellent results according to Majeed questionnaire one year after surgery were achieved in 4 (8.2%) patients, good in 40 (81.6%), acceptable in 5 (10.2%), there were no unsatisfactory results.&#x0D; CONCLUSION: The vertebral-pelvic fixation technique allows specialists to effectively treat long-standing vertically pelvic ring unstable injuries and perform one-stage repositioning and stable fixation of the posterior pelvic ring.

Functional Outcome of Internal Fixation (INFIX) in Anterior Pelvic Ring Fractures.

Introduction Pelvic injuries account for 2% of all orthopedic admissions and are associated with high mortality rates. They need a stable fixation and not an anatomical fixation. Hence, the role of internal fixation (INFIX) comes into play, which provides a stable internal fixation without the complication of open reduction and external fixation with plates and screws. Materials and methodology Thirty-one patients with unstable pelvic ring injuries coming to a tertiary care hospital in the state of Maharashtra, India, were selected retrospectively. They wereoperated on with INFIX. Patients were followed up for a period of six months and evaluated according to the Majeed score. Results There was a significant functional outcome in patients operated on with INFIX in pelvic ring injuries in terms of the ability to sit, stand, rejoin work, take part in sexual intercourse, and bear pain. An average Majeed score of 78 with signs of a stable bony union by six months and a full range of motion was noticed in most patients with no problems in day-to-day work. Conclusion INFIX provides stable internal fixation of pelvic fractures with good functional outcome without the disadvantages of external fixation or open reduction with plates.

Prehospital accuracy of (H)EMS pelvic ring injury assessment and the application of non-invasive pelvic binder devices

BackgroundPre-hospital application of a non-invasive pelvic binder device (NIPBD) is essential to increase chances of survival by limiting blood loss in patients with an unstable pelvic ring injury. However, unstable pelvic ring injuries are often not recognized during prehospital assessment. We investigated the prehospital (helicopter) emergency medical services ((H)EMS)’ accuracy of the assessment of unstable pelvic ring injuries and NIPBD application rate. MethodsWe performed a retrospective cohort study on all patients with a pelvic injury transported by (H)EMS to our level one trauma centre between 2012 and 2020. Pelvic ring injuries were included and radiographically categorized using the Young & Burgess classification system. Lateral Compression (LC) type II/III -, Anterior-Posterior (AP) type II/III - and Vertical Shear (VS) injuries were considered as unstable pelvic ring injuries. (H)EMS charts and in-hospital patient records were evaluated to determine the sensitivity, specificity and diagnostic accuracy of the prehospital assessment of unstable pelvic ring injuries and prehospital NIPBD application. ResultsA total of 634 patients with pelvic injuries were identified, of whom 392 (61.8%) had pelvic ring injuries and 143 (22.6%) had unstable pelvic ring injuries. (H)EMS personnel suspected a pelvic injury in 30.6% of the pelvic ring injuries and in 46.9% of the unstable pelvic ring injuries. An NIPBD was applied in 108 (27.6%) of the patients with a pelvic ring injury and in 63 (44.1%) of the patients with an unstable pelvic ring injury. (H)EMS prehospital diagnostic accuracy measured in pelvic ring injuries alone was 67.1% for identifying unstable pelvic ring injuries from stable pelvic ring injuries and 68.1% for NIPBD application. ConclusionThe (H)EMS prehospital sensitivity of unstable pelvic ring injury assessment and NIPBD application rate is low. (H)EMS did not suspect an unstable pelvic injury nor applied an NIPBD in roughly half of all unstable pelvic ring injuries. We advise future research on decision tools to aid the routine use of an NIPBD in any patient with a relevant mechanism of injury.