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Pathoanatomy of the anterior column-posterior hemitransverse acetabular fracture. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie PURPOSE:To define the pathoanatomy of the anterior column-posterior hemitransverse (ACPHT) subtype of acetabulum fractures and assess the morphologic variation therein. METHODS:Retrospective cohort study including 50 patients age greater than 60 with an ACPHT acetabular fracture managed operatively over an 11-year period at an ACS Level 1 Trauma center. Cross-sectional CT images were reviewed for anterior column/wall comminution, anterior column fracture exit point, completeness of the anterior column and posterior column fractures, articular impaction and quadrilateral surface continuity with the posterior column. RESULTS:Comminution of the anterior column/wall was seen in 60% of patients. The anterior column fracture line exit was variable and exited below the anterior inferior iliac spine (AIIS) in 36% of fractures, at the AIIS or between the iliac spines in 40%, and through the iliac crest in 24%. A complete fracture was present in 72% of anterior column fractures and 44% of posterior column fractures. Impaction of the acetabular joint surface was present in 84% of patients. Continuity of the quadrilateral surface with the posterior column was present in 60% of cases. CONCLUSIONS:Significant variability exists within the ACPHT fracture pattern. Understanding the variability within the ACPHT subtype is critical for adequately analyzing these patterns and has implications in future biomechanical studies and implant design. LEVEL OF EVIDENCE:Level IV. 10.1007/s00590-024-04122-2
[Experiences with the infra-acetabular screw placement technique in acetabular fracture surgery]. Zhongguo xiu fu chong jian wai ke za zhi = Zhongguo xiufu chongjian waike zazhi = Chinese journal of reparative and reconstructive surgery Objective:To investigate the application experiences and effectiveness of the infra-acetabular screw (IAS) placement technique in acetabular fracture surgery. Methods:A clinical data of 34 patients with complex acetabular fractures with anterior and posterior columns separation, who were admitted between January 2019 and October 2023 and treated with IAS fixation, was retrospectively analyzed. There were 23 males and 11 females with an average age of 55.3 years (range, 18-78 years). The acetabular fractures caused by traffic accident in 20 cases, falling from height in 12 cases, crushing injury in 1 case, and bruising with a heavy object in 1 case. According to the Letournel-Judet classification, there were 7 cases of anterior column fracture, 8 cases of anterior wall/column plus posterior hemi-transverse fracture, 2 cases of T-shaped fracture, and 17 cases of both-column fracture. The time from injury to surgery was 4-21 days (mean, 8.6 days). The time of IAS placement and the intraoperative blood loss were recorded. After surgery, the X-ray film and CT scan were re-examined, and the modified Matta score was used to assess the quality of fracture reduction. The trajectory of IAS in the channel was analyzed based on CT scan, and the screw length was measured. During follow-up, the fracture healing was observed and the hip function was assessed according to the modified Merle d'Aubigné-Postel scoring system at last follow-up. Results:The IAS was successfully implanted in all 34 patients. The length of IAS ranged from 70 to 100 mm (mean, 86.2 mm). The time of IAS placement ranged from 10 to 40 minutes (mean, 20.7 minutes). The intraoperative blood loss ranged from 520 to 820 mL (mean, 716.8 mL). All patients were followed up 8-62 months (mean, 21.8 months). After surgery, 4 patients developed lateral femoral cutaneous nerve injury, 2 developed popliteal vein thrombosis of the lower extremity, 3 developed incision infection, and no surgical complication such as arteriovenous injury or obturator nerve palsy occurred. At last follow-up, the hip function was rated as excellent in 14 cases, good in 13 cases, fair in 4 cases, and poor in 3 cases according to the Merle d'Aubigné-Postel scoring system, with an excellent and good rate of 79.41%. Imaging re-examined showed that the quality of fracture reduction was rated as excellent in 9 cases, good in 19 cases, and poor in 6 cases according to the modified Matta score, with an excellent and good rate of 82.35%; and 25 (73.53%) IAS trajectories were located in the channel. All fractures obtained bony union, and the healing time was 12-24 weeks (mean, 18 weeks). During follow-up, there was no loosening or fracture of the plate and screws. Conclusion:IAS placement technique can effectively strengthen internal fixation and prevent fracture re-displacement, making it a useful adjunct for treating complex acetabular fractures with anterior and posterior columns separation. 10.7507/1002-1892.202405036
Algorithms in acetabular fracture classifications. Archives of orthopaedic and trauma surgery Acetabular fractures are still challenging fractures. Fracture classification is the basis for understanding these injuries and to gain treatment and to choose a fracture type-based treatment concept. Using a systematic step-wise concept of fracture analysis, based on specific radiographic lines on standard X-rays allow even less experienced surgeons to get a correct classification of the elementary and associated fracture types of Letournel's classification. Algorithmic analysis of the iliopectineal line, (anterior column involvement), ilioischial line (posterior column involvement), presence of a posterior wall fragment, fracture lines involving the iliac wing and inferior ramus, and the spur sign (representing associated both column fractures) allow for approximately 80-90% correct classifications using standard X-rays when integrating these lines into an algorithm. Especially, T-shaped fractures, ABC and ACPHT fractures may be difficult to classify. Thus, advanced imaging, such as CT scans with multiplanar reconstruction and 3D reconstructions is additionally recommended. 10.1007/s00402-024-05599-6
The Everted Acetabular Labrum: Outcomes of Surgical Management. The American journal of sports medicine BACKGROUND:An everted acetabular labrum (EL) is a pathologic variant in which the labrum is flipped to the capsular side of the acetabular rim. An iatrogenic EL is a known complication of a poorly executed labral repair, and a recent study described the native acetabular EL. PURPOSE:To analyze surgical outcomes after advancement or reconstruction of an EL in a native hip. STUDY DESIGN:Cohort study; Level of evidence, 3. METHODS:This was a multicenter retrospective review of prospectively collected data on primary hip arthroscopic surgeries performed between 2013 and 2023. An EL was identified arthroscopically as a labrum-femoral head gap while off traction in the native hip. All patients with EL who were analyzed in this study underwent arthroscopic labral repair and advancement or labral augmentation or reconstruction. Patients with hip dysplasia also underwent periacetabular osteotomy with or without a derotational femoral osteotomy. Patient-reported outcomes (PROs) were assessed using the 12-item International Hip Outcome Tool (iHOT-12) and the Nonarthritic Hip Score. PROs were obtained preoperatively and up to 24 months after surgery. PROs were compared with those of a case-matched control cohort in a 1:2 ratio. Only patients with PROs available at ≥1 year postoperatively were included in the outcome analysis. RESULTS:A total of 111 patients (129 hips) with EL during the study period were identified, with PROs available in 96 hips. The mean age of patients with EL was 30.5 years, and women made up 87% of the cohort. Of the 129 hips with an EL, an isolated diagnosis of an EL was present in 11.6% of hips. Deficient acetabular coverage (lateral center-edge angle <25°) was seen in 40.6% of EL hips. No difference was seen in iHOT-12 scores between EL and control groups at 12- or 24-month follow-up ( = .18 and .94, respectively). Patients with EL reported a significant improvement of PROs at latest follow-up ( < .001 for iHOT-12 and Nonarthritic Hip Score). CONCLUSION:Surgical management of a native EL with restoration of the labral seal on the femoral head and correction of concomitant pathologies resulted in significant clinical improvement, with postoperative outcome scores comparable to those of patients without an EL. These findings provide evidence supporting surgical intervention for a native EL. 10.1177/03635465241237252
Analysis of High-Risk Factors and Construction of a Nomogram Predictive Model for Deep Venous Thrombosis in Pelvic and Acetabular Fracture Patients Treated Conservatively. Cureus PURPOSE:This study aims to develop a predictive nomogram model to assist physicians in making evidence-based decisions and potentially reduce the incidence of deep venous thrombosis (DVT). METHODS:We conducted a retrospective study, including patients admitted to the hospital from January 2014 to January 2022 with a closed, single pelvic or acetabular fracture. Comprehensive data were collected for each patient, encompassing demographics, injury characteristics, comorbidities, and results from laboratory tests and lower extremity ultrasounds. Potential risk factors were identified by univariate and multivariate logistic regression analyses. The predictive model was constructed and then internally validated. Calibration accuracy was assessed using a calibration slope and the Hosmer-Lemeshow goodness-of-fit test. The discrimination of the nomogram model was evaluated using the C-statistic. RESULTS:Out of 232 individuals who underwent conservative treatment, 57 (24.6%) were classified into the DVT group and 175 (75.4%) into the non-DVT group based on lower extremity ultrasound findings. Predominantly, patients were aged between 41 and 65 in both groups. Body mass index (BMI) comparison showed that 54.29% (95/175) of the non-DVT group fell within the healthy weight range, while 45.61% (26/57) in the DVT group were overweight. Notably, the proportion of obesity in the DVT group was more than double that in the non-DVT group, indicating a higher DVT risk with increasing BMI (P=0.0215). Lower red blood cell (RBC) counts were observed in DVT patients compared to non-DVT ones (P<0.001). A similar pattern emerged for D-dimer, a marker for blood clot formation and dissolution, with significant differences noted (P=0.029). Multivariable analysis identified age, BMI, associated organ injury (AOI), American Society of Anesthesiologists score, hemoglobin (HGB), RBC, and D-dimer as candidate predictors. Significant variables included age (OR, 3.04; 95% CI, 1.76-5.26; P<0.001), BMI (OR, 1.97; 95% CI, 1.22-3.18; P=0.006), AOI (OR, 2.05; 95% CI, 1.07-3.95; P=0.031), and HGB (HR, 0.59; 95% CI, 0.39-0.88; P=0.010). The discrimination was 0.787, with a corrected c-index of 0.753. Calibration plots and the Hosmer-Lemeshow test indicated a good fit (P=0.7729). Decision curve analysis revealed a superior net clinical benefit when the predicted probability threshold ranged from 0.05 to 0.95. CONCLUSIONS:We developed a nomogram predictive model, and it could act as a practical tool in clinical workflows to assist physicians in making favorable medical decisions, which potentially reduces the incidence of DVT in those patients with pelvic and acetabular fractures treated conservatively. 10.7759/cureus.56091
Efficient hip joint distraction using the AO large femoral distractor in treating acetabular fractures associated with marginal impaction and intraarticular incarcerated fragments. BMC musculoskeletal disorders PURPOSE:The results after acetabular fracture are primarily related to the quality of articular reduction. Using the AO large femoral distractor, incarcerated fragments can be easily removed, and marginally impacted fragments can be elevated under direct visualization without further re-dislocating the joint. The current study aimed to evaluate our early results of using the AO large femoral distractor as an assisting tool during ORIF of acetabular fractures associated with marginal impaction or intraarticular incarcerated fragments. METHODS:Eighteen patients were included in this retrospective case series study diagnosed with an acetabular fracture associated with either marginal impaction injury or an intraarticular incarcerated fragment. On a usual operative table, all patients were operated upon in a prone position through the Kocher Langenbeck approach. The AO large femoral distractor was used to facilitate hip joint distraction. Postoperative fracture reduction and joint clearance were assessed in the immediate postoperative CT scans. RESULTS:The average age of the patients was 30 ± 8.2 years; 13 (72.2%) were males. All cases had a posterior wall fracture, and it was associated with transverse fractures, posterior column fractures, and T-type fractures in five (27.8%), two (11.1%), and one (5.6%) patients, respectively. Intraarticular incarcerated fragments were present in 13 (72.2%) cases and marginal impaction in five (27.8%). Fracture reduction measured on the postoperative CT scans showed an anatomical reduction in 14 (77.8%) patients, imperfect in four (22.2%), and complete clearance of the hip joint of any incarcerated fragments. CONCLUSION:The use of the AO large femoral distractor is a reliable and reproducible technique that can be applied to assist in the removal of incarcerated intraarticular fragments and to ease the reduction of marginally impacted injuries associated with acetabular fractures. 10.1186/s12891-023-07143-w
Anterior approaches in acetabular fractures: a true learning curve analysis. Acta orthopaedica Belgica Today, acetabular surgeons in training have to learn ilioinguinal and anterior intrapelvic approaches (AIP). The aim of this study was to describe the 5-years learning curve of a surgeon. Objective was to assess clinical and radiological results; and to assess factors which could influence this learning curve. Between November 2015 and May 2020, patients with an acetabular fracture operated by the surgeon during the 5-years learning curve with an anterior approach were included in this single-center retrospective study based on a prospective database. Epidemiological, operative, clinical, radiological and complications data's were collected. To assess learning-curve effect the series was divided into two groups: first 2.5-years and last 2-years. Subgroup analysis were performed according to the surgical approach, to the reduction quality and the prognostic factors. In total, 46 patients were included, 23 in period 1 and 23 in period 2. 16 patients (35%) had ilioinguinal approach and 30 patients (65%) had modified Stoppa-Cole approach. At mean follow-up of 24 months, 38 patients (83%) were reviewed. Anatomical reduction (< 1 mm) was achieved in 28 patients (60.9%) with a 9% rate of perioperative complications and 37% rate of post-operative complications. In conclusion, this study gives a realistic overview of the learning curve of anterior approaches in acetabular fractures surgery. Our results should encourage surgeons, while keeping in mind how much this surgery can be challenging, with high rate of complications and difficulty to obtain a systematic anatomical reduction. 10.52628/90.1.10974
Double Trouble: Exploring Bilateral Acetabular Fractures in a Trauma Patient. Cureus Bilateral acetabular fractures, though rare, pose significant challenges in both diagnosis and management due to their association with high-energy trauma and the potential for long-term disability. This case report presents the clinical course of a 27-year-old female who presented to our department after a motorcycle accident with bilateral acetabular fractures. Initial assessment revealed nondisplaced bilateral acetabular fractures, along with associated injuries including a right ulnar styloid fracture. Further evaluation via 3D CT scan delineated associated column fractures on the right and posterior + anterior wall fractures on the left, classified according to the Letournel and Judet system. Notably, this specific combination of acetabular fractures has not been documented in existing literature as per our investigation. The surgical intervention involved an anterior intrapelvic approach for open reduction and internal fixation (ORIF) of the right acetabulum, while the left acetabulum was managed conservatively. Postoperatively, the patient is scheduled for non-weightbearing activity until radiographic evidence of fracture healing is observed. This case underscores the importance of tailored surgical approaches and comprehensive management strategies in optimizing outcomes for patients with bilateral acetabular fractures. 10.7759/cureus.56889
Acute Total Hip Arthroplasty Following Acetabular Fracture is Associated With a High Risk of Revision, Dislocation, and Periprosthetic Fracture. The Journal of arthroplasty BACKGROUND:The aim of this study was to compare outcomes between acute, subacute, and delayed arthroplasty for acetabular fractures occurring within 1 week, from 1 week to 6 months, or more than 6 months before the index total hip arthroplasty (THA), versus THA without a history of acetabular fracture as a control. METHODS:We analyzed the records of patients undergoing primary THA who were enrolled in a national database for at least 2 years before and after the index procedure. Patients who had an initial diagnostic code for acetabular fracture occurring less than 1 week, from 1 week to 6 months, or at least more than 6 months before the THA were classified as acute THA (aTHA), subacute THA (saTHA), or delayed THA (dTHA), respectively. The control group was patients undergoing THA who did not have a history of acetabular fracture. There were 430,349 control primary THAs, 462 aTHAs, 675 saTHAs, and 1,162 dTHAs. RESULTS:After adjusting for age, sex, region, and comorbidities, patients who had an aTHA and saTHA experienced statistically significant increased odds of revision, dislocation, and periprosthetic fracture compared to primary THA without a history of acetabular fracture. Similarly, dTHA was associated with increased odds of revision, dislocation, and periprosthetic fractures compared to primary THA. In the multivariate analysis, aTHA had statistically significant higher rates of dislocation when compared to dTHA. CONCLUSIONS:Patients who had a history of acetabular fractures undergoing aTHA, saTHA, or dTHA have significantly increased rates of revision, periprosthetic fracture, and dislocation compared to primary THA in those who did not have a history of acetabular fractures. 10.1016/j.arth.2024.04.046
Patient-reported outcome measures in hip fracture patients. The bone & joint journal Aims:The aims of this study were to assess quality of life after hip fractures, to characterize respondents to patient-reported outcome measures (PROMs), and to describe the recovery trajectory of hip fracture patients. Methods:Data on 35,206 hip fractures (2014 to 2018; 67.2% female) in the Norwegian Hip Fracture Register were linked to data from the Norwegian Patient Registry and Statistics Norway. PROMs data were collected using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) scoring instrument and living patients were invited to respond at four, 12, and 36 months post fracture. Multiple imputation procedures were performed as a model to substitute missing PROM data. Differences in response rates between categories of covariates were analyzed using chi-squared test statistics. The association between patient and socioeconomic characteristics and the reported EQ-5D-3L scores was analyzed using linear regression. Results:The median age was 83 years (interquartile range 76 to 90), and 3,561 (10%) lived in a healthcare facility. Observed mean pre-fracture EQ-5D-3L index score was 0.81 (95% confidence interval 0.803 to 0.810), which decreased to 0.66 at four months, to 0.70 at 12 months, and to 0.73 at 36 months. In the imputed datasets, the reduction from pre-fracture was similar (0.15 points) but an improvement up to 36 months was modest (0.01 to 0.03 points). Patients with higher age, male sex, severe comorbidity, cognitive impairment, lower income, lower education, and those in residential care facilities had a lower proportion of respondents, and systematically reported a lower health-related quality of life (HRQoL). The response pattern of patients influenced scores significantly, and the highest scores are found in patients reporting scores at all observation times. Conclusion:Hip fracture leads to a persistent reduction in measured HRQoL, up to 36 months. The patients' health and socioeconomic status were associated with the proportion of patients returning PROM data for analysis, and affected the results reported. Observed EQ-5D-3L scores are affected by attrition and selection bias mechanisms and motivate the use of statistical modelling for adjustment. 10.1302/0301-620X.106B4.BJJ-2023-0904.R1
A technique for introducing broad-spectrum topical antibiotics during open reduction and internal fixation of acetabular fractures. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Postoperative surgical site infections remain a significant and prevalent complication after open reduction and internal fixation of acetabular fractures. Local antibiotics have been shown to decrease risk of postoperative infection, although recent evidence is conflicting. We provide a consistent and replicable technique for delivering intraoperative broad-spectrum antibiotics in the form of a putty applied directly to surgical implants. With this technique, systemic levels of those antibiotics remain safe and stable. 10.1007/s00590-023-03789-3
Accuracy of FAST in detecting intraabdominal bleeding in major trauma with pelvic and/or acetabular fractures: a retrospective cohort study. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie PURPOSE:The Focused Assessment with Sonography for Trauma (FAST) is a tool to rapidly detect intraabdominal and intrapericardial fluid with point-of-care ultrasound. Previous studies have questioned the role of FAST in patients with pelvic fractures. The aim of the present study was to assess the accuracy of FAST to detect clinically significant intraabdominal hemorrhage in patients with pelvic fractures. METHODS:We included all consecutive patients with pelvic and/or acetabular fractures treated our Level 1 trauma center from 2009-2020. We registered patient and fracture characteristics, FAST investigations and CT descriptions, explorative laparotomy findings, and transfusion needs. We compared FAST to CT and laparotomy findings, and calculated true positive and negative findings, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS:We included 389 patients. FAST had a sensitivity of 75%, a specificity of 98%, a PPV of 84%, and a NPV of 96% for clinically significant intraabdominal bleeding. Patients with retroperitoneal hematomas were at increased risk for laparotomy both because of True-negative FAST and False-positive FAST. CONCLUSION:FAST is accurate to identify clinically significant intraabdominal blood in patients with severe pelvic fractures and should be a standard asset in these patients. Retroperitoneal hematomas challenge the FAST interpretation and thus the decision making when applying FAST in patients with pelvic fractures. 10.1007/s00590-023-03813-6
Acetabular Fractures in older patients Intervention Trial (AceFIT): a feasibility triple-arm randomized controlled study. The bone & joint journal Aims:To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment. Methods:Patients were recruited from seven UK NHS centres and randomized to a three-arm pilot trial if aged older than 60 years and had a displaced acetabular fracture. Feasibility outcomes included patients' willingness to participate, clinicians' capability to recruit, and dropout rates. The primary clinical outcome measure was the EuroQol five-dimension questionnaire (EQ-5D) at six months. Secondary outcomes were Oxford Hip Score, Disability Rating Index, blood loss, and radiological and mobility assessments. Results:Between December 2017 and December 2019, 60 patients were recruited (median age 77.4 years, range 63.3 to 88.5) (39/21 M/F ratio). At final nine-month follow-up, 4/60 (7%) had withdrawn, 4/60 (7%) had died, and one had been lost to follow-up; a 98% response rate (50/51) was achieved for the EQ-5D questionnaire. Four deaths were recorded during the three-year trial period: three in the non-surgical treatment group and one in the fix-and-replace group. Conclusion:This study has shown a full-scale RCT to be feasible, but will need international recruitment. The Acetabular Fractures in older patients Intervention Trial (AceFIT) has informed the design of a multinational RCT sample size of 1,474 or 1,974 patients for a minimal clinically important difference of 0.06 on EQ-5D, with a power of 0.8 or 0.9, and loss to follow-up of 20%. This observed patient cohort comprises a medically complex group requiring multidisciplinary care; surgeon, anaesthetist, and ortho-geriatrician input is needed to optimize recovery and rehabilitation. 10.1302/0301-620X.106B4.BJJ-2023-1080.R1
Heterotopic Ossification Prophylaxis in Acetabular Fracture Surgery: A Systematic Review. Journal of surgical orthopaedic advances Heterotopic ossification (HO) following acetabular fracture surgery is relatively common. The purpose of this study was to perform a systematic review of the literature regarding HO rates following acetabular surgery and the effectiveness of the various prophylactic measures taken to prevent its occurrence. A search of PubMed, MEDLINE, and Cochrane Database of Systematic Reviews was performed using the search terms ("Acetabular" OR "Acetabulum") AND ("Heterotopic Ossification" OR "HO" OR "Ectopic Ossification"). Inclusion criteria included articles published in English reporting on HO in acetabular fracture surgery. Descriptive statistics were calculated with categorical data presented as frequency with percentages and continuous data as means. Standard weighted means were calculated for all parameters. Sixty-six articles were included in this study with a total of 5,028 patients. HO was identified in 1,511 (30%) of fractures. Indomethacin (27%) and radiation therapy (24%) demonstrated decreased rates of HO formation versus no prophylaxis (36%). In particular, rates of severe HO formation were substantially decreased with radiation therapy (3%) and indomethacin (7%) compared to no prophylaxis (18%). Indomethacin and radiation therapy both appear to decrease HO formation and severity without substantially increasing surgical morbidity. (Journal of Surgical Orthopaedic Advances 32(4):217-224, 2023).
Does a simultaneous ventral/dorsal approach provide better reduction quality in treating acetabular fracture involving both columns with displaced posterior wall? Archives of orthopaedic and trauma surgery INTRODUCTION:Various surgical techniques have been proposed to manage acetabular fractures involving both columns with posterior wall displacement. However, the optimal surgical approach to achieve satisfactory reduction quality remains controversial. MATERIALS AND METHODS:This retrospective study evaluated 34 patients with fractures who were treated at a single medical institution. The patients were divided into two groups according to the ventral/dorsal surgical approach employed: simultaneous (SI) and sequential (SE). Perioperative parameters, as well as radiological and functional outcomes, were analyzed and compared between the two groups. RESULTS:The SI and SE groups comprised 9 and 23 out of the 34 patients, respectively. The SI group exhibited a significantly shorter surgical time and lower estimated blood loss than the SE group (p = 0.04 and 0.03, respectively). The quality of reductions of the anterior and posterior columns was similar between the two groups; however, superior reduction in the fracture gap of the posterior wall was observed in the SI group, as revealed by axial and coronal computed tomography scans. CONCLUSIONS:A simultaneous ventral and dorsal approach through the pararectus and the modified Gibson approach confer clinical advantages in reducing the fracture gap, surgical time, and intraoperative blood loss when managing acetabular fractures involving both columns and a displaced posterior wall. Therefore, these surgical approaches may be considered to be optimal for achieving satisfactory reduction quality in such fractures. 10.1007/s00402-024-05224-6
Evaluating Pelvic Tilt Using the Pelvic Antero-Posterior Projection Images: A Systematic Review. The Journal of arthroplasty BACKGROUND:Pelvic tilt (PT) is a routinely evaluated parameter in hip and spine surgeries, and is usually measured on a sagittal pelvic radiograph. This may not always be feasible due to limitations such as landmark visibility, pelvic anomaly, and hardware presence. Tremendous efforts have been dedicated to using pelvic antero-posterior (AP) radiographs for assessing sagittal PT. Thus, this systematic review aimed to collect these methods and evaluate their performances. METHODS:Two independent reviewers searched the PubMed, Ovid, Cochrane, and Web of Science databases in June 2023 with backward reference trailing (Google Scholar archive). There were 30 studies recruited. Risk of bias was assessed using the prediction model risk of bias assessment tool. The relevant data were tabulated in a standardized form for evaluating either the absolute PT or relative PT. Disagreement was resolved by discussing with the senior author. RESULTS:There were 19 parameters from pelvic AP projection images involved, with 4 studies which used artificial intelligence, eyeball, or statistical shape method not involving a specific parameter. In comparing the PT values from pelvic sagittal images with those extrapolated from antero-posterior projection images, the highest correlation coefficient was found to be 0.91. The mean absolute difference (error) was 2.6°, with a maximum error reaching 10.9°. Most studies supported the feasibility of using AP parameters to calculate changes in PT. CONCLUSIONS:No individual AP parameter was found to precisely estimate absolute PT. However, relative PT can be derived by evaluating serial AP radiographs of a patient in varying postures, employing any AP parameters. 10.1016/j.arth.2023.10.035
Acetabular fractures from Judet and Letournel to the present: Research trends and global outcomes with bibliometric analysis during 1980 to 2022. Medicine Fractures of the acetabulum are one of the most challenging injuries treated by orthopedic surgeons. However, a bibliometric analysis has not been performed in the literature on acetabular fractures, which seriously affect the quality of life of patients. The aim of this study was to summarize the bibliometric and intellectual structure, and determine and map the most recent trends on the topic of acetabular fractures by analyzing the social and structural relationships between the different research components of articles published on the acetabular fractures. 1599 articles on acetabular fractures published between 1980 and 2022 were extracted from the Web of Science (WoS) database and analyzed. Bibliometric visualization maps were used to reveal trending topics, citation analyses, and international collaborations. Spearman correlation analysis was performed for correlation investigations. The trend in the expected number of articles to be published over the next few years was displayed using the exponential smoothing estimator. The top 3 contributing countries to the literature were United States of America (USA) (551, 34.4%), China (170, 10.6%), and Germany (160, 10%). The most active author was Berton R. Moed (n = 29) and the most active institution was the University of California System (n = 41). A high-level statistically significant correlation was found between the number of articles on the topic of acetabular fractures published by nations and the gross domestic product (GDP) and GDP per capita values of those countries (R = 0.719, P < .001; R = 0.701, P < .001, respectively). The trending topics researched in recent years were 3D printing, 3-dimensional printing, outcomes, Open Reduction and Internal Fixation (ORIF), mortality, Kocher-Langenbeck, Pararectus approach, tranexamic acid, transfusion, epidemiology, fracture mapping, modified Stoppa approach, post-traumatic osteoarthritis, pelvis fracture, pelvic trauma, fracture reduction, and pelvic ring injury. The leading countries in research on the subject of acetabular fractures were seen to be western countries with large economies (especially the USA, European countries, and Canada) and China, India and Turkey. 10.1097/MD.0000000000034297
Acetabular fractures: Epidemiology and mortality based on 2,132 fractures from the Swedish Fracture Register. Bone & joint open Aims:To describe the epidemiology of acetabular fractures including patient characteristics, injury mechanisms, fracture patterns, treatment, and mortality. Methods:We retrieved information from the Swedish Fracture Register (SFR) on all patients with acetabular fractures, of the native hip joint in the adult skeleton, sustained between 2014 and 2020. Study variables included patient age, sex, injury date, injury mechanism, fracture classification, treatment, and mortality. Results:In total, 2,132 patients with acetabular fractures from the SFR were included in the study. The majority of the patients were male (62%) and aged over 70 years old (62%). For patients aged > 70 years, the 30-day mortality was 8% and one-year mortality 24%. For patients aged ≤ 70 years, the 30-day mortality was 0.2% and one-year mortality 2%. Low-energy injuries (63%) and anterior wall fractures (20%) were most common. Treatment was most often non-surgical (75%). Conclusion:The majority of patients who sustain an acetabular fracture are elderly (> 70 years), of male sex, and the fracture most commonly occurs after a simple, low-energy fall. Non-surgical treatment is chosen in the majority of acetabular fracture patients. The one-year mortality for elderly patients with acetabular fracture is similar to the mortality after hip fracture, and a similar multidisciplinary approach to care for these patients should be considered. 10.1302/2633-1462.49.BJO-2023-0085.R1
Percutaneous pelvic fixation model: an affordable and realistic simulator for pelvic trauma training. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie PURPOSE:To describe the construction and use of a percutaneous pelvic fixation model, evaluate its translational validity among fellowship-trained orthopedic trauma surgeons, and investigate the importance of specific criteria for effective competency-based assessment of pelvic fixation techniques. METHODS:Five orthopedic trauma surgeons were asked to place percutaneous wires on a pelvic fixation model, including anterior column (antegrade/retrograde), posterior column (antegrade/retrograde), supra-acetabular, transsacral, and iliosacral. Evaluation criteria included successful wire placement, redirections, cortical breaches, procedure duration, radiation exposure, and quality of fluoroscopic views. Following completion, participants were provided a survey to rate the model. RESULTS:There were no differences between approaches on successful screw placement, wire redirections, or fluoroscopic quality. Antegrade approaches to the anterior and posterior columns took longer (p = 0.008) and used more radiation (p = 0.02). There was also a trend toward more cortical breaches with the antegrade anterior column approach (p = 0.07). Median ratings among surgeons were 4 out of 5 for their overall impression and its accuracy in tactile response, positioning constraints, and fluoroscopic projections. Learning parameters considered most important to the progression of trainees (most to least important) were successful screw placement, corridor breaches, wire redirections, quality of fluoroscopic views, radiation exposure, and procedure duration. CONCLUSION:In being affordable, accessible, and realistic, this percutaneous pelvic fixation model represents an opportunity to advance orthopedic surgery education globally. Future research is needed to validate the findings of this pilot study and to expand upon how trainees should be evaluated within simulations and the operating room to optimize skill progression. 10.1007/s00590-023-03649-0
Acetabular Rim Disorders: Epidemiology, Etiology, Management, and Outcomes. JBJS reviews » Anatomic disorders of the acetabular rim are a common, correctable source of hip pain in younger patients.» Some common conditions of involving abnormal acetabular rim morphology include developmental dysplasia of the hip, pincer-type femoroacetabular impingement, acetabular protrusion, and acetabular retroversion.» Treatment option for these conditions were historically limited to open osteotomy and osteoplasty procedures; however, there is increasing use of arthroscopic intervention for these patients.» Arthroscopic intervention has demonstrated short-term success in a variety of focal acetabular rim disorders; however, further research is needed to determine the long-term outcomes of these procedures and their utility in more global pathology. e23.00058
Minimally invasive stabilization of pelvic metastatic bone disease: A review of an emerging technique. Journal of surgical oncology Percutaneous pelvic stabilization is an emerging technique that provides mechanical stability to pathologic fractures of the pelvic ring and acetabulum. Variability exists in procedural technique among institutions; however, early case series consistently demonstrate an acceptable complication profile and significant improvement in patients' pain and function. This minimally invasive approach is less morbid than traditional, open acetabular and pelvic reconstructions. Therefore, this procedure is an encouraging palliative intervention for a growing patient population in need. 10.1002/jso.27383
Limited Resources at a Community Based Level 1 Trauma Center: Does This Affect Pelvic Angioembolization Times During Daylight Hours versus after Hours, Weekends, and Holidays? The American surgeon Hemodynamically unstable patients with pelvic fractures require swift intervention due to the high mortality of their injuries. A delay in embolization of these patients significantly affects survival. We therefore, hypothesized that there would be a significant difference between time to embolization at our larger rural Level 1 Trauma Center. This study investigated the relationship between interventional radiology (IR) order time to IR procedure start time over 2 time periods at our large, rural Level 1 Trauma Center with those having sustained a traumatic pelvic fracture requiring IR, and having been identified as being in shock. The current study found no statistically significant difference from time from order to IR start between the 2 cohorts (Mann-Whitney U test, = .902). The results suggest we are delivering a consistent standard of care at our institution for pelvic trauma, based on IR order time to start of the procedure. 10.1177/00031348231167391
Heterotopic Ossification Remodeling After Acetabular Surgery: A Natural History Case Report. JBJS case connector CASE:A 30-year-old woman presented with a transverse plus posterior wall acetabular fracture and underwent operative fixation through a Kocher-Langenbeck approach. Shared decision was made for no heterotopic ossification (HO) prophylaxis. The patient developed symptomatic HO and was scheduled for resection, which was delayed because of the pandemic. She returned with interval remodeling of HO and symptom resolution. No surgery was required. CONCLUSION:HO is a common complication after acetabular injury. Resection is the treatment of choice for symptomatic HO. We are not aware of other reports of spontaneous remodeling of symptomatic HO such that it no longer required surgery. 10.2106/JBJS.CC.23.00055
Both-column Acetabular Fractures with Posterior Wall Involved can be Managed through Single Anterior Approach by Evaluation of Computer-assisted Virtual Surgery Technique. Orthopaedic surgery OBJECTIVE:Posterior wall (PW) fractures were sometimes associated in both-column acetabular fractures. How to evaluate pre-operatively the necessity for the performance of the posterior approach was an issue to be solved. In order to solve this issue, the computer-assisted virtual surgery technique was used to evaluate if the involved PW in both-column acetabular fractures (BACF) should be managed through posterior approach and verify the feasibility of this method. METHODS:Data of a consecutive cohort of 72 patients with both-acetabular fractures from January 2012 to January 2020 was collected for retrospective study, of which 44 patients had concomitant acetabular PW fractures, and patients without PW fractures were labeled as the BCAF group. Computer-assisted virtual surgery technique was performed pre-operatively to evaluate the necessity for performance of posterior approach in 44 patients, and posterior approach was required if more than 3 mm of displacement was still present in the reduced 3D model. The 23 patients without treatment through posterior approach were labeled as the BCAF-PW group, and the 21 patients with treatment through posterior approach were labeled as the BCAF-PW group. Operation-related and post-operative parameters were recorded. The quality of reduction and functional outcomes were assessed by the Matta scoring system and modified Merle d'Aubigné and Postel scoring system. The measurement data were analyzed using the t-test of independent samples and rank-sum test of ranked data between every two groups. Also, the one-way analysis of variance (ANOVA) was used to analyze data between the three groups. RESULTS:Comparing operation-related and post-operative parameters in the three groups, some PW fractures in both-column acetabular fractures could be ignored, and which could be evaluated pre-operatively for necessity of an additional posterior approach. Operative time (271.2 ± 32.8 mins) and intra-operative blood loss (1176.7 ± 211.1 mL) were significantly higher in the BCAF-PW group. The excellent/good of reduction (25/28 of the BCAF group, 21/23 of the BCAF-PW group, 19/21 of the BCAF-PW group) and functional outcomes (24/28 of the BCAF group, 18/23 of the BCAF-PW group, 18/21 of the BCAF-PW group) of three groups were similar. The incidence of complications, such as deep vein thrombosis (4/28 of the BCAF group >3/23 of the BCAF-PW group >1/21 of the BCAF-PW group) and injury of lateral femoral cutaneous nerve (3/23 of the BCAF-PW group >2/28 of the BCAF group >0/21 of the BCAF-PW group), was no significant difference. CONCLUSION:The partial both-column acetabular fractures with PW involvement could be managed through a single anterior approach without another posterior approach by evaluation of computer-assisted virtual surgery technique. 10.1111/os.13775
Management of a complex acetabular fracture following defibrillation for ventricular fibrillation cardiac arrest. BMJ case reports In this case report, we describe the first case of a patient who sustained a complex acetabular fracture following defibrillation for ventricular fibrillation cardiac arrest in the context of acute myocardial infarction. The patient was unable to undergo definitive open reduction internal fixation surgery due to the need to continue dual antiplatelet therapy following coronary stenting of his occluded left anterior descending artery. Following multidisciplinary discussions, a staged approach was opted for, with percutaneous closed reduction screw fixation of the fracture performed while the patient was maintained on dual antiplatelet therapy. The patient was discharged with a plan to perform definitive surgical management when safe to discontinue dual antiplatelets. This is the first confirmed case of defibrillation causing an acetabular fracture. We discuss the various aspects that need to be considered when patients are being worked up for surgery while on dual antiplatelet therapy. 10.1136/bcr-2022-253421
Complete Ossification of Transverse Acetabular Ligament - Embryological and Clinical Perspective. La Clinica terapeutica Abstract:Transverse acetabular ligament (TAL) is one of the important ligaments, which provide stability to the hip joint. On rare occasions, it can get ossified leading to limited mobility of the hip joint. Ossified TAL also converts acetabular notch to a foramen and neurovascular structures passing through the notch can get compressed leading to ischaemic symptoms. During routine demonstration of hip bone to undergraduate students, complete ossification of TAL was found in a right sided hip bone. Present case report with this rare finding also includes a short review of literature impressing on embryological and clinical perspectives of ossified TAL. Ossification of this ligament can be caused by defective ossification of hip bone as three secondary ossification centres develop around the acetabulum in triradiate carti-lage. Also, this can be caused due to heterotopic ossification of TAL after an inflammatory or traumatic injury. This ligament is extremely important in total hip replacement surgery being utilised in determining the position of the acetabular component. Anatomical knowledge of abnormal ossification of TAL is imperative in diagnosis and treatment of various pathologies of the hip joint. 10.7417/CT.2023.2445
Defining Posterior Wall Fragments in Associated Both Column Acetabular Fractures (OTA/AO 62C). Journal of orthopaedic trauma OBJECTIVE:Associated both column acetabular fractures (OTA/AO 62C) with concomitant posterior wall fracture fragments (ABC + PW) have not been well-defined. The purpose of this study was to report on the incidence and morphology of ABC + PW fractures. METHODS:A retrospective review of associated both column (ABC) fractures between 2014 and 2020 was performed. Computed tomography scans including 3-D surface rendered reformats for each were reviewed to determine whether a posterior wall (PW) fragment was present and its morphologic characteristics. RESULTS:One hundred fifty-two ABC fractures were identified. Sixty-two fractures (41%) were identified as ABC + PW. 3D-computed tomographies were available on 58 fractures. Morphologic analysis was performed based on the relationship of the fracture to the gluteal pillar. Twenty PW fragments were posterior to the gluteal pillar, 19 extended into the gluteal pillar, and 19 extended anterior. Fifty-two fractures were treated with operative fixation; 32 (62%) were clamped and fixed with screws from the same anterior approach whereas 15 (29%) required a separate posterior approach; and no fixation was placed in 5 (9%). 29 of 32 PW fragments (91%) requiring fixation that extended into or anterior to the pillar were fixed from the anterior approach, and 7 of 15 posterior fractures (47%) required a separate posterior approach. CONCLUSIONS:A separate PW fragment was identified in 41% of ABC fractures. Their variation in morphology can be classified into 3 types based on the relation to the gluteal pillar that has potential implications for treatment from the anterior approach compared with requiring a separate posterior approach. We suggest these data could be used to update the 2018 OTA/AO Fracture Compendium. LEVEL OF EVIDENCE:Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. 10.1097/BOT.0000000000002607
The impact of anxiety on postoperative pain following pelvic reconstructive surgery. International urogynecology journal INTRODUCTION AND HYPOTHESIS:Despite the prevalence of anxiety, its impact on postoperative pain remains poorly characterized. The present study was aimed at assessing the impact of preoperative anxiety on postoperative pain in patients undergoing pelvic reconstructive surgery. We hypothesized that greater anxiety would be associated with increased postoperative pain for patients undergoing pelvic reconstructive surgery. METHODS:This was a prospective multi-center observational study in Baltimore between September 2018 and June 2019. The Beck Anxiety Inventory was used to assess preoperative anxiety and the validated Surgical Pain Scale instrument was used to assess pain in the postoperative period. The association between anxiety and postoperative pain was analyzed using multivariate logistic regression, adjusting for relevant confounders. RESULTS:A total of 149 patients undergoing pelvic reconstructive surgery completed preoperative surveys. The median age of the study population was 59. The prevalence of preoperative anxiety (anxiety score > 9) in our study population was 26.8% (95% CI 19.7-34.0%). Women with preoperative anxiety reported higher postoperative pain on days 1-2 (relative odds 1.05, 95% confidence interval 1.01-1.10) and day 14 (relative odds 1.53, 95% confidence interval 1.00-2.34). CONCLUSIONS:A large fraction of women undergoing pelvic reconstructive surgery have moderate to severe preoperative anxiety. Women with preoperative anxiety appear to have greater odds of increased postoperative pain. Understanding this association may help surgeons with preoperative counseling and expectations regarding postoperative pain. 10.1007/s00192-022-05423-y
Incidence of and Risk Factors for Screw Loosening after Iliosacral Screw Fixation for Posterior Pelvic Ring Injury. Orthopaedic surgery PURPOSES:Screw loosening is a common complication of iliosacral screw fixation, with subsequent loss of stability and fracture re-displacement. This study aimed to investigate the incidence of and risk factors for screw loosening after iliosacral screw fixation for posterior pelvic ring injury. METHODS:A total of 135 patients with posterior pelvic ring injuries who were treated with iliosacral screw fixation in our department between July 2015 and April 2021 were selected for this retrospective analysis. The possible risk factors for screw loosening were investigated using univariate and multivariate logistic regression analyses of patient demographics and trauma-related and iatrogenic variables, including age, sex, body mass index, Osteoporosis Self-Assessment Tool for Asians (OSTA) index, mechanism of injury, Young-Burgess classification, site of injury, type of injury, type of screw, mode of fixation, numbers of guidewire adjustments, accuracy of screw position, and quality of fracture reduction. RESULTS:The incidence of screw loosening was 15.6% (n = 21). The mean duration for screw loosening was 3.2 ± 1.5 months after operation. Univariate analysis results showed that the Young-Burgess classification, type of injury, site of injury, type of screw, mode of fixation, and OSTA index might be related to screw loosening (p < 0.05). According to the multivariate logistic regression, vertical shear injuries (Odds ratios [OR] 9.80, 95% Confidence intervals [CI] [1.96-73.28], p = 0.008), type of injury (OR 0.25, 95% CI [0.13-0.79], p = 0.027), common screws (OR 6.94, 95% CI [1.53-31.40], p = 0.012), screws insertion only at the level of the first sacral segment (S1) (OR 8.79, 95% CI [1.18-65.46], p = 0.034), injury site located in the medial sacral foramina (OR 6.28, 95% CI [1.16-34.06], p = 0.033), and lower OSTA index [OR 0.41, 95% CI [0.24-0.71], p = 0.001] were significantly related to screw loosening. CONCLUSIONS:Vertical shear injuries, sacral fractures, injury site located in the medial sacral foramina, and lower OSTA index are significantly associated with the postoperative occurrence of screw loosening. Transiliac-transsacral screw fixation and screws insertion both at the level of the S1 and second sacral segment can prevent screw loosening. 10.1111/os.13763
A review of acetabular fracture patterns, etiologies, and management in Jordan. Saudi medical journal OBJECTIVES:To review the epidemiology of acetabular fractures in Jordan and to provide a base to advance high-level clinical research in the future. METHODS:A total of 141 acetabular fractures admitted to King Hussein Medical City, Amman, Jordan, from July 2018 to December 2022 were reviewed retrospectively. Fractures were classified according to Judet and Letournel and were analyzed regarding age, gender, the cause of injury, fracture classification, mode of treatment, and associated nerve and other body part injuries. RESULTS:Males represented 84.4% of patients. The mean age was 42.52 (±17.655) years, and the age group from 20 to 39 represented 54.6% of patients. Road traffic accidents caused 56.7% of injuries, and 53.9% had other accompanying injuries. Posterior wall fractures were the most common (37.6%) patterns, and femoral head dislocation was reported in 28.4%. Posttraumatic and iatrogenic sciatic nerve injuries were reported in 7% of patients. The mean time from admission to surgery was 7.62 (±7.915) days; 66% of patients received surgical treatment, and 83.9% had a satisfactory reduction. CONCLUSION:Acetabular fractures are uncommon injuries, with road traffic accidents being the most common cause of injury. Posterior wall fracture was the most frequent pattern; most patients were males. Our results are comparable to the literature. However, we recommend future studies to measure the outcome of acetabular fracture management. 10.15537/smj.2023.44.6.20220931
Simultaneous reduction and fixation of concomitant acetabular fracture and ipsilateral sacroiliac joint injury through the pararectus approach: a technical report and early radiological outcome. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie PURPOSE:Osteosynthesis for acetabular fractures with ipsilateral sacroiliac joint (SIJ) injuries remains challenging for orthopedic surgeons, despite the evolution of surgical approaches, such as the pararectus approach, and treatment sequences. The study aimed to describe the details of the treatment of acetabular fracture with ipsilateral SIJ injury by the pararectus approach and to report its surgical outcomes. METHODS:We retrospectively assessed patients with acetabular fractures and ipsilateral SIJ injuries undergoing osteosynthesis by the pararectus approach over a three-year period. Evaluation parameters of the quality of reduction of both acetabulum and pelvis injuries were, among others, Matta's criteria, Lefaivre's criteria, inlet/outlet ratios, and maximal gap measured on computed tomography (CT) scans. RESULTS:Ten patients (seven men and three women) were enrolled. Pelvic ring injuries classified as AO B2.3 and acetabular fractures involving two columns were the most common fractures, accounting for 70% and 60%, respectively. Radiological evaluation for pelvic ring injury revealed three excellent and seven good results according to Matta's criteria, as well as five excellent, three good, and one fair results according to Lefaivre's criteria. Inlet and outlet ratios were between 0.84-1.06 and 0.93-1.60, respectively. The distance of the sacroiliac joints significantly improved postoperatively in both axial and coronal views (P = 0.002). Further, the maximal articular gap and step-off of acetabular fractures on axial, coronal, and sagittal view CT scans showed statistically significant improvements after osteosynthesis. CONCLUSION:Simultaneous reduction and fixation of acetabular fractures with ipsilateral SIJ injuries using the pararectus approach achieved satisfactory radiological outcomes. LEVEL OF EVIDENCE:IV. TRIAL REGISTRATION:Retrospectively registered. 10.1007/s00590-022-03367-z
Fracture lines and comminution zones in acetabular fractures based on three dimensional computed tomography. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie PURPOSE:To characterize the fracture patterns of acetabular fractures and create fracture maps and comminution zones based on three-dimensional (3D) computed tomography (CT) images. METHODS:Sixty-eight computed tomography images of 67 patients (47 male [70.1%] and 20 female [29.9%], mean age: 45.2 ± 17.2 [range, 18-85 years] with the diagnosis of intra-articular acetabulum fracture were analyzed. Individual fracture lines were drawn and superimposed to a healthy acetabular template according to Judet-Letournel and simplified fracture classification systems. Fracture line, comminution zone, and heat maps were created using the computed tomography mapping technique. RESULTS:Fracture lines were distributed mainly in a horizontal and oblique orientation, which concentrated in the anteroinferior part of the joint in anterior fractures. Posterior fractures mostly had an oblique orientation, which lied between the acetabular dome and middle part of the posterior wall. In complex fractures, fracture lines were concentrated just above the cotyloid fossa, acetabular dome, and posterosuperior part of the acetabulum. The most common comminuted zones were around the central area of the articular surface and the anterior wall in anterior fractures, between the cotyloid fossa and dome in complex fractures, and the upper half posterior wall. CONCLUSION:Fracture patterns and comminution zones of acetabular fractures displayed certain characteristics. Some areas had higher comminution zones, and some areas remained intact in repeatable fracture patterns. These results may help surgeons in fixing acetabular fractures, designing new implants, and placement of acetabular component while performing THA after acetabular fractures. 10.1007/s00590-022-03347-3
Hip Function after Surgically Treated Isolated Traumatic Acetabular Fracture: A Prospective Series of Consecutive Cases. Hip & pelvis Purpose:Isolated acetabular fractures can occur as a result of a high energy impact on the hip joint. Surgery is required for most patients with an isolated acetabular fracture in order to alleviate pain, restore joint stability, and regain hip function. This study was conducted in order to examine the course of hip function in patients after surgical treatment of an isolated traumatic acetabular fracture. Materials and Methods:This prospective series of consecutive cases included patients who underwent surgery for treatment of an isolated acetabular fracture in a European level one trauma center between 2016 and 2020. Patients with relevant concomitant injuries were excluded. Scoring of hip function was performed by a trauma surgeon using the Modified Merle d'Aubigné and Postel score at six-week, 12-week, six-month, and one-year follow-up. Scores between 3-11 indicate poor, 12-14 fair, 15-17 good, and 18 excellent hip function. Results:Data on 46 patients were included. The mean score for hip function was 10 (95% confidence interval [CI] 7.09-12.91) at six-week follow-up (23 patients), 13.75 (95% CI 10.74-16.76) at 12-week follow-up (28 patients), 16 (95% CI 13.40-18.60) at six-month follow-up (25 patients), and 15.50 (95% CI 10.55-20.45) at one-year follow-up (17 patients). After one-year follow-up, the scores reflected an excellent outcome in 11 patients, good in five patients, and poor in one patient. Conclusion:This study reports on the course of hip function in patients who have undergone surgical treatment for isolated acetabular fractures. Restoration of excellent hip function takes six months. 10.5371/hp.2023.35.2.133
Risk of Revision and Complications After Total Hip Arthroplasty for Acute Treatment of Acetabular Fracture. The Journal of arthroplasty BACKGROUND:Total hip arthroplasty (THA) for the treatment of acute acetabular fractures may be indicated where there is high risk for failure of open reduction and internal fixation. This study aimed to determine risks of revision and rates of major complications of THA for acute acetabular fractures. METHODS:A retrospective review was performed (all-claims data files of a large national database) by querying International Classification of Disease, 10th revision procedure codes for THA within 14 days of acetabular fracture. We identified all-cause revision and surgical complications including dislocations, mechanical failures (loosenings or broken prostheses), infections, as well as medical complications. Demographic data collected included age, sex, obesity, and Charlson Comorbidity Index (CCI). Multivariate analyses evaluated the association of revision and major surgical complications after adjusting for demographic characteristics and comorbidities. We identified 956 THAs for the treatment of acute acetabular fracture from 2015 to 2020. Of all acute acetabular fractures treated with THA, 241 were concomitant with open reduction and internal fixation (ORIF), and 715 were THA-alone. RESULTS:All-cause revision risk was 18.2%, overall major surgical complication rate 26.9%, and medical complication rate was 13.2%. Women were associated with increased risk of revision (adjusted odds ratio (aOR) 1.8; confidence interval (CI) 1.3 to 2.6, P = .001), dislocation (aOR 2.0; CI 1.5 to 3.1, P < .001), mechanical complication (aOR 2.1; CI 1.4 to 3.2, P < .001), and infection (aOR 1.6; CI 1.0 to 2.5, P = .044). CONCLUSION:We noted risk of all-cause revision of 18.2%, overall major surgical complication rate of 26.9%, and overall major medical complication rate of 13.2% for THA as the treatment of acute acetabular fracture. We caution against broad expansion of THA for treatment of acute acetabular fractures. Furthermore, increased risks of revision and complications in women warrant additional investigation into patient and fracture characteristics that may contribute to this finding. 10.1016/j.arth.2023.05.038
A new classification for quadrilateral plate fracture of acetabulum. Injury BACKGROUND:Recently, quadrilateral plate (QLP) fractures of acetabulum have attracted increasing attention. However, evidence for the appropriate classification of QLP fractures is still lacking, making it difficult to understand and manage these fractures. This study aimed to introduce a new classification for QLP fractures and evaluate its reproducibility. METHODS:A series of 1101 consecutive patients with acetabular fractures from 8 level-I trauma centers were enrolled in this study. All patients underwent preoperative radiograph and computed tomography imaging. QLP fractures were identified and classified using the new and Judet-Letournel classification system. The inter- and intra-observer reliabilities (kappa coefficients, κ) of these two systems were investigated by 4 observers. Furthermore, surgical approaches and fixation methods for each fracture type are described. RESULTS:In total, 243 (243/1101, 22%) patients with QLP fractures were identified and included in this analysis. The mean κ value of the intra-observer reliability was 0.84 (range, 0.763-0.919) for the new classification, indicating excellent agreement, and the inter-observer reliability was 0.762 (range, 0.625-0.876), indicating substantial agreement. The values were 0.649 (range, 0.523-0.708) and 0.584 (0.497-0.646), respectively, according to the Judet-Letournel classification. Six cases (6/243, 2.5%) could not be classified using the Judet-Letournel classification. The selection of surgical approaches and fixation methods depends on the fracture type; however, an anterior intra-pelvic approach and buttressing fixation using the plate or screw are preferred for QLP fractures. CONCLUSION:This study presents a new classification for QLP fractures, showing higher intra- and inter-observer reliabilities than those obtained using the Judet-Letournel classification. This allowed us to obtain an in-depth and comprehensive understanding of QLP fractures. Additionally, the new classification might guide further studies on surgical strategies for QLP fractures. LEVEL OF EVIDENCE:Level II. 10.1016/j.injury.2023.04.049
Severe intraoperative vascular bleeding as main complication of acetabular fractures treated with plate osteosynthesis via the modified Stoppa approach. Injury Acetabular fractures are challenging fractures and finding the best supportive treatment is complex. Many operative treatment options exist - one of them is the plate osteosynthesis via the modified Stoppa approach gaining popularity over the last decades. The purpose of this study is to give an overview of this surgical techniques and its main complications. Patients ≥ 18 years between the years 2016 and 2022 with acetabular fractures in our department received a surgical intervention with plate fixation via the modified Stoppa approach. All protocols and documents during a patient's hospital stay were analyzed to find relevant perioperative complications concerning this operative technique. Between 01/2016 und 12/2022 75 patients with acetabular fractures were treated surgically in the author's institution with a plate osteosynthesis via the modified Stoppa approach. In 26.7 % (n = 20) of all cases, patients were confronted with one or more perioperative complications typical for this operation. Intraoperative venous bleedings were the main complication with 10.6 % (n = 8). Postoperative functional impairment of the obturator nerve and deep vein thrombosis occurred with 2.7 % (n = 2) and 9.3 % (n = 7). This retrospective study shows that plate fixation via the Stoppa approach is a good treatment option because of the excellent intraoperative overview of the fracture, but has its pitfalls and complications. Especially severe vascular bleedings must be taken into account and its management well known. 10.1016/j.injury.2023.05.004
Custom Triflange Acetabular Components For Catastrophic Bone Loss: Minimum 5-Year Results. The Journal of arthroplasty INTRODUCTION:Custom acetabular components are an increasingly utilized reconstructive option in total hip arthroplasty for catastrophic bone loss and acetabular failure. The purpose of this study was to determine the survivorship of such components for reconstruction due to catastrophic bone loss at a minimum 5-year follow-up. METHODS:From August 2003 to July 2016, 64 patients (66 hips) underwent acetabular reconstruction with custom triflange components. All hips were classified as Paprosky 3B or 3C. Harris hip scores were analyzed. Overall survivorship was determined by survival analysis. RESULTS:Seventeen patients (18 hips) died prior to returning for 5-year follow-up. One presumed living patient was lost to contact, yielding a cohort of 46 patients (47 hips) who had minimum 5-year follow-up. The mean age was 65 years (range, 46 to 85), mean body mass index was 29.4 (range, 18 to 45), and 72% were women. Mean follow-up was 8 years (range, 5 to 16). There were 3 revisions of the triflange device (6.4%) due to infection. Survivorship to end point of triflange removal for any reason was 94.1% (95% confidence interval: ±3.4%) at a mean of 16 years. In the overall series (n = 66), there were 9 (13.6%) additional reoperations as follows: 5 incision and debridements, one open reduction internal fixation, two stem revisions for periprosthetic femoral fracture, and one head revision. Harris hip scores improved significantly from a mean of 41 points preoperatively to 64 points postoperatively. CONCLUSIONS:Custom acetabular triflange components represent a highly effective tool in a surgeon's armamentarium. These devices are extremely helpful in managing catastrophic bone loss and have a good mean 16-year survival. 10.1016/j.arth.2023.01.023
Acetabular coverage analysis of the proximal femoral head accurately characterizes dysplastic acetabular morphology. Journal of orthopaedic research : official publication of the Orthopaedic Research Society This study aimed to (1) measure acetabular sector angle (ASA) from proximal to distal positions along the axial femoral head axis, (2) identify acetabular deficiency patterns, and (3) correlate ASA at different axial positions with other radiological measurements in acetabular dysplasia. We identified 30 hips with dysplasia (lateral center edge angle [LCEA] <20°) and 30 hips without dysplasia (LCEA >25°) from a retrospective cohort. Anterior and posterior ASA (AASA, PASA) were measured in the axial computed tomography plane through the femoral head center (equatorial) and two axial positions above the equatorial line (intermediate and proximal). Deficiency patterns were identified using ASA cut-off values determined from receiver operating characteristic curves. Pearson's coefficients were used for correlations. Compared to non-dysplastic hips, AASA in dysplastic hips was significantly smaller in all levels: equatorial (46.1 ± 7.3 vs. 54.9 ± 8.5,° p < 0.001), intermediate (62.1 ± 11.2 vs. 69.0 ± 10.6,° p = 0.02), and proximal (102.9 ± 14.2 vs. 128.3 ± 23.0,° p < 0.001). According to proximal ASA (Pro-ASA) cut-off values in dysplastic hips, global deficiency was most prevalent (19/30, 63.3%), followed by anterior (6/30, 20%) and posterior (3/30, 10%) deficiency. There were strong correlations between acetabular anteversion and Eq-AASA (r = -0.74, p < 0.001) and LCEA and pro-PASA (r = 0.82, p < 0.001). Clinical significance: Acetabular sector angle provides insight into acetabular morphology and patterns of deficiency, providing essential information for precise acetabular reorientation. 10.1002/jor.25479
Combined pelvic and acetabular injuries: clinical features and treatment strategies of a unique injury pattern. Journal of orthopaedic surgery and research BACKGROUND:To explore the clinical characteristics of patients with unstable pelvic fractures combined with acetabular fractures and to discuss the treatment strategies for such patients to help guide treatment. METHODS:We retrospectively assessed 24 patients admitted to our hospital from June 2018 to June 2022 with unstable pelvic fractures combined with acetabular fractures, including 15 male patients and 9 female patients with a mean age of 44.8 years. According to the Tile pelvic fracture classification, 15 cases were type B, and 9 cases were type C. The acetabular fractures were classified using the Letournel-Judet classification. There were 8 transverse fractures, 4 transverse and posterior wall fractures, 3 anterior and posterior hemitransverse fractures, 6 both-column fractures, 2 T-shaped fractures and 1 anterior column fracture. We recorded the cause of the patient's injury and vital signs on admission and assessed the patient's treatment strategy and prognosis. RESULTS:All patients completed the surgery successfully, and the follow-up ranged from 6 to 42 months, with a mean of 23 months. The healing time for pelvic fractures ranged from 11 to 21 weeks, with a mean of 14.8 weeks, and the postoperative displacement of the posterior pelvic ring ranged from 1.2 to 9.0 mm, with a mean of 3.5 mm. The final clinical outcome at follow-up was evaluated using the Majeed scale: excellent in 11 cases, good in 10 cases and fair in 3 cases; the excellent rate was 87.5%. The time to healing of the acetabular fracture ranged from 13 to 25 weeks, with a mean of 15.9 weeks, and the postoperative displacement of the acetabular fracture ranged from 0.6 to 5.2 mm, with a mean of 1.9 mm. Hip function was assessed at the final follow-up using a modified Merle D' Aubigné and Postel scale: there were 9 excellent, 11 good and 4 acceptable scores; an excellent rate of 83.3% was achieved. CONCLUSION:Patients with unstable pelvic fractures combined with acetabular fractures suffer severe trauma and complex mechanisms of injury. Treatment needs to be individualized, taking into account the patient's physiological status, fracture classification and degree of displacement. 10.1186/s13018-023-03897-0
Acetabular fracture pattern is altered by pre-injury sacroiliac joint autofusion. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie PURPOSE:Acetabular fracture shape is determined by the direction of force applied. We perceive an anecdotally observed connection between pre-existing autofused sacroiliac joints (aSIJ) and high anterior column (HAC) injuries. The purpose of this study was to compare variations in acetabular fracture patterns sustained in patients with and without pre-injury sacroiliac (SI) joint autofusion. METHODS:All adult patients receiving unilateral acetabular fixation (level 1 academic trauma; 2008-2018) were reviewed. Injury radiographs and CT scans were reviewed for fracture patterns and pre-existing aSIJ. Fracture types were subgrouped presence of HAC injury (includes anterior column (AC), anterior column posterior hemitransverse (ACPHT), or associated both column (ABC)). ANALYSIS:Logistic regression determined the association between aSIJ and HAC. RESULTS:A total of 371 patients received unilateral acetabular fixation (2008-2018); 61 (16%) demonstrated CT evidence of idiopathic aSIJ. These patients were older (64.1 vs. 47.4, p < 0.01), more likely to be male (95% vs. 71%, p < 0.01), less likely to be smokers (19.0% vs. 44.8%, p < 0.01), and were injured from lower energy mechanisms (21.3% vs. 8.4%, p = 0.01). The most common patterns with autofusion were ACPHT (n = 13, 21%) and ABC (n = 25, 41%). Autofusion was associated with greater odds of patterns involving a high anterior column injury (ABC, ACPHT, or isolated anterior column; OR = 4.97, p < 0.01). After adjusting for age, mechanism, and body mass index, the connection between autofusion and high anterior column injuries remained significant (OR = 2.60, p = 0.01). CONCLUSIONS:SI joint autofusion appears to change mode of failure in acetabular injuries; a more rigid posterior ring may precipitate a high anterior column injury. LEVEL OF EVIDENCE:Prognostic level III. 10.1007/s00590-023-03588-w
Allograft reconstruction of acetabular labrum has comparable outcomes to labral refixation. Journal of hip preservation surgery The acetabular labrum plays an important role in hip stability, intra-articular fluid pressurization and force distribution. For irreparable labral pathology, labral reconstruction is an increasingly adopted technique shown to decrease hip pain and improve function. We evaluated survivorship and clinical outcomes of allograft labral reconstruction using the mini-open anterior surgical approach. Twelve patients who underwent labral reconstruction using a semitendinosus tendon allograft (reconstruction group) were matched 1:3 based on age, gender, body mass index, year of surgery, preoperative Tönnis grade, previous hip surgery, residual hip pathology and extent of acetabular chondral lesion to a control group of 36 patients who underwent direct labral repair with anchors (refixation group). At a minimum follow-up of 2 years, patient-reported outcomes, radiological findings and failure rates were compared. The average age was 31.3 years (±13.6) for reconstruction and 34.7 (±10.2) for refixation. Both groups had similar preoperative symptomatic periods ( = 0.3), prevalence of residual hip pathology ( = 1.0) and prevalence of prior hip surgeries ( = 1.0). both groups had a significant improvement of modified Harris Hip scores and 36-Item Short-Form Health Survey physical scores. There was no statistically significant difference in conversion rates to total hip arthroplasty (25% versus 8.3%,  = 0.2); however, time to conversion was significantly longer in the reconstruction group (3.58 years ±1.04) compared to the refixation group (1.20 years± 0.93;  = 0.04). In conclusion, at a minimum of 2 years of follow-up, mini-open labrum reconstruction for severe insufficiency of acetabular labrum demonstrated comparable improvements in functional outcomes and significantly longer survivorship compared to labral refixation. 10.1093/jhps/hnac053
Irreducible posterior hip dislocation in the setting of a multifocal displaced pelvic ring injury: A case report. Trauma case reports Case report:Traumatic hip dislocations require prompt diagnosis and reduction to preserve the native joint. The classic irreducible posterior hip fracture-dislocation has been described as an immobile, slightly flexed, and internally rotated hip on physical exam. Classically, this irreducible pattern is associated with an ipsilateral femoral head fracture. The purpose of our report is to present an irreducible posterior hip dislocation with preserved motion in the setting of an unstable pelvic ring injury without associated femoral head pathology. Despite lacking clinical features of an irreducible hip, closed reduction in the emergency and operating rooms was unsuccessful, even after frame application for pelvis stability. Persistent irreducibility necessitated open reduction, where the femoral head was found to be buttonholed through the posterior hip capsule and blocking reduction. Conclusion:A posteriorly dislocated hip with preserved motion in the setting of a concomitant unstable pelvic ring injury may belie the true locked nature of the femoroacetabular dislocation and high suspicion for femoral head incarceration is required. The description of this unique irreducible fracture pattern and the stepwise approach used for reduction may be useful for other surgeons who may encounter similar patterns of injury. 10.1016/j.tcr.2023.100836
Equivalent loads from the life-cycle of acetabular cages in relation to bone-graft transformation. Computer methods and programs in biomedicine BACKGROUND AND OBJECTIVES:Bone grafts placed behind acetabular cages change their structure in response to mechanical stimuli. The full consideration of lifestyle loads is extremely resource-intensive, so a method using substitutive loads was proposed to reduce the calculation cost. The aim of the study is to present and prove this method. METHODS:By means of mechanical equations and using the force vectors from the literature which have the same initial point and their relative frequency, while applying a linear model, the average strain energy density distribution for all load cases can be calculated, compiling a matrix from the external loads. From the elements of this matrix, three substitutive load vectors can be calculated, which can be proven to produce the same strain energy density distribution by averaging their effects. The feasibility of using this to model the transformation of bone grafts placed behind acetabular cages is demonstrated with a finite element model, along with a reference calculation. RESULTS:The substitutive load vectors could be calculated in closed form and the simulations showed that they produced a similar density distribution to the reference model with a numerical calculation error range. Accordingly, the density distribution calculated from bone graft transformation is almost the same. CONCLUSIONS:In addition to the aforementioned linearity and the same initial point limitations, the applied method is able to produce the substitutive load vectors with which the calculation of the strain energy density distribution and the bone graft's new density distributions can be carried out faster. 10.1016/j.cmpb.2023.107564
The accuracy and precision of acetabular implant measurements from CT imaging. Frontiers in bioengineering and biotechnology The placement of acetabular implant components determines the short- and long-term outcomes of total hip replacement (THR) and a number of tools have been developed to assist the surgeon in achieving cup orientation to match the surgical plan. However, the accuracy and precision of 3D-CT for the measurement of acetabular component position and orientation is yet to be established. To investigate this, we compared measurements of cobalt chrome acetabular components implanted into 2 different bony pelvic models between a coordinate measuring Faro arm and 3 different low dose CT images, including 3D-CT, 2D anterior pelvic plane (APP) referenced CT and 2D scanner referenced (SR) CT. Intra-observer differences were assessed using the Intraclass correlation coefficient (ICC). The effect of imaging the pelvis positioned in 3 different orientations within the CT scanner was also assessed. The measured parameters were the angles of inclination and version. 3D-CT measurements were found to closely match the "true values" of the component position measurements, compared with the 2D-CT methods. ICC analysis also showed good agreement between the coordinate measuring arm (CMA) and 3D-CT but poor agreement between the 2D SR method, in the results from two observers. When using the coordinate system of the CT scanner, the measurements consistently produced the greatest error; this method yielded values up to 34° different from the reference digitising arm. However, the difference between the true inclination and version angles and those measured from 3D APP CT was below half a degree in all cases. We concluded that low radiation dose 3D-CT is a validated reference standard for the measurement of acetabular cup orientation. 10.3389/fbioe.2023.1150061
Trends and treatments of pelvic and acetabular fractures in Taiwan: facing an aging society. Archives of osteoporosis Pelvic-acetabular fractures lead to high mortality in elders and their association between different groups is not known. Our results indicate that older age with pelvic-acetabular fracture was significantly associated with mortality. This finding may help planning and allocating healthcare resources, risk stratification, and optimizing the treatment of pelvic fractures. PURPOSE:Pelvic or acetabular fractures are among main outcomes of low-energy trauma such as falls, especially in older adults. They represent approximately 3-8% of all fractures and are associated with a high mortality rate ranging from 4 to 28%. This study is aimed at comparing the incidence and trends of hip fractures and pelvic-acetabular fractures in the Taiwanese general population, gender differences in adults aged over 65 years, and mortality risk between pelvic or acetabular fractures and hip fractures and surgery trends in patients with these fractures. METHODS:A retrospective study was conducted extracting data from the National Health Insurance Research Database of patients diagnosed with hip fracture and pelvic acetabular fracture between 2000 and 2018. RESULTS:Older age with pelvic-acetabular fracture was significantly associated with increased mortality. No significant differences were found in comorbidities between the two fracture groups. Results provide clear epidemiological evidence for trends in pelvic-acetabular fractures in Taiwan and demonstrate the need for better strategies to manage these fractures and comorbidities, particularly in older adults. CONCLUSION:Findings of this study may aid in planning and allocating healthcare resources, risk stratification, and optimizing the treatment of pelvic fractures among older adults in Taiwan. 10.1007/s11657-023-01255-5
Validation of a pelvic surgery difficulty risk model to predict difficult pelvic dissection and poor outcomes. Surgery BACKGROUND:We previously developed the Pelvic Surgery Difficulty Index for predicting intraoperative events and postoperative outcomes associated with rectal mobilization with or without proctectomy ("deep pelvic dissection"). The aim of this study was to validate the scoring system as a prognostic tool for outcomes of pelvic dissection, regardless of the cause of dissection. METHODS:Consecutive patients who underwent elective deep pelvic dissection at our institution from 2009 to 2016 were reviewed. Pelvic Surgery Difficulty Index score (0-3) was calculated from the following parameters: male sex (+1), prior pelvic radiotherapy (+1), and linear distance from sacral promontory to pelvic floor >13 cm (+1). Patient outcomes stratified by Pelvic Surgery Difficulty Index score were compared. The outcomes assessed included operative blood loss, operative time, length of hospital stay, cost, and postoperative complications. RESULTS:A total of 347 patients were included. Higher Pelvic Surgery Difficulty Index scores were associated with significantly more blood loss, operative time, postoperative complications, hospital costs, and hospital stay. The model achieved good discrimination with area under the curve ≥0.7 for most outcomes. CONCLUSION:Preoperative prediction of the morbidity associated with difficult pelvic dissection is possible with an objective, feasible, and validated model. Such a tool may facilitate preoperative preparation and allow for better risk stratification and uniform quality control across centers. 10.1016/j.surg.2022.12.023
Pediatric Pelvic and Acetabular Fractures: Discerning Severity by Classification and Clinical Management. Journal of pediatric orthopedics BACKGROUND:Existing classification systems may not adequately describe the injury patterns seen pelvic ring and acetabular fractures in the skeletally immature population. Pediatric patients, once stabilized, are often transferred for these injuries. We evaluated which commonly used systems correlate with clinical management in pediatric patients, including transfer patterns based on injury severity. METHODS:A retrospective review of patients aged 1 to 15 treated for traumatic pelvic or acetabular fractures over a 10-year period at an academic level I Pediatric Trauma Center reviewed demographic, radiographic, and clinical data. RESULTS:A total of 188 pediatric patients (average age 10.1 y) were included. Increasing injury severity based on classification Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA P <0.001; Young and Burgess P <0.001; Torode/Zieg P <0.001), increasing Injury Severity Score ( P =0.0017), and decreasing hemoglobin levels ( P =0.0144) were significantly associated with operative management. Injury characteristics did not differ between patients who were transferred versus patients who were brought in directly from the field. Air transport was significantly associated with surgical treatment, pediatric intensive care unit admission, polytrauma, and Torode/Zieg classification ( P =0.036, <0.0001, 0.0297, 0.0003, respectively). CONCLUSIONS:Although not fully descriptive of skeletally immature fracture patterns, the AO/OTA and Young and Burgess classification systems adequately assess the severity of pelvic rings and injuries in pediatric patients and predict management patterns. The Torode and Zieg classification also predicts management. In a large cohort, air transport was significantly associated with surgical treatment, need for pediatric intensive care unit stay, the presence of an additional injury, and instability in the Torode and Zieg classification. These findings suggest that air transfers are being utilized to expedite advanced-level care in more severe injuries. Further studies with long-term follow-up are required to assess the clinical outcomes of both nonoperatively and operatively treated pediatric pelvic fractures and to guide both triage and treatment decisions for these rare but severe injuries. LEVEL OF EVIDENCE:Level III. 10.1097/BPO.0000000000002426
OUTCOMES FOLLOWING ZONE 3 AND ZONE 1 AORTIC OCCLUSION FOR THE TREATMENT OF BLUNT PELVIC INJURIES. Shock (Augusta, Ga.) ABSTRACT:Background: A 2021 report of the Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery multicenter registry described the outcomes of patients treated with Zone 3 resuscitative endovascular balloon occlusion of the aorta (REBOA zone 3). Our study builds upon that report, testing the hypothesis that REBOA zone 3 is associated with better outcomes than REBOA Zone 1 in the immediate treatment of severe, blunt pelvic injuries. Methods: We included adults who underwent aortic occlusion (AO) via REBOA zone 1 or REBOA Zone 3 in the emergency department for severe, blunt pelvic injuries [Abbreviated Injury Score ≥ 3 or pelvic packing/embolization/first 24 hours] in institutions with >10 REBOAs. Adjustment for confounders was accomplished with a Cox proportional hazards model for survival, generalized estimating equations for intensive care unit (ICU)-free days (IFD) and ventilation-free days (VFD) > 0 days, and mixed linear models for continuous outcomes (Glasgow Coma Scale [GCS], Glasgow Outcome Scale [GOS]), accounting for facility clustering. Results: Of 109 eligible patients, 66 (60.6%) underwent REBOA Zone 3 and 43 (39.4%) REBOA Zone 1. There were no differences in demographics, but compared with REBOA Zone 3, REBOA Zone 1 patients were more likely to be admitted to high volume centers and be more severely injured. These patients did not differ in systolic blood pressure (SBP), cardiopulmonary resuscitation in the prehospital/hospital settings, SBP at the start of AO, time to AO start, likelihood of achieving hemodynamic stability or requirement of a second AO. After controlling for confounders, compared with REBOA Zone 3, REBOA Zone 1 was associated with a significantly higher mortality (adjusted hazard ratio, 1.51; 95% confidence interval [CI], 1.04-2.19), but there were no differences in VFD > 0 (adjusted relative risk, 0.66; 95% CI, 0.33-1.31), IFD > 0 (adjusted relative risk, 0.78; 95% CI, 0.39-1.57), discharge GCS (adjusted difference, -1.16; 95% CI, -4.2 to 1.90) or discharge GOS (adjusted difference, -0.67; 95% CI -1.9 to 0.63). Conclusions: This study suggests that compared with REBOA Zone 1, REBOA Zone 3 provides superior survival and is not inferior regarding other adverse outcomes in patients with severe blunt pelvic injuries. 10.1097/SHK.0000000000002098
Bladder deformity accompanied by pelvic fracture indirectly indicates clinical severity. The American journal of emergency medicine BACKGROUND:That the bladder can be compressed by extraperitoneal hematoma induced by obstetrics and gynecologic diseases, is well known. However, there have been no reports on the clinical significance of compressed bladder induced by pelvic fracture (PF). We therefore retrospectively investigated the clinical features of compressed bladder induced by the PF. METHODS:From January 2018 to December 2021, we performed a retrospective review of the hospital medical charts of all emergency outpatients who were treated by emergency physicians at the department of acute critical care medicine in our hospital, and who were diagnosed with PF based on computed tomography (CT) on arrival. The subjects were divided into two groups: the Deformity group, in which the bladder was compressed by extraperitoneal hematoma, and the Normal group. Variables were compared between the two groups. RESULTS:During the investigation period, 147 patients with PF were enrolled as subjects. There were 44 patients in the Deformity group and 103 in the Normal group. There were no significant differences between the two groups with regard to sex, age, GCS, heart rate or final outcome. However, the average systolic blood pressure in the Deformity group was significantly lower, and the average respiratory rate, injury severity score, rate of unstable circulation, rate of transfusion and duration of hospitalization in the Deformity group were significantly greater in comparison to the Normal group. CONCLUSIONS:The present study showed that bladder deformity induced by PF tended to be a poor physiological sign that was associated with severe anatomical abnormality, unstable circulation requiring transfusion, and long hospitalization. Accordingly, physicians should evaluate shape of bladder when treating PF. 10.1016/j.ajem.2023.02.029
Intra-articular fragment mapping in associated both-column acetabular fractures. Archives of orthopaedic and trauma surgery INTRODUCTION:Associated both-column acetabular fractures (ABC-AF) are complex. A detailed description of the morphology of the articular surface of the acetabulum is not reported. This study was designed to describe the morphology of the intra-articular fragments using a fracture mapping technique to provide reference in more appropriate approach selection in surgical treatment of the fractures. MATERIALS AND METHODS:Three-dimensional reconstruction CT images from 100 cases of ABC-AFs were retrospectively analyzed using Mimics and 3-matic software. The fractured as well as the reduced three-dimensional models were investigated, and the intra-articular fragments were identified. The distribution of the fracture lines of each main fragment and the overlapping lines of all the fragments were verified on the images. RESULTS:The articular surface of ABC-AFS consist of three types of fragments: column fragment (CF), wall fragment (WF) and isolated fragment (IF), with the total number varying from 2 to 6. CF characterized by long fracture lines exited to periphery of innominate bone while the lines of WF were confined to the walls. IF was a free fragment found in the dome and in the quadrilateral plate. The surface was composed only by CFs in 17 cases (17%), by CFs and WFs in 59 cases (59%) and by all fragments in 24 cases (24%). The distribution of the overall fracture lines was a "dumbbell shaped" pattern, starting from the infero-anterior aspect, passing through the junction of the fossa to the anterior lunate surface and extending into the posterior region of the acetabulum. CONCLUSIONS:The articular fragments of ABC-AFs were composed of CFs, WFs and IFs. The junction of the fossa to the anterior lunate surface and the posterior region of the rim were mostly involved. The location of the articular fragments and their connections to the periphery of the innominate may be considered in selection of approaches. 10.1007/s00402-022-04381-w
Biomechanical study of different fixation constructs for anterior column and posterior hemi-transverse acetabular fractures: a finite element analysis. Journal of orthopaedic surgery and research BACKGROUND:To compare the biomechanical properties and stability, using a finite element model, of four fixation constructs used for the treatment of anterior column and posterior hemi-transverse (ACPHT) acetabular fractures under two physiological loading conditions (standing and sitting). METHODS:A finite element model simulating ACPHT acetabular fractures was created for four different scenarios: a suprapectineal plate combined with posterior column and infra-acetabular screws (SP-PS-IS); an infrapectineal plate combined with posterior column and infra-acetabular screws (IP-PS-IS); a special infrapectineal quadrilateral surface buttress plate (IQP); and a suprapectineal plate combined with a posterior column plate (SP-PP). Three-dimensional finite element stress analysis was performed on these models with a load of 700 N in standing and sitting positions. Biomechanical stress distributions and fracture displacements were analysed and compared between these fixation techniques. RESULTS:In models simulating the standing position, high displacements and stress distributions were observed at the infra-acetabulum regions. The degree of these fracture displacements was low in the IQP (0.078 mm), as compared to either the IP-PS-IS (0.079 mm) or the SP & PP (0.413 mm) fixation constructs. However, the IP-PS-IS fixation construct had the highest effective stiffness. In models simulating the sitting position, high fracture displacements and stress distributions were observed at the regions of the anterior and posterior columns. The degree of these fracture displacements was low in the SP-PS-IS (0.101 mm), as compared to the IP-PS-IS (0.109 mm) and the SP-PP (0.196 mm) fixation constructs. CONCLUSION:In both standing and sitting positions, the stability and stiffness index were comparable between the IQP, SP-PS-IS, and IP-PS-IS. These 3 fixation constructs had smaller fracture displacements than the SP-PP construct. The stress concentrations at the regions of quadrilateral surface and infra-acetabulum suggest that the buttressing fixation of quadrilateral plate was required for ACPHT fractures. 10.1186/s13018-023-03715-7
[The pararectus approach: surgical procedure for acetabular fractures]. Operative Orthopadie und Traumatologie OBJECTIVE:The pararectus approach was rediscovered several years ago for pelvic surgery and described as an alternative approach especially for the treatment of acetabular fractures of the anterior column involving the quadrilateral plate. INDICATIONS:For optimal visualization of acetabular fractures involving the quadrilateral plate, fractures of the anterior wall and anterior column, anterior column/posterior hemitransverse fractures, and fractures with central impression of dome fragments, the pararectus approach has proven to be a useful access. CONTRAINDICATIONS:The pararectus approach is not used for posterior column fractures, posterior wall fractures, combined posterior wall and posterior column fractures, transverse fractures with displaced posterior column or in combination with posterior wall fractures, and T‑fractures with displaced posterior column or in combination with posterior wall fractures. SURGICAL TECHNIQUE:The entire pelvic ring, including the quadrilateral plate, can be accessed via the pararectus approach. The choice of the correct surgical window depends on the fracture location and the requirements of fracture reduction. POSTOPERATIVE MANAGEMENT:In general, partial weight-bearing should be maintained for 6 weeks, although earlier weight-bearing release may be possible if necessary, depending on fracture pattern and osteosynthesis. Particularly in geriatric patients, partial weight-bearing is often not possible, so that early and often relatively uncontrolled full weight-bearing has to be accepted. RESULTS:In a comparative gait analysis between patients following surgical stabilization of an isolated unilateral acetabular fracture through the pararectus approach and healthy subjects, sufficient stability and motion function of the pelvis and hip during walking was already evident in the early postoperative phase. 10.1007/s00064-023-00800-2
A novel anatomical self-locking plate fixation for both-column acetabular fractures. Chinese journal of traumatology = Zhonghua chuang shang za zhi PURPOSE:To compare the stability of the posterior anatomic self-locking plate (PASP) with two types of popular reconstruction plate fixation, i.e. double reconstruction plate (DRP) and cross reconstruction plate (CRP), and to explore the influence of sitting and turning right/left on implants. METHODS:PASP, DRP and CRP were assembled on a finite element model of both-column fractures of the left acetabulum. A load of 600 N and a torque of 8 N·m were loaded on the S1 vertebral body to detect the change of stress and displacement when sitting and turning right/left. RESULTS:The peak stress and displacement of the three kinds of fixation methods under all loading conditions were CRP > DRP > PASP. The peak stress and displacement of PASP are 313.5 MPa and 1.15 mm respectively when turning right; and the minimal was 234.0 Mpa and 0.619 mm when turning left. CONCLUSION:PASP can provide higher stability than DRP and CRP for both-column acetabular fractures. The rational movement after posterior DRP and PASP fixation for acetabular fracture is to turn to the ipsilateral side, which can avoid implant failure. 10.1016/j.cjtee.2022.04.003
Use of a Six-Item Modified Frailty Index to Predict 30-day Adverse Events, Readmission, and Mortality in Older Patients Undergoing Surgical Fixation of Lower Extremity, Pelvic, and Acetabular Fractures. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews INTRODUCTION:This is a retrospective study evaluating the use of a new six-item modified frailty index (MF-6) to predict short-term outcomes of patients receiving surgery for lower extremity fractures. METHODS:Patients older than 65 years undergoing open reduction and internal fixation for lower extremity, pelvic, and acetabulum fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program. The MF-6 was calculated by assigning one point for each of six common conditions. Multivariable analysis was used to compare patients with an MF-6 of <3 and ≥3. Outcome measures included complications, mortality, readmission, revision surgery, and length of stay. An area under the curve receiver operator analysis was conducted to compare the MF-6 with MF-5, an existing five-item frailty index. RESULTS:Nine thousand four hundred sixty-three patients were included. Patients with an MF-6 of ≥3 were at markedly higher risk of discharge destination other than home (Exp[B] = 2.09), mortality (Exp[B] = 2.48), major adverse events (Exp[B] = 2.16), and readmission (Exp[B] = 1.82). Receiver-operating curve analysis demonstrated an area under the curve of 0.65 for mortality, 0.62 for major adverse events, and 0.62 for discharge destination other than home, all of which outperformed the MF-5. DISCUSSION:The MF-6 was correlated with a 30-day postoperative incidence of infectious complications, readmission, and discharge destination. MF-6 scores can be used to risk-stratify patient populations as shifts to value-based care continue to develop. 10.5435/JAAOSGlobal-D-22-00286
Can Pelvic Incidence Change After Lumbo-Pelvic Fixation for Adult Spine Deformity, and Would the Change be Affected by the Type of Pelvic Fixation? Spine STUDY DESIGN:Retrospective review. OBJECTIVE:To assess the change in pelvic incidence (PI) after lumbo-pelvic fixation and the differential impact of the type of pelvic fixation: S2-alar-iliac screws (S2AI) versus Iliac screws (IS) on postoperative PI. SUMMARY OF BACKGROUND DATA:Recent studies suggest that changes occur to the previously assumed fixed PI after spino-pelvic fixation. METHODS:Adult spine deformity (ASD) patients who underwent spino-pelvic fixation with≥4 levels of fusion were included. Preoperative and postoperative PI, lumbar lordosis (LL), thoracic kyphosis, pelvic tilt, sacral slope, PI-LL mismatch, and the Sagittal Vertical Axis (SVA) were analyzed on EOS imaging. A significant PI change was established at≥6°. Patients were categorized based on the type of pelvic fixation (S2AI vs. IS). RESULTS:One-hundred-forty-nine patients were included. Of these, 77(52%) had a>6° change in their PI postoperatively. In patients with high preoperative PI (>60°), 62% had a significant PI change compared with 33% of patients with normal PI (40°-60°) and 53% in patients with low PI (<40°; P =0.01). PI was likely to decrease in patients with high baseline PI (>60°) and to increase in patients with low baseline PI (<40°). Patients with a significant PI change had a higher PI-LL. Patients in the S2AI group (n=99) and those in the IS group (n=50) were comparable at baseline. In the S2AI group, 50 (51%) patients had>6° change in their PI compared with 27(54%) patients in the IS group( P =0.65). In both groups, patients with high preoperative PI were more prone to significant postoperative changes ( P =0.02 in IS, P =0.01 in S2AI). CONCLUSION:PI changed significantly in 50% of patients postoperatively, especially in those with high/low preoperative PI and those with severe baseline sagittal imbalance. This occurs similarly in patients with S2AI and those with IS screws. Surgeons should keep in mind these anticipated changes while planning ideal LL, as this impacts postoperative PI-LL mismatch. LEVEL OF EVIDENCE:4. 10.1097/BRS.0000000000004651
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. Orthopaedic surgery OBJECTIVE: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. METHODS: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. RESULTS: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 ± 67.4 min. In a typical case, bone union was obtained 1 year after surgery, and we removed all implants. CONCLUSIONS: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. 10.1111/os.13713
Interfacility Transfer Patients With Pelvic, Acetabular, and Lower Extremity Fractures Are at Higher Risk for Major Complications and Readmissions. Journal of orthopaedic trauma OBJECTIVE:To compare the adverse event profile and patient comorbidity profile of lower extremity orthopaedic trauma patients admitted via interfacility transfer (IT) to direct admission (DA) patients from home. METHODS:A total of 39,497 patients from 2012 to 2019 were identified in the American College of Surgeon National Surgical Quality Improvement Program database. DA patients were compared with IT patients for differences in preoperative comorbidities, adverse events, length of stay, and readmissions in the 30-day postoperative period. Student t tests were used to assess continuous variables. Pearson χ 2 test and odds ratios (ORs) were used for categorical variables. RESULTS:The IT group comprised 7167 patients, and the DA group comprised 32,330 patients. IT patients were on average older (65.5 vs. 58.8 years, P < 0.01), more likely to be American Society of Anesthesiologists Status >2 ( P < 0.01), and had a worse comorbidity profile for numerous preoperative risk factors. IT patients had significantly higher rates of mortality [3.3% vs. 1.4%; odds ratio (OR) 2.29; 95% confidence interval (CI), 1.96-2.77], major complications (10.2% vs. 6.1%; OR 1.74; 95% CI, 1.60-1.91), significantly higher readmission rates (5.8% vs. 4.8%, P < 0.01, OR 1.22 95% CI, 1.09-1.36), and more infectious complications (7% vs. 4.7%; OR 1.54; 95% CI, 1.38-1.71) than DA patients. Transfer remained a significant factor predicting major adverse events in regression analysis controlling for patient characteristics and fracture type ( P < 0.01; B 1.197; 95% CI, 1.09-1.32). CONCLUSIONS:This study revealed that IT patients undergoing operative management of pelvic, acetabular, and lower extremity fractures are at a significantly increased risk of major complications, readmission, and have a higher morbidity burden than DA patients. As healthcare transitions to value-based care and bundled payments, hospitals that accept a high volume of ITs will face exposure to added risk and financial penalties without adequate policy protections. LEVEL OF EVIDENCE:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence. 10.1097/BOT.0000000000002478
The management of pelvic ring fractures in low-resource environments: review. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Although improvement of pelvic trauma care has been successful in decreasing mortality rates in major trauma centers, such changes have not been implemented in low-resource environments such as low-middle-income countries (LMICs). This review details the evaluation and management of pelvic ring fractures and recommends improvements for trauma care in low-resource environments. Prehospital management revolves around basic life support techniques. Application of non-invasive pelvic circumferential compression devices, such as bed sheet or pelvic binders, can be performed as early as the scene of the accident. Upon arrival at the emergency department, rapid clinical evaluation and immediate resuscitation should be performed. Preperitoneal pelvic packing and external fixation devices have been considered as important first-line management tools to achieve bleeding control in hemodynamically unstable patients. After patient stabilization, immediate referral is mandated if the hospital does not have an orthopedic surgeon or facilities to perform complex pelvic/acetabular surgery. Telemedicine platforms have emerged as one of the key solutions for informing decision-making. However, unavailable referral systems and inaccessible transportation systems act as significant barriers in LMICs. Tendencies toward more "old-fashioned" protocols and conservative treatments are often justified especially for minimally displaced fractures. But when surgery is needed, it is important to visualize the fracture site to obtain and maintain a good reduction in the absence of intraoperative imaging. Minimizing soft tissue damage, reducing intraoperative blood loss, and minimizing duration of surgical interventions are vital when performing pelvic surgery in a limited intensive care setting. 10.1007/s00590-022-03420-x
RESUSCITATIVE RECTAL BALLOON COMPRESSION COMBINED WITH PELVIC BINDER EFFICIENTLY CONTROLLED FATAL VENOUS HEMORRHAGE IN A HEMODYNAMICALLY UNSTABLE PELVIC FRACTURE CANINE MODEL. Shock (Augusta, Ga.) ABSTRACT:Objective: This study evaluated the feasibility of a combination of pelvic binder and rectal balloon compression in managing fatal venous hemorrhage in a canine model of pelvic fracture. Methods: Rectums from humans (rectal cancer patients), swine, and canines were retrieved to determine their elasticity by measuring their stress and strain. Canines were selected as the animal model in this study because their rectum demonstrated more reversible strain than swine rectum. Doppler ultrasound was used to assess the effect of rectal balloon volume on the blood flow of pelvic iliac blood vessels in three canines. A rectal balloon of 250 mL was chosen to control pelvic venous bleeding as it could provide a peak effect in reducing the blood flow of bilateral internal iliac veins. Then, the open-book pelvic fracture with fatal bleeding of both internal iliac veins animal model was built. The animals were divided into four groups after the modeled surgery to undergo no treatment, pelvic binder, rectal balloon compression, or a combination of pelvic binder and rectal balloon compression. The treatment efficacy was evaluated based on their survival time, survival rate, blood loss, bleeding rate, infusion rate, blood pH, lactate concentration, the stability of hemodynamics, blood loss, and fluid infusion volume. Results: Our results showed that after the reproducible injuries in both internal iliac veins, the combination of pelvic binder and rectal balloon compression was associated with the best survival rate and survival time compared with the other treatment groups. In addition, the combination of pelvic binder and rectal balloon compression exhibited more stable hemodynamics than the pelvic binder or rectal balloon compression treatment alone. Conclusions: This study demonstrated the potential feasibility of using pelvic binder combined with rectal balloon compression to manage the fatal venous bleeding in pelvic fractures. 10.1097/SHK.0000000000002116
Percutaneous robot-assisted screw fixation for nondisplaced pelvic fractures: a good choice? International orthopaedics PURPOSE:To compare the merits and demerits of percutaneous robot-assisted screw fixation for nondisplaced pelvic fractures with other treatments via long-term follow-up. METHODS:This was a retrospective analysis of nondisplaced pelvic fractures treated between January 2015 and December 2021. The number of fluoroscopy exposures, operative duration, intraoperative blood loss, surgical complications, screw placement accuracy and Majeed score were compared among the nonoperative group (24 cases), open reduction and internal fixation (ORIF) group (45 cases), free-hand empirical screw fixation (FH) group (10 cases) and robot-assisted screw fixation (RA) group (40 cases). RESULTS:There was less intraoperative blood loss in the RA and FH groups than in the ORIF group. The number of fluoroscopy exposures in the RA group was lower than that in the FH group but much higher than that in the ORIF group. There were five cases of wound infection in the ORIF group and no surgical complications in the FH or RA group. The medical expenses were higher in the RA group than in the FH group, with no significant difference from the ORIF group. The Majeed score was lowest in the nonoperative group three months after injury (64.5±12.0) but lowest in the ORIF group one year after injury (88.6±4.1). CONCLUSION:Percutaneous RA for nondisplaced pelvic fractures is effective and minimally invasive and does not increase medical expenses compared with ORIF. Therefore, it is the best choice for patients with nondisplaced pelvic fractures. 10.1007/s00264-023-05794-x
Open Posterior Reduction and Stabilization of AO Spine C3 Sacral Fractures. Clinical spine surgery AO Spine C3 sacral fractures are defined by separation of the spine including S1 from the pelvic ring and are usually result of a high-energy injury. Besides their high biomechanical instability and high rate of associated neurological impairment, these fractures are often extremely difficult to reduce due to severe bony impaction and dislocation. Additional difficulties in management of these fractures arise from only a thin-layer of soft-tissue coverage overlying the injured area. 10.1097/BSD.0000000000001391
Management of pelvic ring fractures in limited resources country: a retrospective study. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie PURPOSE:Pelvic ring fractures (PRFs) management needs adequate facilities and human resources. However, the prehospital ambulance management role in Indonesia is insufficient. Many hospitals have limited resources that necessitate patients to be referred to higher trauma centers. This study aims to describe the state of PRFs management at a level 1 trauma center in limited-resource country. METHODS:We conducted retrospective studies of PRFs management from 2011 to 2021 at Cipto Mangunkusumo Hospital. We analyzed patient's management flow from injury, referral process, initial to definitive treatment, mortality, and Majeed functional score. RESULTS:From 109 patients, 30.3% were non-referrals that came without ambulance, while 69.7% were referrals using an ambulance. All non-referral patients came without pelvic binder with 54.5% unstable hemodynamic, while 35.5% of the referrals came with unstable hemodynamic and 72.4% had pelvic binder. Median time for non-referrals reaching our hospital is 12.5 h. Unlike local referrals, 75% of regional and 85.7% of national referrals general improvement had to be improved before being referred. Polytrauma cases were 33.9% with 12 days mean interval to definitive treatment. Mortality rate in this study was 13.8%. During post-operative follow-up with a mean of 4 years, 83% of patients could be followed up and reported 93 median Majeed score. CONCLUSION:The management of PRFs at level 1 trauma center in limited-resource country shows a mortality rate of 13.8% through various limitations such as unimplemented ambulance prehospital management, number of patients who were referred without pelvic binder applied, and the long waiting interval for definitive treatment. 10.1007/s00590-022-03457-y
Worse outcomes with resuscitative endovascular balloon occlusion of the aorta in severe pelvic fracture: A matched cohort study. American journal of surgery BACKGROUND:Severe pelvic fracture is the most common indication for resuscitative endovascular balloon occlusion of the aorta (REBOA). This matched cohort study investigated outcomes with or without REBOA use in isolated severe pelvic fractures. METHODS:Trauma Quality Improvement Program database study, included patients with isolated severe pelvic fracture (AIS≥3), excluded associated injuries with AIS >3 for any region other than lower extremity. REBOA patients were propensity score matched to similar patients without REBOA. Outcomes were mortality and complications. RESULTS:93 REBOA patients were matched with 279 without. REBOA patients had higher rates of in-hospital mortality (32.3% vs 19%, p = 0.008), higher rates of venous thromboembolism (14% vs 6.5%, p = 0.023) and DVT (11.8% vs 5.4%, p = 0.035). In multivariate analysis, REBOA use was independently associated with increased mortality and venous thromboembolism. CONCLUSIONS:REBOA in severe pelvic fractures is associated with higher rates of mortality, venous thromboembolism. 10.1016/j.amjsurg.2022.09.057
Bilateral Ischial Tuberosity Stress Fractures in an Adolescent Football Player: A Case Report. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine ABSTRACT:Pelvic stress fractures are rare, making up an estimated 1% to 7% of all stress fractures with the primary locations being the pubic rami, pubic symphysis, and sacrum. Two cases of stress fractures of the ischium have been previously described in the literature, with both occurring in the ischial body. In this case, a 17-year-old high school American football player presented with nonspecific pelvic pain and bilateral point tenderness on deep palpation of the ischial tuberosities. Advanced imaging identified bilateral ischial tuberosity stress fractures. This report outlines the diagnosis and management of the first reported case of bilateral ischial tuberosity stress fractures. We report how ischial tuberosity stress fractures present clinically, potential management strategies, and highlight the use of computed tomography imaging for pelvic stress fractures. Knowledge of unusual stress fracture locations may improve early diagnosis, limit complications, reduce healthcare costs, and promote an accelerated recovery time. 10.1097/JSM.0000000000001103
Positive Predictive Factors for Urogenital Injuries in Severely Injured Patients with Pelvic and Spinal Fractures: Introducing the UPPS Scoring System. Medicina (Kaunas, Lithuania) Background and Objectives: Although urogenital injuries are common in severely injured patients, their diagnosis is often delayed. Predicting genitourinary injuries (GUI), especially in the immediate stages post injury, remains a challenge. This study aims to evaluate and determine positive predictive factors for the presence of GUI in polytrauma patients. Subsequently, these factors shall be used to develop an easy-to-use scoring system, deployable directly in the emergency setting. Materials and Methods: This study evaluates all severely injured patients with an Injury Severity Score (ISS) ≥ 16 admitted to the emergency departments of two German university hospitals between 2016 and 2020. These patients were retrospectively scanned for injuries of the thoracic and/or lumbar spine and/or the pelvic girdle. Demographic data was analyzed alongside trauma mechanism, type of injuries, mortality, length of hospital stays, surgeries, laboratory results, and urological treatment. Subgroup analysis was performed to compare patients with and without GUIs using t-tests. Conducting a binary logistic regression model, the significant factors were combined to create a scoring system, which was further analyzed for accuracy. Results: In total, 413 patients with an average ISS of 33.8 ± 15.0 were identified, and 47 patients (11.4%) sustained urogenital injuries with an average Abbreviated Injury Scale (AIS) score of 2.3 ± 1.1 (range: 1−5). The severity of the pelvic girdle injury correlated with the presence of urogenital injuries (p = 0.002), while there was no correlation with spinal injuries. Moreover, most GUIs resulted from motorcycle accidents (p < 0.001) and 87.2% of these patients were male. Patients with GUI were significantly more likely to show macrohematuria (p < 0.001) on admission and were more severely injured overall (ISS > 34). There was no significant difference in the length of intensive care unit (ICU) stay, the days until discharge, or death rates. Conclusions: Factors or circumstances which reliably predict the presence of GUI were found to include the male sex, a motorcycle accident, high severity of pelvic girdle fractures, macrohematuria on admission to the emergency department, and an ISS > 34. With these findings, we introduce the ‘Urotrauma in Polytrauma patients with Pelvic and/or Spinal injuries’ (UPPS) score for easier prediction of GUI in the emergency setting. 10.3390/medicina58111583
Management of Pelvic Fractures and Hip Dislocation in Pregnancy: A Case Report and Review of Literature. Journal of orthopaedic case reports Introduction:Trauma is the leading non-obstetric cause of maternal mortality during pregnancy and pelvic fractures are challenging to manage in such cases due to the effect of trauma on the gravid uterus and altered maternal physiology. About 8-16% of pregnant females can have fatal outcome after trauma, with pelvic fractures contributing majorly to the same, and also can have severe fetomaternal complications. There are only two cases reported till date of hip dislocation in pregnancy, with very little literature available on its outcome. Case Report:We, hereby, present a case of a 40-year-old pregnant female hit by a moving car with the right superior and inferior pubic rami fracture and left anterior hip dislocation. Closed reduction of the left hip was done under anesthesia and pubic rami fractures were managed conservatively. On follow-up after 3 months, the fracture was completely healed and the patient had a normal vaginal delivery. We have also reviewed management protocols for such cases. Aggressive maternal resuscitation is important for both maternal and fetal survival. Pelvic fractures should not be left unreduced in such cases to prevent mechanical dystocia and can have a good outcome with both closed and open reduction and fixation techniques. Conclusion:Pelvic fractures in pregnancy should be treated by careful maternal resuscitation and timely intervention. The majority of such patients can deliver vaginally if the fracture heals before delivery. 10.13107/jocr.2022.v12.i10.3342
Acute Pelvic and Hip Apophyseal Avulsion Fractures in Adolescents: A Summary of 719 Cases. Journal of pediatric orthopedics BACKGROUND:Apophyseal avulsion fractures of the pelvis and hip are common injuries in adolescent athletes. However, high volume comparative studies elucidating the spectrum of injuries are largely absent from the literature. The current study provides a comprehensive analysis of demographic, anatomic, pathophysiological, clinical, and athletic-related variables associated with such injuries in an extensive population of affected adolescents. METHODS:A retrospective review was performed of records of patients presenting to a single tertiary care pediatric hospital between January 1, 2005, and July 31, 2020, collecting variables including patient sex, age, body mass index, fracture location, injury mechanism, sport at the time of injury, and duration of prodromal symptoms. RESULTS:Seven hundred nineteen fractures were identified in 709 patients. The average patient age was 14.6, and 78% of the fractures occurred in male patients. The anterior inferior iliac spine (33.4%), anterior superior iliac spine (30.5%), and ischial tuberosity (19.4%) were the most common fracture sites. The most common injury mechanisms were running (27.8%), kicking (26.7%), and falls (8.8%). The most common sports at the time of injury were soccer (38.1%), football (11.2%), and baseball (10.5%). Fracture site was significantly associated with patient sex, age, body mass index, laterality, mechanism, sport, time from injury, and presence of prodromal symptoms. The annual volume of pelvic avulsion fractures treated at the institution increased significantly from n=17 in 2005 to n=75 in 2019. CONCLUSIONS:Adolescent pelvic and hip avulsion fractures occur during a narrow window of age and skeletal maturation and are frequently sustained during sporting activities. Each fracture location is associated with certain demographic, mechanistic, and patient-specific characteristics. The associations between fracture site and patient-specific or injury-specific variables offer insights into the pathophysiology and possible underlying biomechanical risk factors that contribute to these injuries. LEVEL OF EVIDENCE:This is a level III retrospective study. 10.1097/BPO.0000000000002355
Transiliac Cerclage in Unstable Pelvic Ring Fractures. Ortopedia, traumatologia, rehabilitacja BACKGROUND:To evaluate the outcomes of transiliac cerclage with Dall-Miles cable in the internal fixation of the posterior complex in unstable pelvic ring fractures between January 1995 and December 2014. MATERIAL AND METHODS:A study of 42 men injured at work with an average age of 35.2 years (range, 23 to 61) was conducted. The mechanisms of injury were traffic accidents in 25 cases (59.5%), crushing accidents in 12 cases (28.6%), and fall from height in 5 cases (11.9%). Thirty-six cases were polytraumatized patients (85.7%). The patients were evaluated using Majeeds functional score and Mattas radiological criteria. RESULTS:The average follow-up time was 135.8 45.6 months. The clinical outcomes were excellent in 17 cases (40.5%), good in 19 cases (45.2%), fair in 5 cases (11.9%), and poor in 1 case (2.4%). The radiological outcomes were satisfactory in 32 cases (76.2%) and unsatisfactory in 10 cases (23.8%). All fractures were healed. The sequelae were 3 cases (7.2%) of lower limb dysmetria and 3 cases (7.2%) of chronic neuropathic pain. CONCLUSION:The internal fixation of the sacroiliac complex by Dall-Miles cable cerclage reinforced with small fragment plates should be considered as an alternative method for minimally invasive osteosynthesis in selected cases of unstable pelvic ring fractures. 10.5604/01.3001.0015.9052
Angioembolization versus preperitoneal packing for severe pelvic fractures: A propensity matched analysis. American journal of surgery BACKGROUND:Whether AE or PPP would be associated with survival among hemodynamically unstable pelvic fracture remains controversial. STUDY DESIGN:This is a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program database from 2016 to 2018. Patients >16 years with a severe pelvic fracture (abbreviated injury scale 3-5) who underwent AE or PPP were recruited. The primary outcome was in-hospital survival. Data were evaluated using a propensity-score matching (PSM) analysis. RESULTS:A total of 1123 patients met our inclusion criteria. Of these, AE and PPP were performed in 964 (85.8%) and 159 (14.2%) patients, respectively. Concomitant hemorrhage control laparotomy was performed in 25.6% and 82.4% of AE and PPP patients, respectively. In 220 PSM patients, the mortality rate between AE and PPP groups was not significantly different (30.9% vs. 38.2%, P = 0.321). CONCLUSIONS:Though patients' characteristics differed between AE and PPP groups, comparable propensity-matched patients with severe pelvic fractures showed no significant difference in in-hospital survival. PPP was more likely to be selected for severe pelvic fractures necessitating laparotomy. 10.1016/j.amjsurg.2022.09.003
Assessment and management of pelvic fractures from high-energy trauma in adults. Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association Pelvic fractures caused by high-energy trauma such as falling from a height or road traffic collisions have a high mortality rate and patients are also at high risk of life-changing injuries. High-energy trauma to the pelvis is associated with major haemorrhage and injuries to the internal pelvic organs. Emergency nurses have a fundamental role in the initial assessment and management of patients, as well as in their ongoing care once the fracture has been stabilised and bleeding is controlled. This article describes the anatomy of the pelvis, discusses the initial assessment and management of patients who have sustained high-energy pelvic trauma, details the complications of pelvic fractures and explains patients' ongoing care in the emergency department. 10.7748/en.2023.e2151
Novel Covert-Inferior Pelvic Approach with a Subpubic Plate for Anterior Pelvic Ring Fractures: Preliminary Results. The Journal of bone and joint surgery. American volume BACKGROUND: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. METHODS: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. RESULTS: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. CONCLUSIONS: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. LEVEL OF EVIDENCE:Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence. 10.2106/JBJS.22.00371
Lower urinary tract injuries in patients with pelvic fractures at a level 1 trauma center - an 11-year experience. Scandinavian journal of urology BACKGROUND:Urological injuries can occur in patients with pelvic fractures. Treatment recommendations lack solid evidence and is often pragmatical. There is a continuous need to describe short- and long-term morbidity following lower urinary tract trauma. OBJECTIVE:To describe incidence, diagnosis, treatment, and morbidity following lower urinary tract injuries in pelvic fractures. PATIENTS AND METHODS:Retrospective study including patients with pelvic, including acetabular, fractures admitted to a Level I Trauma Centre covering 2.8 million citizens between 2009 and 2020. Outcome measurements comprised primary management, treatment trajectory, short- and long-term complications and outcomes. RESULTS:A total of 39 (5%) patients with pelvic fractures had concomitant urethral and/or bladder injuries, and one patient with an acetabular fracture had a bladder injury. The management of urethral injuries varied vastly, and complete urethral ruptures were associated with severe short- and long-term complications. Only one patient with bladder injury experienced severe long-term complications. CONCLUSIONS:Management of lower urinary tract injuries in patients with major pelvic fractures remains a major challenge. Special attention should be focused on urethral injuries where we uncovered an unsystematic treatment and follow-up even in a highly experienced centre, although this is also attributed to complicated multidisciplinary patient trajectories. There is a continuous need to reduce long-term complications following urethral trauma which should be addressed in multicenter studies. 10.1080/21681805.2022.2141311
Management strategy for open pelvic fractures: A 11-year single-centre, retrospective observational study. Injury INTRODUCTION:Open pelvic fractures are commonly associated with life-threatening, uncontrollable haemorrhages. Although management methods for pelvic injury-associated haemorrhage have been established, the early mortality rate associated with open pelvic fractures remains high. This study aimed to identify predictors of mortality and effective treatment methods for open pelvic fractures. METHODS:We defined open pelvic fractures as pelvic fractures with an open wound directly connected to the adjacent soft tissue, genitals, perineum, or anorectal structures, resulting in soft tissue injuries. This study was performed on trauma patients (age ≥15 years) injured by a blunt mechanism between 2011 and 2021 at a single trauma centre. We collected and analysed the data on the Injury Severity Score (ISS), the Revised Trauma Score (RTS), the Trauma and Injury Severity Score (TRISS), length of hospital stay, length of intensive care unit stay, transfusion, preperitoneal pelvic packing (PPP), resuscitative endovascular balloon occlusion of the aorta (REBOA), therapeutic angio-embolisation, laparotomy, faecal diversion, and mortality. RESULTS:Forty-seven patients with blunt open pelvic fractures were included. The median age was 45 years (interquartile range, 27-57 years) and median ISS was 34 (24-43). The most frequently performed treatment methods were laparotomy (53%) and pelvic binder (53%), followed by faecal diversion (40%) and PPP (38%). PPP was the only method performed at a higher rate in the survival group for haemorrhagic control (41% vs. 30%). Haemorrhagic mortality was present in one case that received PPP. The overall mortality was 21%. In the univariate logistic regression analysis, initial systolic blood pressure (SBP), TRISS, RTS, packed red blood cell transfusion for the first 24 h, and base excess showed statistical significance (p<0.05). In the multivariate logistic regression model, initial SBP was identified as an independent risk factor for mortality (odds ratio, 0.943; 95% confidence interval, 0.907-0.980; p = 0.003). CONCLUSION:A low initial SPB may be an independent predictor of mortality in patients with open pelvic fractures. Our findings suggest that PPP might be a feasible method to decrease haemorrhagic mortality from open pelvic fractures, especially for haemodynamically unstable patients with low initial SBP. Further studies are required to validate these clinical findings. 10.1016/j.injury.2023.02.040
[Effectiveness of three-dimensional visible technique without fluoroscopy versus two-dimensional fluoroscopy in reduction of unstable pelvic fractures]. Zhongguo xiu fu chong jian wai ke za zhi = Zhongguo xiufu chongjian waike zazhi = Chinese journal of reparative and reconstructive surgery Objective:To compare the reduction qualities of three-dimensional visible technique without fluoroscopy and two-dimensional fluoroscopy for unstable pelvic fractures during operations. Methods:The clinical data of 40 patients with unstable pelvic fractures, who met the selection criteria in three clinical centers between June 2021 and September 2022, were retrospectively analyzed. According to the reduction methods, the patients were divided into two groups. Twenty patients in trial group were treated with unlocking closed reduction system combined with three-dimensional visible technique without fluoroscopy; 20 patients in control group with unlocking closed reduction system under two-dimensional fluoroscopy. There was no significant difference in the gender, age, injury mechanism, Tile type of fracture, Injury Severity Score (ISS), and the time between injury to operation between the two groups ( >0.05). The qualities of fracture reduction according to the Matta criteria, operative time, intraoperative blood loss, fracture reduction time, times of fluoroscopy, and System Usability Scale (SUS) score were recorded and compared. Results:All operations were successfully completed in both groups. According to the Matta criteria, the qualities of fracture reduction were rated as excellent in 19 patients (95%) in trial group, which was better than that in the control group (13 cases, 65%), with a significant difference ( =3.906, =0.048). The operative time and intraoperative blood loss had no significant differences between the two groups ( >0.05). The fracture reduction time and times of fluoroscopy were significantly less in trial group than in control group ( <0.05), and SUS score in trial group was significantly higher in trial group than in control group ( <0.05). Conclusion:Compared to using unlocking closed reduction system under two-dimensional fluoroscopy, three-dimensional visible technique without fluoroscopy can significantly improve the reduction quality of unstable pelvic fractures without prolonging the operative time, and is valuable to reduce iatrogenic radiation exposure for patients and medical workers. 10.7507/1002-1892.202210073
Preperitoneal Packing for Pelvic Fracture Bleeding Control: A Human Cadaver Study. World journal of surgery BACKGROUND:Preperitoneal packing (PPP) has been widely accepted as a damage control technique for severe bleeding from pelvic fractures. It is supposed to work by direct compression and tamponade of the bleeding source in the pelvis and it has been suggested to be effective for both venous and arterial bleeding. However, there is little evidence to support its efficacy or the ability to place the laparotomy pads in proximity of the desired location. METHODS:Bilateral PPP was performed on 10 fresh human cadavers, followed by laparotomy and measurements of resultant pad placement in relation to critical anatomic structures. RESULTS:A total of 20 assessments of laparotomy pad placement were performed. Following completion of PPP, a midline laparotomy was performed to determine proximity and closest distance of the laparotomy pads to sites of potential bleeding in pelvic fractures. In almost all cases, the pad placement was not contiguous with the key anatomic structure with mean placement 3.9 + 1.1 cm from the sacroiliac joint, 3.5 + 1.6 cm from the common iliac artery, 1.1 + 1.2 cm from the external iliac artery, 2.8 + 0.8 cm from the internal iliac artery, and 2.3 + 1.2 cm from the iliac bifurcation. Surgeon experience resulted in improved placement relative to the sacroiliac joint, however the pads still did not directly contact the target point. CONCLUSION:This human cadaver study has shown that PPP, even in experienced hands, may not be placed in significant proximity of anatomical structures of interest. The role of PPP needs to be revisited with better clinical or human cadaver studies. 10.1007/s00268-022-06859-5
Effectiveness and safety of bilateral internal iliac artery ligation with pre-peritoneal pelvic packing for life-threatening pelvic trauma. Injury This study analyzed the outcomes of bilateral internal iliac artery (IIA) ligation with preperitoneal pelvic packing (PPP) in hemodynamically unstable patients with major pelvic fractures. All-cause mortality was examined, periprocedural safety for critical circumstances was reviewed, and iliac artery ligation-related complications of the postoperative phase were evaluated. A total of 20 patients who suffered substantially from severe pelvic trauma with hemodynamic instability and subsequently underwent bilateral IIA ligation with PPP between January 1, 2017, and December 31, 2021, were enrolled in the study. The median participant age was 60.5 years, and 65.0% were male. The median systolic blood pressure was 68.5 mmHg on arrival. Increased lactate level (median, 11.05 mmol/L) suggested that the patients were in shock distinctly due to hypovolemia. It took approximately 1 h to complete the ligation of bilateral IIA to accomplish hemostasis (median, 65.5 min). The iliac vein was injured during dissection in three cases. During the ICU stay (median, 17.5 days), acute kidney injury was identified in 13 patients, likely due to volume depletion. The median ventilator-free days was 13.5; six patients were confirmed with ventilator-associated pneumonia. Moreover, 12 patients were diagnosed with acute respiratory distress syndrome. There was one case in which the lower extremity artery was acutely occluded. Anatomic hemostasis was achieved in 18 patients. The two patients for which anatomic hemostasis failed became two mortality cases from preperitoneal hemorrhage. Our analysis showed that bilateral IIA ligation with PPP was effective as a lifesaving procedure in hemodynamically unstable patients with a major pelvic fracture in terms of mortality due to fracture-related exsanguination. Moreover, the incidence of periprocedural complications was considered tolerable, making the procedure worth a try, especially in austere and underdeveloped healthcare settings. 10.1016/j.injury.2022.11.003
Epidemiology and burden of pelvic fractures: Results from the Global Burden of Disease Study 2019. Injury INTRODUCTION:Pelvic fracture is a severe injury resulting in high mortality and disability rate, and brought heavy health burden. However, existing research conclusions only restricted to the national level while global estimation of pelvic fracture was lack. We aimed to estimate the global incidence, prevalence, and years lived with disability (YLDs) of pelvic fracture by region, age, gender, cause and sociodemographic index (SDI). MATERIALS AND METHODS:Publicly available data was gained based on the Global Burden of Disease Study (GBD) 2019. We calculated the estimated annual percent change (EAPC) to analyze the temporal trends of pelvic fractures from 1990 to 2019. Incidence, prevalence and YLDs were analyzed by region, age, gender, cause and SDI. Spearman's rank order correlation was used to determine the correlation between SDI and incidence, prevalence and YLDs. RESULTS:Globally, there were about 6 million incident cases, 18.8 million prevalent cases and 3.2 million YLDs cases of pelvic fractures for both sexes in 2019. The incidence number increased over 40% compared to 1990. However, the age standardized rate of incidence (ASIR) (EAPC = -0.22; 95% CI, -0.38 to -0.05), prevalence (ASPR) (EAPC = -0.42; 95% CI, -0.51 to -0.32) and YLDs (ASYR) (EAPC = -0.41; 95% CI, -0.50 to -0.32) all presented downward trends. Males had higher ASIR, ASPR and ASYR than females in each year from 1990 to 2019. The incidence, prevalence and YLDs rates were higher in males in early adulthood but exceeded in females at older age. A positive correlation was observed between ASIR and SDI (rho = 0.3732, p < 0.01). Regions with higher SDI tended to have higher ASIR, ASPR and ASYR than lower SDI regions. Falls and road injuries were the major causes of pelvic fracture at all ages and during the whole period. CONCLUSION:The global health burden of pelvic fracture still remained high during the past thirty years. More policies and strategies are needed to face the challenge brought by population growth and aging. 10.1016/j.injury.2022.12.007
Intelligent robot-assisted minimally invasive reduction system for reduction of unstable pelvic fractures. Injury OBJECTIVE:Currently, minimally invasive internal fixation is recommended for the surgical treatment of unstable pelvic fractures. The premise and difficulty of minimally invasive internal fixation are minimally invasive reduction of fractures. This review aimed to investigate the indications, surgical strategy and techniques, safety, and efficacy of intelligent robot-assisted fracture reduction (RAFR) system of pelvic ring injuries. METHODS:This retrospective study reviewed a case series from March 2021 to November 2021. A total of 22 patients with unstable pelvic fracture injuries underwent minimally invasive internal fixations. All pelvic ring fractures were reduced with our intelligent RAFR system. The robot system intelligently designs the optimal position and reduction path based on the patient's preoperative 3D CT. During the operation, the three-dimensional visualization of the fracture is realized through image registration, and the Robot completes the automatic reduction of the fracture. The global 3D point cloud error between the preoperative planning results and the actual postoperative reduction results was calculated. The postoperative reduction results of residual displacement were graded by the Matta Criteria. RESULTS:Minimally invasive closed reduction procedures were completed in all 22 cases with our RAFR system. The average global 3D point cloud reduction error between the preoperative planning results and the actual postoperative reduction results was 3.41mm±1.83mm. The mean residual displacement was 4.61mm±3.29mm. Given the Matta criteria, 16 cases were excellent, five were good, and one was fair, with an excellent and good rate of 95.5%. CONCLUSION:Our new pelvic fracture reduction robot system can complete intelligent and minimally invasive fracture reduction for most patients with unstable pelvic fractures. The system has intelligent reduction position and path planning and realizes stable pelvis control through a unique holding arm and a robotic arm. The operation process will not cause additional damage to the patient, which fully meets the clinical requirements. Our study demonstrated the safety and effectiveness of our robotic reduction system and its applicability and usability in clinical practice, thus paving the way towards Robot minimally invasive pelvic fracture surgeries. 10.1016/j.injury.2022.11.001
Epidemiology of pelvic and acetabular fractures in the USA from 2007 to 2014. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA Incidence of pelvic and acetabular fracture is increasing in Europe. From 2007 to 2014 in the USA, this study found an age-adjusted incidence of 198 and 40 fractures/100,000/year, respectively, much higher than what has been described before. Incidence remained steady over that period and only a small increase in incidence of pelvic fracture in men was identified. PURPOSE:To determine the incidence of pelvic ring and acetabular fractures in the USA over the period 2007-2014 and to examine trends over time. METHODS:Retrospective population-based observational study using data from the Nationwide Emergency Department Sample (NEDS), a 20% stratified all-payer sample of US hospital-based emergency departments (EDs). All patients seen in the ED and diagnosed with pelvic/acetabular fracture from 2007 to 2014 were included. The primary outcome was age-adjusted incidence of pelvic and acetabular fractures per 100,000 persons/years. Secondary outcomes included incidence stratified by age and sex, patient- and hospital-related characteristics, and ED procedures. Tests for linear trends were used to determine if there were statistically significant differences by sex and age groups over time. RESULTS:The age-adjusted incidence of pelvic fracture was 198 fractures/100,000/year, 323 in women and 114 in men. The age-adjusted incidence of acetabular fracture was 40 fractures/100,000/year, 36 in women and 51 in men. A small increase in the age-adjusted incidence of pelvic fracture in men was the only significant trend observed during the study time (p = 0.03). Over that period, the mean age of patients at presentation increased, as well as their number of comorbidities and associated fragility fractures, and they were more often sent home or to nursing facilities. CONCLUSIONS:When considering all patients coming to the ED, not only those admitted to the hospital, adjusted incidence of pelvic and acetabular fracture is much higher than what has been described before. Contrarily to the global increase seen in other countries, incidence of pelvic and acetabular fractures dropped in the USA from 2007 to 2014 and only a small increase in age-adjusted incidence of pelvic fracture in men was identified. 10.1007/s00198-022-06636-z
Curvafix: A novel implant for pelvic fragility fractures. Trauma case reports Fragility fractures of the pelvis are a frequently encountered injury in orthopedic practice. These injuries occur in patients with diminished bone density secondary to low energy mechanisms. This injury is associated with increased mortality and decreased quality of life. These fractures have been treated conservatively and with open or percutaneous surgical fixation. This case report illustrates the use of the Curvafix, a novel intramedullary implant used to treat a patient with a pelvic fragility fracture. 10.1016/j.tcr.2022.100749
Neuromodulation in Chronic Pelvic Pain: A Narrative Review. Pain and therapy Chronic primary pelvic pain syndrome (CPPPS) is a heterogeneous disease with unknown pathogenesis and a lack of distinct pathological features, which complicates diagnosis and therapy and has a significant impact on patients' daily life. Because pharmacological management is ineffective and long-term use may result in additional system damage, developing a more effective treatment is critical. Neuromodulation has advanced rapidly over the last few decades, and various types of neuromodulations have demonstrated efficacy in the treatment of CPPPS. In this article we discuss the evolution of neuromodulation technology in the treatment of chronic pelvic pain, its application to various subtypes of chronic pelvic pain, and the comparison of relevant efficacy and parameter differences, as well as assess the relative advantages and disadvantages of sacral neuromodulation, percutaneous tibial nerve stimulation , transcutaneous electrical nerve stimulation, electroacupuncture, and pudendal neuromodulation. Furthermore, it was noted that chronic pelvic pain should be evaluated in terms of pain, associated symptoms, psychological problems, and quality of life. Although neuromodulation approaches have been shown to be effective in treating chronic pelvic pain, more extensive multicenter trials are required to confirm this. 10.1007/s40122-022-00405-w
Prospective Characterization of Pain and Function in Patients With Unstable Pelvic Fractures Treated With Posterior Screw Fixation. Journal of orthopaedic trauma OBJECTIVES:Describe patient-reported pain and function within 24 months of a pelvic fracture treated with posterior screw fixation and identify factors associated with increased pain. DESIGN:Prospective case series. SETTING:Academic trauma center. PATIENTS/INTERVENTION:Eighty-eight patients with adult pelvic fracture treated with sacroiliac or transiliac screws. MAIN OUTCOME MEASURES:Average pain measured with the Brief Pain Inventory (BPI); function measured with the Majeed Pelvic Outcome Score from 6 to 24 months postinjury. RESULTS:The mean pain from 6 to 24 months postinjury was 2.22 on the 10-point BPI scale (95% CI, 0.64-3.81). Sixty-nine patients (78.4%) reported mild to no pain at 6 months; 12 (13.6%) patients had severe pain. Two years after injury, 71 patients (80.6%) exhibited mild to no pain. Within 24 months of injury, the mean pelvic function was 71 on the 100-point Majeed scale (95% CI, 60-82). Half of the sample (n = 44) had good to excellent pelvis function by 6 months postinjury; 55 patients (62.5%) attained this level of function by 24 months. A history of chronic pain (1.31; 95% CI, 0.26-2.37; P = 0.02), initial fracture displacement (≥5 mm) (0.99; 95% CI, 0.23-1.69; P = 0.01), and socioeconomic deprivation (0.28; 95% CI, 0.11-0.44; P < 0.01) were significantly associated with increased pain. CONCLUSION:Our findings suggest that most patients with unstable pelvic ring fractures treated with posterior screw fixation achieve minimal to no pelvis pain and good to excellent pelvic function 6-24 months after injury. LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. 10.1097/BOT.0000000000002416
Use of calcaneal plates in the treatment of posterior pelvic ring injuries and displaced iliac blade fractures- A case series. Journal of clinical orthopaedics and trauma Introduction:The operative fixation of pelvic ring injuries and associated acetabulum fractures presents a challenging scenario to most of the orthopaedic trauma surgeons. Current development of anatomically contoured reconstruction (ACR) plates gained popularity in fixing complex pelvic ring fractures. This study was done to assess the functional and radiological outcomes using of lateral wall stainless steel (LWSS) calcaneal plates in posterior pelvic ring injuries and displaced iliac blade fractures. Materials and methods:Retrospectively selected eight cases of pelvic ring injuries planned for fixing posterior pelvic instability and iliac blade fractures using LWSS plates. Mean follow-up was 18 months (Range 12-26 months). Results:Average time for radiological bony union achieved in 18 weeks (Range 13-22). Seven patients returned to their normal work. Average Majeed score was 60 (Range 50-68). Mean duration of surgery was 160 min (Range 120-200). Conclusion:This technique can be routinely used as supplementary fixation for posterior pelvic ring instability and iliac blade fractures. LWSS calcaneal plates showed no screw breakage or implant failure. Further this technique was cost effective in developing countries with limited resources. 10.1016/j.jcot.2022.102091
Sexual Dysfunction in Women after Traumatic Pelvic Fracture Negatively Affects Quality of Life and Mental Health. The journal of sexual medicine BACKGROUND:While the impact of female sexual dysfunction (FSD) on mental health and overall health-related quality of life (HrQOL) has been previously documented, no prior work has evaluated this relationship in women following traumatic pelvic injuries. AIM:This study aims to understand the relationship of FSD with HrQOL and depression in women with a history of traumatic pelvic fracture. METHODS:Data were collected with an electronic survey that included queries regarding mental and sexual health. Inverse probability weighting and multivariate regression models were utilized to assess the relationships between sexual dysfunction, depression and HrQOL. OUTCOMES:Study outcome measures included the Female Sexual Function Index (FSFI) to evaluate sexual functioning, the 8-item patient health questionnaire (PHQ-8) to assess depression symptoms, and the visual analog scale (VAS) component of the EuroQol 5 Dimensions Questionnaire (EQ-5D) to determine self-reported HrQOL. RESULTS:Women reporting FSD had significantly higher PHQ-8 scores with a median PHQ-8 score of 6 (IQR 2, 11) relative to those without FSD who had a median score of 2 (IQR 0, 2) (P < .001). On multivariate linear regression, presence of FSD was significantly associated with higher PHQ-8 scores (β = 4.91, 95% CI 2.8-7.0, P < .001). FSFI score, time from injury, and age were all independently associated with improved HrQOL, with FSFI having the largest effect size (β = 0.62, 95% CI 0.30-0.95, P < .001). CLINICAL IMPLICATIONS:These results underscore importance of addressing not just sexual health, but also mental health in female pelvic fracture survivors in the post-injury setting. STRENGTHS AND LIMITATIONS:This study is one of the first to examine women with traumatic pelvic fractures who did not sustain concomitant urinary tract injuries. Study limitations include low response rate and the inherent limitations of a cross-sectional study design. CONCLUSION:Patients with persistent, unaddressed FSD after pelvic fracture are at unique risk for experiencing depression and reporting worse health-related quality of life due to complex biopsychosocial mechanisms. Gambrah HA, Hagedorn JC, Dmochowski RR, et al. Sexual Dysfunction in Women after Traumatic Pelvic Fracture Negatively Affects Quality of Life and Mental Health. J Sex Med 2022;19:1759-1765. 10.1016/j.jsxm.2022.08.198
Spinopelvic fixation for vertically unstable AO type C pelvic fractures and sacral fractures with spinopelvic dissociation- A systematic review and pooled analysis involving 479 patients. Journal of orthopaedics BACKGROUND:Posterior pelvic ring injuries can be fixed using iliosacral screws, plates or bars. Another promising modality is spinopelvic fixation or triangular osteosynthesis, indicated in vertical instability and sacral fractures associated with spinopelvic dissociation. QUESTION/PURPOSE:This systematic review and pooled analysis was conducted to analyze the outcomes (functional and radiological) of the use of spinopelvic fixation, as well as assess the associated complications and neurological recovery. METHODS:A systematic review of literature was performed from the PubMed/Medline, EMBASE and the SCOPUS databases. All studies reporting on spinopelvic fixations, with a minimum follow up of 1 year were included in the review. Pooled analysis was done for the outcome and complication rates. The MINORS Tool was used for assessing the risk of bias. RESULTS:A total of 22 studies were included with average follow-up between 12 and 86.4 months. There were 7 prospective and 15 retrospective case series. The functional outcomes were excellent/good in 90% cases, across 8 studies (95% CI 84-95%); radiological outcomes were excellent/good in 97% cases (95% CI 94-100%) across 5 studies. The most commonly reported complications were hardware prominence in 21.3% (95% CI 11.6,30.9%) and infections in 7.2% cases (95% CI 4.8,9.5%). 73% of the patients reported partial or complete improvement in their neurological condition. CONCLUSION:Spinopelvic fixation is an effective method in vertical instability of the pelvis and sacral fractures with spinopelvic dissociations, with good to excellent radiological and functional outcomes. However, adequate precautions are needed to avoid infections and wound complications. 10.1016/j.jor.2022.01.010
Prolonged ileus in traumatic pelvic ring injury patients who underwent arterial angio-embolization: A retrospective study. Medicine Paralytic ileus occurs in up to 18% of the patients with pelvic bone fractures. The aim of this study is to determine if massive bleeding requiring arterial angio-embolization is related with the duration of ileus in patients with traumatic pelvic ring injuries. This retrospective study included 25 patients who underwent arterial angio-embolization for traumatic pelvic ring injuries. Data were collected from prospectively maintained databases of two independent hospitals. Demographic characteristics (such as age, sex, body mass index, and Charlson Comorbidity Index), cause of trauma, and severity of pelvic injuries were similar in the non-prolonged and prolonged ileus groups. As expected, the prolonged ileus group had a significantly longer duration of ileus than the non-prolonged ileus group (8.0 ± 4.2 days vs 1.2 ± 0.4 days, respectively; P < .001). The mortality rate was higher in the prolonged ileus group (20% vs 0%), but it was not significantly different (P = .13). Interestingly, the prolonged ileus group received significantly higher amounts of packed red blood cell transfusions (6.1 ± 2.1 units vs 3.8 ± 2.5 units; P = .02). The amount of packed red blood cell transfusions was associated with a greater risk of prolonged ileus development (P = .03, odds ratio = 2.04, 95% confidence interval = 1.08-3.88). This study supports the idea that the duration of the ileus is related with the amount of bleeding caused by the traumatic pelvic ring injury. In order to prevent further complications, conservative treatments of the ileus should be considered. 10.1097/MD.0000000000030684
Risk of Fractures, Repeated Fractures and Osteoporotic Fractures among Patients with Hemophilia in Taiwan: A 14-Year Population-Based Cohort Study. International journal of environmental research and public health The world is aging, and hemophilia patients are as well. The association between patients with hemophilia (PWH) and low bone mineral density is clear. However, the incidence of fractures in patients with hemophilia is inconclusive, and no research has yet explored repeated fractures among PWH. In this study, we investigated the incidence of all-site fractures, repeated fractures and osteoporotic fractures amongst PWH. The study compared the incidence of all-site fractures, repeated fractures and osteoporotic fractures occurring in all PWH who were enrolled in Taiwan's National Health Insurance Research Database between 1997 and 2013 with an age- and gender-matched group from the general population. Eight-hundred thirty-two PWH, along with 8320 members of the general population, were included in the final analysis. After multivariate COX regression analysis with an adjustment for confounding factors, it was found that PWH experienced a higher risk of osteoporotic fracture (HR: 1.25 with 95% CI of 1.03-2.52) but only saw a neutral effect with regards to both all-sites of fracture (HR: 1.00 with 95% CI of 0.92-1.09) and repeated fractures (HR: 1.01 with 95% CI of 0.92-1.10), when compared with the general population. This 14-year population-based cohort study showed that PWH had a higher risk of osteoporotic fracture, but that hemophilia only had a neutral effect in all-sites of fracture and repeated fractures. Screening, prevention and treatment for osteoporosis and further osteoporotic fractures among PWH, in order to improve quality of life and achieve healthy aging in this particular population, remain essential. 10.3390/ijerph20010525
Biomechanical analysis of pelvic holding pathways and strategies for use of the steinmann pin in pelvic fracture reduction. Computers in biology and medicine Pelvic fracture is the most serious bone trauma and has the highest mortality and disability rate. Surgical treatment of pelvic fracture is very challenging for surgeons. Minimally invasive close reduction of pelvic fracture is considered the most difficult operation due to the complex pelvic morphology and abundant soft tissue anatomy, both of which increase the difficulty of pelvic fracture reduction. The most challenging aspect of such surgery is how to hold the pelvic bone and effectively transmit the reduction force to the bone. Therefore, a safe and effective pelvic holding pathway for reduction is necessary for pelvic fracture operations. Existing research on the pelvic holding pathway addresses anatomical position and dimension. Few studies have focused on biomechanical properties or on surgical techniques related to these pathways. This paper studies the three holding pathways that are most commonly used in clinical practice. The most effective force direction for each holding pathway is identified through finite element modeling. Pathway 1 is suitable for internal rotation operation and open/close-book operation of the pelvis; Pathway 2 is suitable for translation of the fractured pelvis toward the sacrum and internal pelvic rotation operations; Pathway 3 is suitable for pulling and lifting of the fractured pelvis against gravity and open/close-book operation of the pelvis. In addition, we find through our simulation that the use of a combined holding strategy can reduce the reduction force during the reduction process. We compared the performances of the 2-pin combined holding strategy (2P-CH) and the 3-pin combined strategy (3P-CH). During translational reduction, 2P-CH and 3P-CH showed little difference in pelvic reduction force. However, in rotational reduction, 3P-CH shows advantages. It has less reduction force and the least combined muscle resistance. It can also maximize the displacement of the iliac crest under the same conditions. The results of this study can be applied to surgical planning and to the development of robot-assisted surgery systems in selecting holding pathways and operation strategies for fractured pelvis. 10.1016/j.compbiomed.2022.106310
Revisiting Non-operative Treatment of Lateral Compression Pelvic Fractures, Analysis of Rehabilitation, and Radiologic Outcomes in a Historical Cohort Using Today's Association of Osteosynthesis (AO) Stability Criteria. Cureus BACKGROUND:Type I lateral compression pelvic fractures (LC-I) have historically been treated conservatively. Inferior outcomes in a distinctive subset of these injuries have been reported, therefore their management has shifted towards surgery. Revisiting the historical series of LC-I allows us to determine whether non-operative management of these unstable patterns results in poorer outcomes. The objective was to evaluate the differences in the rehabilitation progress, fracture consolidation, and displacement in non-operatively treated LC-I fractures that would be considered unstable using today's Association of Osteosynthesis (AO) criteria. METHODS:We conducted a retrospective review of conservatively treated LC-I injuries in a single-level I trauma center between June 2010 and June 2014. Patients were distributed in stable (group A) and unstable (group B) groups according to the 2018 AO classification. Time to walk independently (TWI), time to return to work (TRW), fracture consolidation, and displacement were analyzed. RESULTS:34 patients, mean age of 45.5 ±14.5 years, were included. Mean TWI in groups A and B were 71.2 ±31.9 and 105.9 ±50.9 days (p=0.027). Mean TRW was 106 ±51.3 and 157 ±84 days in groups A and B, respectively (p=0.038). A difference in mean TWI and TRW of 34.7 and 51.3 days between groups was observed. No significant differences in fracture consolidation or displacement were observed. CONCLUSION:Unstable fractures presented significantly longer TWI and TRW. The revised AO classification contributes to the identification of fracture patterns that correlate with prolonged rehabilitation in which additional treatment strategies might be considered. 10.7759/cureus.32101
[Osteosynthesis of geriatric acetabular fractures]. Unfallchirurgie (Heidelberg, Germany) The aim of the treatment of acetabular fractures is principally an anatomical reconstruction of the joint surface to avoid posttraumatic arthritis. The increasing number of geriatric patients with acetabular fractures of the anterior column type resulting from simple falls on the side and substantial patient-related inherited comorbidities, represent particular challenges for the surgical approach and osteosynthesis due to the osteoporotic bone quality. Due to the establishment of minimally invasive lateral pelvic accesses to the acetabulum and the adaptation of the osteosynthesis technique and material to these approaches, it appears that even in very old patients with acetabular fractures mobility can be better and more rapidly restored and sequelae caused by immobility can be prevented. 10.1007/s00113-022-01276-8
Fertility and reproductive outcomes following high-energy pelvic fractures: A systematic review and meta-analysis. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics BACKGROUND:There is a need to decipher the effect of pelvic fractures (PFs) upon female fertility and live birth rate, as data including treatment regimens in large, unselected populations remain scarce. OBJECTIVES:To assess the effect of high energy PFs upon female fertility and live birth rate. SEARCH STRATEGY:Literature search for relevant studies was performed up to March 2022 in five databases: Embase, MEDLINE, CAB Abstracts, ClinicalTrials.gov, and Google Scholar. SELECTION CRITERIA:Retrospective studies assessing live birth, infertility, and dyspareunia rates following PFs. DATA COLLECTION AND ANALYSIS:Data were extracted from studies independently by two authors. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS) for observational studies. MAIN RESULTS:A total of 763 female patients of median age 27.8 years (95% CI 22-38 years) were included with median follow up of 5 years. Among PF patients, infertility hazard ratio (HR) 1.18 (95% CI 0.76-1.84, P = 0.47; I  = 18%) and dyspareunia HR 0.60 (95% CI 0.34-1.08, P = 0.09; I  = 66%), did not significantly differ from the age-matched literature-reported rates among non-PF patients. CONCLUSIONS:No significant differences of live birth, infertility, and dyspareunia rates across patients with PFs were found compared with non-PF counterparts. 10.1002/ijgo.14652
Chronic Pelvic Pain: A Comprehensive Review. Cureus Chronic pelvic pain (CPP) is explained as a complaint of cyclic or non-cyclic pelvic pain lasting for at least six months with or without dysmenorrhea, dyspareunia, dysuria, and dyschezia. The etiology of symptoms can be categorized according to organ system involvement. Gynecological causes typically involve endometriosis-related pain, pelvic congestion syndrome, pelvic inflammatory disease, adenomyosis, hydrosalpinx, etc. Endometriosis-related pain is seldom non-cyclic and may present due to recurrent bleeding in endometriotic implants. Engorgement of veins leads to inadequate venous washout and presents chronic pelvic pain in pelvic congestion syndrome. The pressure effect of benign lesions of the uterus and cervix may lead to cyclic pain, as in uterine fibroids. Often presentation of diseases like hydrosalpinx may not present until it has overdistended or may at times present as acute pelvic pain if it undergoes torsion. Long-standing untreated pelvic inflammatory diseases in sexually active females is another cause of pelvic pain. The complaint of CPP is also shared due to the involvement of the gastrointestinal system in conditions like irritable bowel syndrome, inflammatory bowel diseases, long-standing abdominal hernias, colorectal cancer, etc. Alteration of the gut biome and dysregulated brain-gut associations lead to typical manifestations of chronic lower back pain and pelvic pain in irritable bowel syndrome. Colorectal tumors, when in the advanced stage, may spread to nearby tissues creating fistulas and affecting nearby nerves, causing pelvic, perineal, and sacral pain. Abdominal hernias with small bowel prolapse are always related to pelvic pain symptoms. Infections in the urinary tract like urethral syndrome, chronic prostatitis, and chronic recurrent cystitis present with CPP and voiding problems. Musculoskeletal etiologies, though varying in degrees, are responsible for isolated complaints of CPP. Examples include pelvic girdle pain, levator syndrome, coccygodynia, and pelvic floor prolapse. 10.7759/cureus.30691
Evolution of the AO Spine Sacral and Pelvic Classification System: a systematic review. Journal of neurosurgery. Spine OBJECTIVE:The purpose of this study was to describe the genesis of the AO Spine Sacral and Pelvic Classification System in the context of historical sacral and pelvic grading systems. METHODS:A systematic search of MEDLINE, EMBASE, Google Scholar, and Cochrane databases was performed consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all existing sacral and pelvic fracture classification systems. RESULTS:A total of 49 articles were included in this review, comprising 23 pelvic classification systems and 17 sacral grading schemes. The AO Spine Sacral and Pelvic Classification System represents both the evolutionary product of these historical systems and a reinvention of classic concepts in 5 ways. First, the classification introduces fracture types in a graduated order of biomechanical stability while also taking into consideration the neurological status of patients. Second, the traditional belief that Denis central zone III fractures have the highest rate of neurological deficit is not supported because this subgroup often includes a broad spectrum of injuries ranging from a benign sagittally oriented undisplaced fracture to an unstable "U-type" fracture. Third, the 1990 Isler lumbosacral system is adopted in its original format to divide injuries based on their likelihood of affecting posterior pelvic or spinopelvic stability. Fourth, new discrete fracture subtypes are introduced and the importance of bilateral injuries is acknowledged. Last, this is the first integrated sacral and pelvic classification to date. CONCLUSIONS:The AO Spine Sacral and Pelvic Classification is a universally applicable system that redefines and reorders historical fracture morphologies into a rational hierarchy. This is the first classification to simultaneously address the biomechanical stability of the posterior pelvic complex and spinopelvic stability, while also taking into consideration neurological status. Further high-quality controlled trials are required prior to the inclusion of this novel classification within a validated scoring system to guide the management of sacral and pelvic injuries. 10.3171/2022.5.SPINE211468
Three-Dimensional Printing Model Enhances Correct Identification and Understanding of Pelvic Fracture in Medical Students. Journal of surgical education OBJECTIVE:Understanding the anatomy behind a pelvic fracture can be a significant challenge to medical students. Recent advances in three-dimensional printing technology offers a novel approach to facilitate the learning of complex fracture. We have described here how the 3-dimension printing (3Dp) models can help medical students improve their understanding in and identification of pelvic fractures. DESIGN:One hundred students were randomized into 2 teaching module groups (with or without 3Dp models). Prior to randomization assignment, a 50-minute didactic lecture covering elementary knowledge of anatomy, Young-Burgess classification, and traumatic mechanism of pelvic fracture was delivered to all students. The 3Dp group received X-rays, CT images, and 3Dp models of the eight pelvic fractures during presentation, while the students in the control group only obtained X-rays and CT scans of the same 8 pelvic fractures. Young-Burgess classification system and injury mechanism of pelvic fracture, time for evaluation, and subjective questions were conducted to assess the learning outcomes. SETTING:A medical student program based in a LevelⅠtrauma center PARTICIPANTS: One hundred students in their 4th year of a 5-year clinical medicine program (for a medical bachelor degree) RESULTS: Students receiving 3Dp model had a higher rate of identifying the correct pelvic fracture via Young-Burgess identification compared to these without 3Dp model. Moreover, the accuracy of identifying the injury mechanism was significantly higher in the 3Dp group than that in group without 3Dp model. Participant in 3Dp group had faster assessment time compared to the control group. Subjective survey results suggested that 3Dp model would increase the learning interest and enhance the understanding of pelvic fracture. In addition, majority of students (83%) reported that they would like to use 3Dp model in other surgical course education. CONCLUSIONS:3Dp model increased the perceived accuracy of pelvic fracture identification and understanding of injury mechanism. Moreover, 3Dp model promoted the subjective interest and motivation of students in pelvic fracture learning. Therefore, 3Dp model can be considered as a valuable educational tool for learning pelvic fracture in medical students. 10.1016/j.jsurg.2022.10.016
Pelvic Ring and Peritrochanteric Fractures in a Patient with Osteogenesis Imperfecta Treated Surgically: Case Report with a 5-Year Follow-Up. The American journal of case reports BACKGROUND Osteogensis imperfecta (OI) is a rare disorder associated with brittle bones, skeletal deformities, short stature, and conductive hearing loss. It is caused by mutations in genes encoding collagen type I production and is associated with multiple fractures occurring during a patient's lifetime. Atypical fractures can occur without a history of previous injury or diagnosis. CASE REPORT A 52-year old man sustained a fall from his own height. He experienced pelvic pain but could bear weight. He was referred to the hospital by his primary care physician and was admitted to the Orthopedic Department with a pelvic ring fracture. We performed open reduction and internal fixation with a reconstruction plate via an intrapelvic approach. At 12 weeks after discharge, he sustained a peritrochanteric fracture. It was surgically treated with a dynamic hip screw. The patient commenced weight-bearing 20 weeks after the initial procedure. Bone union was achieved clinically and radiographically. He did not have any revision procedures. At the time of this report, 5 years after the described period, he felt no discomfort around the hips, sacroiliac joints, and pubic symphysis. CONCLUSIONS OI poses a difficult treatment challenge, but, achieving a good clinical and functional result is possible with a precise surgical technique and meticulous preoperative planning. Clinicians should always consider the possibility of a simultaneous fracture occurrence in different parts of the body. Some patients present without a previous diagnosis, and we should always have some suspicion of OI in cases of young patients presenting with low-energy fractures. 10.12659/AJCR.938414
Modified percutaneous iliosacral screw and anterior internal fixator technique for treating unstable pelvic fractures: a retrospective study. BMC musculoskeletal disorders BACKGROUND:The commonly used technique for treating unstable pelvic fractures with sacroiliac screws and anterior internal fixator (INFIX) is prone to complications, such as injury to the pelvic vasculature and nerves, life-threatening bleeding, lateral femoral cutaneous neuritis, and wound infection. This study investigated the clinical effects of using a modified percutaneous iliosacral screw and INFIX technique for treating unstable pelvic fractures. METHODS:A retrospective analysis of minimally invasive internal fixation using modified incision of an anterior-ring INFIX application combined with modified percutaneous iliosacral screw placement was performed for 22 cases of unstable pelvic fractures from January 2017 to December 2018. Based on the Tile classification, there were 4 type B1, 7 type B2, 5 type B3 and 6 type C1 injuries. Preoperatively, the length and orientation of the internal fixation were computer-simulated and measured. On postoperative day 3, pelvic radiographs and three-dimensional computed tomograms were used to assess fracture reduction and fixation. All patients were regularly followed up at 4 weeks, 12 weeks, 6 months, 12 months, 24 months and annually thereafter. Fracture healing, complications, visual analogue scale (VAS) scores, the quality of fracture repositioning and Majeed score were assessed during follow-up. RESULTS:All patients were followed up for a mean of 25.23 ± 1.48 months. All fractures healed without loss of reduction and no patient showed evidence of delayed union or nonunion. Two years postoperatively, the mean VAS score was 0.32 ± 0.09 and the mean Majeed score was 94.32 ± 1.86. CONCLUSION:The modified percutaneous iliosacral screw technique increases the anterior tilt of the sacroiliac screw by shifting the entry point posteriorly to increase the safety of the screw placement. Downward modification of the INFIX incision reduces the risk of lateral femoral cutaneous nerve injury. This technique is safe, effective and well tolerated by patients. 10.1186/s12891-022-06036-8
Fix and replace: Simultaneous fracture fixation and hip replacement for acetabular fractures in older patients. Injury INTRODUCTION:Displaced acetabular fractures in the elderly present significant treatment challenges. The 'fix and replace' concept involves open reduction and internal fixation of the acetabulum, providing bony stability to accept the press-fit of an acetabular cup, with a cemented femoral stem. This allows early mobilisation and the advantages this confers. This study of 57 patients treated with fix and replace describes our technique, outcomes, and survival analysis. METHODS:A retrospective review of 57 'fix and replace' procedures in patients aged over 60 was performed. Data was collected on mechanism, fracture type, demographics, time to surgery, comorbidity index, complications, EQ-5D and Oxford hip scores (OHS). Radiographs were reviewed for fracture healing, implant loosening, cup migration, and heterotopic ossification. RESULTS:57 patients aged 60 to 95 had fix and replace surgery. The median ASA score was 3. The mean Charlson Index was 4.8. 45 patients had a low-energy fall, 6 had a road traffic accident, 3 fell off a bicycle, and 1 mechanism was unclear. The fracture patterns were anterior column posterior hemitransverse (67%), associated both columns (9%), posterior column (9%), posterior column and posterior wall (9%), and transverse (2%). The mean time to surgery was 8.4 days (0-14). 26 out of 57 (46%) received a blood transfusion. Mean length of stay was 17.6 days (7-86). The mean follow-up was 35.5 months. 4 dislocations were treated with closed reduction, whilst 1 required excision arthroplasty. 2 infections resolved with debridement, antibiotics, and implant retention (DAIR), whilst 1 required a two-stage revision. 1 acetabular component had migrated requiring revision. The median pre-injury OHS was 44 (26-48) compared to 37.3 (28-48) at 1 year. There were no deaths at 30-days, whilst at 1 year 7 patients had died. Kaplan Meier survival analysis showed mean survival was 1984.5 days. Implant survival was 90% at 1 year. CONCLUSION:While fix and replace is conceptually attractive, this medically complex patient group requires considerable support peri‑ and post-operatively. Further studies are required to provide clinicians with more information to decide on how best to provide a holistic management strategy for such injuries in this frail patient cohort. 10.1016/j.injury.2022.09.024
How Safe is Antegrade Femoral Nailing in Ipsilateral Acetabulum Fractures Requiring Kocher-Langenbeck Approach? An Analysis of 23 Fractures. Indian journal of orthopaedics Objective:The ipsilateral acetabulum and femur fracture (IAFF) is an uncommon entity. This combination challenges the surgeon in the optimal management of each injury component, fixation sequence, surgical approaches, implant choices and complications. Inappropriate approach for one fracture may affect the fixation of another or modify the overall outcome. In this perspective, we aim to analyze our results in patients who underwent acetabulum fixation with Kocher-Langenbeck (K-L) approach and antegrade femur nailing (AFN), emphasizing the incidence of infection, skin necrosis and heterotopic ossification (HO). Methods:During the five years, 22 patients with 23 IAFF (mean age of 36.5 years) were treated operatively. All the patients underwent K-L approach for acetabulum fixation and AFN for femur fracture. All the patients were treated under the supervision of a pelvi-acetabular trauma consultant. Demographic data, injury, surgical, and postoperative details were collected. The quality of acetabular reduction was evaluated using Matta's criteria. The radiological outcome, obtained at final follow-up, was graded according to Matta's criteria. Functional outcome was evaluated by Merle d'Aubigné and Postel system. HO was graded according to the Brooker system. Complications recorded were DVT, skin necrosis, infection, arthritis, HO, AVN and need for additional surgery. Results:Out of 23, 11 had posterior dislocation, 6 had quadrilateral plate injury with central protrusion and six without dislocation. Femur fractures include 9-midshaft, 4-proximal third, 3-distal third, 3-trochanteric fractures and 4-segmental fractures. There were 11 elementary and 12 associated acetabulum fractures. 21 fractures underwent staged-fixation. Single-stage fixation was done in 2. In all cases treated with staged-fixation, AFN was done first. The mean duration of follow-up was 28 months (16-57). All femur fractures united with a mean union time of 21.3 weeks (11-37). The radiological outcome was excellent in 13, good in 4, fair in 3 and poor in 3. The functional outcome was excellent in 3, good in 11, fair in 4 and poor in 4 patients. None had skin necrosis. Three patients had infection. 14 (60.8%) hips had HO, with clinically significant HO (grade 4) in 2(8.6%). Six (26%) patients had arthritic changes. Four (17.3%) hips had avascular necrosis. Conclusion:AFN is a viable option in IAFFs requiring a K-L approach under the supervision of a pelvi-acetabular surgeon. This combined approach per se does not demonstrate an increased risk of infection, wound healing problems or HO. Graphical abstract: Supplementary Information:The online version contains supplementary material available at 10.1007/s43465-021-00544-w. 10.1007/s43465-021-00544-w
Emergency Department Stress Radiographs of Lateral Compression Type-1 Pelvic Ring Injuries Are Safe, Effective, and Reliable. The Journal of bone and joint surgery. American volume BACKGROUND:Occult instability of lateral compression type-1 (LC1) pelvic ring injuries may be determined with a fluoroscopic stress examination under anesthesia (EUA) performed in the operating room. We hypothesized that LC1 injuries, similar to some fractures of the extremities, could be radiographically stressed for stability in the emergency department (ED). Our primary objective was to determine if stress examination of LC1 fractures could be safely and accurately performed in the ED and could be tolerated by patients. METHODS:A prospective, consecutive series of 70 patients with minimally displaced LC1 pelvic injuries (<10-mm displacement on presentation) underwent stress examinations performed by the on-call orthopaedic resident in the ED radiology suite. The stress examination series included static 40° inlet, internal rotation stress inlet, and external rotation stress inlet views. Pelvic fractures that had positive stress results (≥10 mm of overlap of the rami) were indicated for a surgical procedure. These fractures also underwent EUA in order for the 2 techniques to be compared. RESULTS:All patients tolerated the ED stress examination without general anesthetic or hemodynamic instability. Fifty-seven patients (81%) had negative stress results and were allowed to bear weight. All patients with negative stress results who had 3-month follow-up went on to radiographic union without substantial displacement. For the patients with a positive stress result in the ED, the mean displacement was 15.15 mm (95% confidence interval [CI], 10.8 to 19.4 mm) for the ED stress test and 15.60 mm (95% CI, 11.7 to 19.4 mm) for the EUA (p = 0.86). Two patients with a negative ED stress test did not mobilize during their hospitalization and underwent EUA and conversion to a surgical procedure. Thus, a total of 11 patients underwent both stress testing in the ED and EUA; no patient had a positive result on one test but a negative result on the other. CONCLUSIONS:ED stress examination of LC1 injuries is a safe and reliable method to determine pelvic ring stability. The displacement measured in the ED stress examination is similar to the displacement measured under general anesthesia. Furthermore, a negative ED stress examination predicts successful nonoperative treatment. Given the results of this study, we encourage the use of stress examination in the ED for LC1-type injuries involving complete sacral fractures only. Widescale adoption of this streamlined protocol may substantially diminish cost, anesthetic risk, and potential operations for patients. LEVEL OF EVIDENCE:Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence. 10.2106/JBJS.21.00737
Advantages of three-dimensional printing in the management of acetabular fracture fixed by the Kocher-Langenbeck approach: randomised controlled trial. International orthopaedics PURPOSE:To compare the outcomes of the Kocher-Langenbeck reduction and fixation of the posterior structures of the acetabulum between 3D printing technique and conventional technique. METHODS:Forty-three patients who sustained fractures of the posterior part of the acetabulum were randomly assigned to two groups: 3D printing (G1; n = 20) and conventional technique (G2; n = 23). The surgical time, intra-operative blood loss, differences between pre-and post-operative haemoglobin, universal functional and radiographic scores, and complications were compared between the groups. The minimum follow-up was 18 months. RESULTS:The average operating time (120.75 min) and intra-operative blood loss (244 ml) were lower in G1 than in G2 (125.87 min and 268.7 ml, respectively; p = 0.42, p = 0.1, respectively). The difference between the pre- and post-operative haemoglobin was 1.71 g/dl in G1 and 1.93 g/dl in G2 (p = 0.113). Post-operative complications occurred more frequently in patients in G2 (34.7%) than in patients in G1 (15%), though these differences were also not significant (p = 0.6). The radiographic result was satisfactory in 16 patients (80%) in G1 and 18 patients (78.26%) in G2 (p = 0.5). The clinical result was satisfactory in 15 patients (75%) in G1 and in 17 patients (73.9%) in G2 (p = 0.6). CONCLUSIONS:No significant differences were found in terms of surgical time, overall complications, and radiographic or functional outcomes between 3D printing and the conventional technique. 10.1007/s00264-022-05319-y
Comparison between external fixation and pelvic binder in patients with pelvic fracture and haemodynamic instability who underwent various haemostatic procedures. Scientific reports Haemostatic procedures such as preperitoneal pelvic packing (PPP), pelvic angiography (PA), and internal iliac artery ligation are used for haemorrhage control in pelvic fracture patients with haemodynamic instability. Pelvic external fixation (PEF) and pelvic binder (PB) are usually applied with haemostatic procedures to reduce the pelvic volume. This study aimed to compare the clinical outcomes between patients who underwent PEF and PB. Among 173 patients with pelvic fracture admitted to the emergency room of three regional trauma centres between January 2015 and December 2018, the electronic charts of haemodynamically unstable patients were retrospectively analysed. Among the 84 patients included in the analysis, 20 underwent PEF with or without PB, and 64 underwent only PB. There were significant differences in tile classification and laparotomy between the PEF and PB groups (p = 0.023 and p = 0.032). PPP tended to be more frequently preformed in the PEF group (p = 0.054), whereas PA tended to be more commonly performed in the PB group than in the PEF group (p = 0.054). After propensity score matching to adjust for differences in patient characteristics and adjunct haemostatic procedure, there was no significant difference in 7-day, 30-day, and overall mortality rates between the PEF and PB groups (10.5% vs 21.1%, p = 0.660, 21.1% vs 26.3%, p = 1.000, and 26.3% vs 26.3%, p = 1.000). Cox proportional hazard regression analysis and multivariate analysis for correction of covariates (age, lactate, and abdominal injury) showed that PEF was not an independent factor for 30-day mortality compared with PB (adjusted hazard ratio, 0.526; 95% confidence interval, 0.092-3.002; p = 0.469). Among the volume reduction procedures performed with other haemostatic procedures in patients with pelvic fracture and haemodynamic instability, PEF did not significantly reduce the 30-day mortality rate compared to PB. 10.1038/s41598-022-07694-3
Implant and patient survival rates using Exeter Trauma Stem hemiarthroplasty in fracture neck of femur patients: The largest study to date. Injury INTRODUCTION:Exeter Trauma Stems (ETS) femoral hemiarthroplasties are based on Exeter THR stems with a few design changes. Little has been published on ETS survival rates to justify their high cost compared to other cheaper implants. This is the largest prospective study to assess ETS implant failure-free survival rates in fracture neck of femur patients (NOF). This non-developing-centre study examined whether these design differences have altered implant survival (compared with Exeter THR's published survival data). METHODS:Data were prospectively collected by independent audit officers. Dislocation, periprosthetic fracture, re-admission with severe hip pain, deep infection and revision surgery were considered events of interest in implant failure-free survival. RESULTS:This study assessed 1,123 ETS stems (36 patients received bilateral ETS) in NOF patients. The mean patient age at the time of operation was 83 years (range; 49 - 102 years). The mean observation period was 2.5 years (range; 0 days - 8 years). Only 29 implants failed. All failure events were reported within the first year. Stem failure-free survival was 97.2% at eight years (CI 95.9% - 98%). Dislocation occurred in 10 patients (1%), periprosthetic femoral fracture in 4 (0.4%), and deep infection in 11 patients (1.2%). Patient survival rates were 75% and 48% at one and five years respectively. CONCLUSION:ETS has high implant failure-free survival rates when used in hip fractures. ETS design changes have not altered ETS survival when used in hip fractures compared with the published literature of Exeter THR stem when used as a treatment for OA. Exeter Trauma Stems in NOF patients might last these elderly patients their entire short lifetime. 10.1016/j.injury.2022.03.019
To Summarize and Analyze the Epidemiological Characteristics and Prognostic Risk Factors of Patients with Pelvic Fracture Complicated with Perineal Injury. Journal of healthcare engineering This study is aimed at summarizing and analyzing the epidemiological characteristics and prognostic risk factors of patients with a pelvic fracture with perineal injury. The clinical data of 153 patients with pelvic fracture with perineal injury treated in our hospital from January 2012 to June 2021 were analyzed retrospectively. The data of sex, age, injury mechanism, pelvic fracture type, shock index (SI), perineal wound depth, concomitant injury, total hospital stay, and death were collected by the electronic medical record system. Among the 153 patients, there were 94 males and 59 females, with an average age of (43.2 ± 16.8) years. The cases were mainly concentrated into two age groups: 20-29 years old and 50-59 years old. In a year, pelvic fractures were mainly concentrated in 1-2 months and 11-12 months. In terms of injury time, there were mainly two periods of time in a day: 10 : 00~12 : 00 and 15 : 00~18 : 00. The MOTS-RTS scores of the patients in the undead group and the dead group were (7.12 ± 1.52), (2.69 ± 0.96), ISS scores were (27.36 ± 15.84), (61.32 ± 7.08), GCS scores were (12.84 ± 3.69), (4.13 ± 1.25), APACH II scores were (12.87 ± 8.84), (32.41 ± 6.98), and SOFA scores were (6.68 ± 5.87), (17.12 ± 3.12). The MOTS-RTS and GCS scores of the nondeath group were significantly higher, while the ISS score, APACH II score, SOFA score, and shock index were significantly lower. The overall mortality rate of 153 patients was 13.7%. The average area of perineal trauma in undead and dead patients was (54.5 ± 113.52) cm and (262.63 ± 300.84) cm, respectively. The average depth of perineal trauma was (9.63 ± 7.22) cm and (16.23 ± 10.13) cm, respectively. The larger the area of perineal injury and the deeper the depth of perineal trauma, the worse their prognosis. Cox multivariate analysis showed that complications, MOTS-RTS score, ISS score, GCS score, perineal trauma area, and perineal trauma depth were independent risk factors affecting the prognosis of patients with pelvic fracture with perineal injury. Most of the patients with pelvic fracture complicated with perineal injury are 20-29 years old and 50-59 years old. The more serious the perineal injury is, the higher the mortality is. The main causes of death are refractory hemorrhagic shock and infection. 10.1155/2022/4831330
Design and evaluation of an intelligent reduction robot system for the minimally invasive reduction in pelvic fractures. Zhao Chunpeng,Wang Yu,Wu Xinbao,Zhu Gang,Shi Shuchang Journal of orthopaedic surgery and research INTRODUCTION:Pelvic fracture is a severe high-energy injury with the highest disability and mortality of all fractures. Traditional open surgery is associated with extensive soft tissue damages and many complications. Minimally invasive surgery potentially mitigates the risks of open surgical procedures and is becoming a new standard for pelvic fracture treatment. The accurate reduction has been recognized as the cornerstone of minimally invasive surgery for pelvic fracture. At present, the closed reduction in pelvic fractures is limited by the current sub-optimal 2D intra-operative imaging (fluoroscopy) and by the high forces of soft tissue involved in the fragment manipulation, which might result in fracture malreduction. To overcome these shortcomings and facilitate pelvic fracture reduction, we developed an intelligent robot-assisted fracture reduction (RAFR) system for pelvic fracture. METHODS:The presented method is divided into three parts. The first part is the preparation of 20 pelvic fracture models. In the second part, we offer an automatic reduction algorithm of our robotic reduction system, including Intraoperative real-time 3D navigation, reduction path planning, control and fixation, and robotic-assisted fracture reduction. In the third part, image registration accuracy and fracture reduction accuracy were calculated and analyzed. RESULTS:All 20 pelvic fracture bone models were reduced by the RAFR system; the mean registration error E1 of the 20 models was 1.29 ± 0.57 mm. The mean reduction error E2 of the 20 models was 2.72 ± 0.82 mm. The global error analysis of registration and reduction results showed that higher errors are mainly located at the edge of the pelvis, such as the iliac wing. CONCLUSION:The accuracy of image registration error and fracture reduction error in our study was excellent, which could reach the requirements of the clinical environment. Our study demonstrated the precision and effectiveness of our RAFR system and its applicability and usability in clinical practice, thus paving the way toward robot minimally invasive pelvic fracture surgeries. 10.1186/s13018-022-03089-2
Pain management in emergency department older adults with pelvic fracture: still insufficient. CJEM 10.1007/s43678-022-00299-9
Computer-aided automatic planning and biomechanical analysis of a novel arc screw for pelvic fracture internal fixation. Computer methods and programs in biomedicine BACKGROUND AND OBJECTIVE:The sacroiliac joint screw is a common fixation method for pelvic posterior ring fractures. The complex anatomical structure around the pelvis makes it impossible to find a suitable fixed path, which increases the difficulty of surgical operation. In this paper, we propose an automatic planning algorithm based on a computer-aided internal arc fixation channel for pelvic fractures for the first time. METHODS:A channel generation algorithm based on seed derived points was designed, and the optimal channel was selected by scoring rules based on 3D erode algorithm for the generated channel. The biomechanical properties of the internal arc fixation screw and traditional internal straight fixation screw in three postures were compared using biomechanical finite element analysis. RESULTS:The proposed algorithm verified the existence of a more adaptable internal arc fixation channel and can quantitatively plan a relatively optimal constant-curvature internal arc fixation channel in pelvises of ten adults. Significantly high stresses concentrated around the interaction region between the screws and bone may increase the risk of bone fractures and screw loosening in the long term. The experimental results show that the internal arc fixation screw has better strain and deformation performance than the internal straight fixation screw. CONCLUSIONS:A novel arc internal fixation method for pelvic fractures was proposed to improve the safety and stability of screw fixation of pelvic fracture. The nonparametric test proved that the sacroiliac dislocation model repaired by internal arc fixation screw was significantly different from that repaired by internal straight fixation screw. The computer-aided automatic planning algorithm provides the possibility of robot-assisted pelvic fracture fixation. 10.1016/j.cmpb.2022.106810