Biomechanical Comparison of Five Fixation Techniques for Unstable Fragility Fractures of the Pelvic Ring

Background: Incidence of pelvic ring fractures has increased over the past four decades, especially after low-impact trauma—classified as fragility fractures of the pelvis (FFP). To date, there is a lack of biomechanical evidence for the superiority of one existing fixation techniques over another. An FFP type IIc was simulated in 50 artificial pelvises, assigned to 5 study groups: Sacroiliac (SI) screw, SI screw plus supra-acetabular external fixator, SI screw plus plate, SI screw plus retrograde transpubic screw, or S1/S2 ala–ilium screws. The specimens were tested under progressively increasing cyclic loading. Axial stiffness and cycles to failure were analysed. Displacement at the fracture sites was evaluated, having been continuously captured via motion tracking. Results: Fixation with SI screw plus plate and SI screw plus retrograde transpubic screw led to higher stability than the other tested techniques. The S1/S2 ala–ilium screws were more stable than the SI screw or the SI screw plus external fixator. Conclusions: In cases with displaced fractures, open reduction and plate fixation provides the highest stability, whereas in cases where minimally invasive techniques are applicable, a retrograde transpubic screw or S1/S2 ala–ilium screws can be considered as successful alternative treatment options.

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Plate fixation of the anterior pelvic ring in patients with fragility fractures of the pelvis

European Journal of Trauma and Emergency Surgery ◽

10.1007/s00068-021-01625-z ◽

2021 ◽

Author(s):

Michiel Herteleer ◽

Mehdi Boudissa ◽

Alexander Hofmann ◽

Daniel Wagner ◽

Pol Maria Rommens

Keyword(s):

Pelvic Ring ◽

Plate Osteosynthesis ◽

Plate Fixation ◽

Weight Bearing ◽

Fragility Fractures ◽

Pubic Symphysis ◽

Osteoporotic Bone ◽

Screw Loosening ◽

Posterior Pelvic Ring ◽

Pelvic Brim

Abstract Introduction In fragility fractures of the pelvis (FFP), fractures of the posterior pelvic ring are nearly always combined with fractures of the anterior pelvic ring. When a surgical stabilization of the posterior pelvis is performed, a stabilization of the anterior pelvis is recommended as well. In this study, we aim at finding out whether conventional plate osteosynthesis is a valid option in patients with osteoporotic bone. Materials and methods We retrospectively reviewed medical charts and radiographs of all patients with a FFP, who underwent a plate osteosynthesis of the anterior pelvic ring between 2009 and 2019. Patient demographics, fracture characteristics, properties of the osteosynthesis, complications and revision surgeries were documented. Single plate osteosynthesis (SPO) at the pelvic brim was compared with double plate osteosynthesis (DPO) with one plate at the pelvic brim and one plate anteriorly. We hypothesized that the number and severity of screw loosening (SL) or plate breakage in DPO are lower than in SPO. Results 48 patients with a mean age of 76.8 years were reviewed. In 37 cases, SPO was performed, in 11 cases DPO. Eight out of 11 DPO were performed in patients with FFP type III or FFP type IV. We performed significantly more DPO when the instability was located at the level of the pubic symphysis (p = 0.025). More patients with a chronic FFP (surgery more than one month after diagnosis) were treated with DPO (p = 0.07). Infra-acetabular screws were more often inserted in DPO (p = 0.056). Screw loosening (SL) was seen in the superior plate in 45% of patients. There was no SL in the anterior plate. There was SL in 19 of 37 patients with SPO and in 3 of 11 patients with DPO (p = 0.16). SL was localized near to the pubic symphysis in 19 of 22 patients after SPO and in all three patients after DPO. There was no SL in DPO within the first month postoperatively. We performed revision osteosynthesis in six patients (6/48), all belonged to the SPO group (6/37). The presence of a bone defect, unilateral or bilateral anterior pelvic ring fracture, post-operative weight-bearing restrictions, osteosynthesis of the posterior pelvic ring, and the presence of infra- or supra-acetabular screws did not significantly influence screw loosening in SPO or DPO. Conclusion There is a high rate of SL in plate fixation of the anterior pelvic ring in FFP. In the vast majority, SL is located near to the pubic symphysis. DPO is associated with a lower rate of SL, less severe SL and a later onset of SL. Revision surgery is less likely in DPO. In FFP, we recommend DPO instead of SPO for fixation of fractures of the anterior pelvic ring, which are located in or near to the pubic symphysis.

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Insufficiency Fractures vs. Low-Energy Pelvic Ring Fractures – Epidemiological, Diagnostic and Therapeutic Characteristics of Fragility Fractures of the Pelvic Ring

Zeitschrift für Orthopädie und Unfallchirurgie ◽

10.1055/a-1394-6502 ◽

2021 ◽

Author(s):

Manuel Sterneder ◽

Patricia Lang ◽

Hans-Joachim Riesner ◽

Carsten Hackenbroch ◽

Benedikt Friemert ◽

...

Keyword(s):

Pelvic Ring ◽

Diagnostic Testing ◽

Insufficiency Fracture ◽

Fragility Fractures ◽

Relative Increase ◽

Trauma Centre ◽

Low Energy ◽

Insufficiency Fractures ◽

Type Iv ◽

Pelvic Ring Fractures

Abstract Background Fragility fractures of the pelvis (FFP) encompass two fracture entities: fracture after low-energy trauma and insufficiency fracture without trauma. It is unclear whether the two subgroups differ in terms of diagnosis and therapy. The aim of this retrospective study was to evaluate insufficiency fractures with regard to defined parameters and to compare specific parameters with the fractures after low-energy trauma. Patients and Methods In the period from 2008 to 2017, 203 patients with FFP were recorded at our clinic (Level 1 Trauma Centre DGU, SAV approval). Of these, 25 had an insufficiency fracture and 178 had a pelvic ring fracture after low-energy trauma. Epidemiological, diagnostic and therapeutic parameters were examined. Results There was a relative increase in the insufficiency fracture within the FFP (2008 – 2009: 5.0% vs. 2015 – 2017: 17.8%). In these patients, osteoporosis tended to be more pronounced than in patients after low-energy trauma (t-value: − 3.66 vs. − 3.13). The diagnosis of insufficiency fractures showed increased use of MRI and DECT (60.9% vs. 26.0%) and a high proportion of type IV fractures after FFP (40.0% vs. 7.9%). In terms of therapy, surgical treatment of the insufficiency fracture was sought more often (68,2% vs. 52,1%), with a tendency towards increased use of combined osteosynthesis procedures (14.3% vs. 7.6%). Conclusion We were able to show that as the number of cases increases, the insufficiency fracture becomes more important within FFP. If these patients tend to have more pronounced osteoporosis, particular attention should be paid to the diagnosis and adequate therapy of the osteoporosis, especially in the case of an insufficiency fracture. In addition to the increased diagnostic testing using MRI and DECT to detect oedema and the increased surgical therapy for this type of fracture, it is also noteworthy that the insufficiency fracture can cause higher-grade fractures after FFP.

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Conventional plate fixation versus minimally invasive modified pedicle screw-rod fixation for anterior pelvic ring fractures

PLoS ONE ◽

10.1371/journal.pone.0215233 ◽

2019 ◽

Vol 14 (4) ◽

pp. e0215233

Author(s):

Yao-Tung Tsai ◽

Chun-Liang Hsu ◽

Chun-Chi Hung ◽

Yu-Ching Chou ◽

Chia-Chun Wu ◽

...

Keyword(s):

Minimally Invasive ◽

Pedicle Screw ◽

Pelvic Ring ◽

Plate Fixation ◽

Pelvic Ring Fractures ◽

Conventional Plate

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‘Within Ring’ Concept Treatment for Displaced H-Shaped Type IVb Fragility Fractures of the Pelvis

Case Reports in Orthopedics ◽

10.1155/2021/6864910 ◽

2021 ◽

Vol 2021 ◽

pp. 1-5

Author(s):

Yohei Yanagisawa ◽

Yusuke Eda ◽

Shotaro Teruya ◽

Hisanori Gamada ◽

Masashi Yamazaki

Keyword(s):

Pelvic Ring ◽

Pedicle Screws ◽

Fragility Fractures ◽

Clinical Results ◽

High Energy ◽

Fixation Method ◽

Case Presentation ◽

Pelvic Fixation ◽

Pelvic Ring Fractures ◽

Sacroiliac Rod Fixation

Introduction. Sacroiliac rod fixation (SIRF) preserves the mobility of L5/S1 (lumber in the pelvis), as a surgical procedure for high-energy pelvic ring fractures. The concept of SIRF method without pedicle screws into L4 and L5 is called ‘within ring’ concept. Case Presentation. We report here the clinical results of ‘within ring’ concept treatment with sacroiliac rod fixation for a case of displaced H-shaped Rommens and Hofmann classification type IVb fragility fractures of the pelvis (FFP), which A 79-year-old woman had been difficult to walk due to pain that had been prolonged for more than one month since her injury. The patient was successfully treated with SIRF, no pain waking with a walking stick and returned to most social activities including living independently within 6 months of the operation. Conclusion. SIRF is useful because it can preserve the mobility in the lumbar pelvis; not including the lumbar spine in the fixation range like spino pelvic fixation is a simple, safe, and low-invasive internal fixation method for displaced H-shaped type IVb fragility fractures of the pelvis.

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Fragility Fractures of the Pelvic Ring – Does the Evidence of Oedema Lead us to More Surgeries?

Zeitschrift für Orthopädie und Unfallchirurgie ◽

10.1055/a-1192-7583 ◽

2020 ◽

Author(s):

Patricia Lang ◽

Manuel Sterneder ◽

Hans-Joachim Riesner ◽

Carsten Hackenbroch ◽

Benedikt Friemert ◽

...

Keyword(s):

Pelvic Ring ◽

Fragility Fractures ◽

Diagnostic Procedures ◽

Fracture Morphology ◽

Therapy Regimen ◽

Therapeutic Consequences ◽

Pelvic Ring Fractures ◽

Clear Change ◽

Choice Of Therapy

Abstract Introduction The choice of therapy for fragility fractures of the pelvis (FFP) is largely determined by the diagnosed fracture morphology. It is now unclear whether the change in diagnostic options – sensitive detection of fracture oedema in the sacrum using MRI and dual-energy computed tomography (DECT) – has an impact on the therapeutic consequences. The aim of this retrospective study was therefore to evaluate the change in the diagnostics used and the resulting therapy regimen in our patient population. Materials and Methods We performed a monocentric-retrospective analysis of 196 patients with a fragility fracture of the pelvis in our clinic (national TraumaZentrum® DGU and SAV approval) in the period from 2008 to 2017. We examined changes in epidemiology, diagnostics/classification and therapy of the pelvic ring fractures treated by us. Results The diagnostic procedures used are subject to a clear change towards oedema detection using MRI and DECT. The graduation has changed towards more severe forms of fracture after FFP. There is now also an increasing proportion of patients treated by surgery (2008 – 2009: 5.3% vs. 2015 – 2017: 60.3%). Conclusion We were able to show that the introduction of sensitive diagnostic procedures coincided with a higher classification of the fractures. It is also noteworthy that the increase in operations is not only due to a higher degree of classification; also in relative terms, more patients are operated on within type FFP II.

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A retrospective study about functional outcome and quality of life after surgical fixation of insufficiency pelvic ring injuries

BMC Musculoskeletal Disorders ◽

10.1186/s12891-021-04925-y ◽

2021 ◽

Vol 22 (1) ◽

Author(s):

Katharina Jäckle ◽

Marc-Pascal Meier ◽

Mark-Tilmann Seitz ◽

Sebastian Höller ◽

Christopher Spering ◽

...

Keyword(s):

Quality Of Life ◽

Surgical Treatment ◽

Functional Outcome ◽

Pelvic Ring ◽

Fragility Fractures ◽

Well Being ◽

Posterior Pelvic Ring ◽

Pelvic Ring Fractures ◽

Sf 36

Abstract Background Fragility fractures without significant trauma of the pelvic ring in older patients were often treated conservatively. An alternative treatment is surgery involving percutaneous screw fixation to stabilize the posterior pelvic ring. This surgical treatment enables patients to be mobilized quickly and complications associated with bedrest and temporary immobility are reduced. However, the functional outcome following surgery and quality of life of the patients have not yet been investigated. Here, we present a comprehensive study addressing the long-term well-being and the quality of life of patients with fragility pelvic ring fractures after surgical treatment. Methods Between 2011–2019, 215 geriatric patients with pelvic ring fractures were surgically treated at the university hospital in Göttingen (Germany). Of these, 94 patients had fragility fractures for which complete sets of computer tomography (CT) and radiological images were available. Fractures were classified according to Tile and according to the FFP classification of Rommens and Hofmann. The functional outcome of surgical treatment was evaluated using the Majeed pelvic score and the Short Form Health Survey-36 (SF-36). Results Thirty five tile type C and 48 type B classified patients were included in the study. After surgery eighty-three patients scored in average 85.92 points (± 23.39) of a maximum of 100 points using the Majeed score questionnaire and a mean of 1.60 points on the numerical rating scale ranging between 0 and 10 points where 0 points refers to “no pain” and 10 means “strongest pain”. Also, the SF-36 survey shows that surgical treatment positively effects patients with respect to their general health status and by restoring vitality, reducing bodily pain and an increase of their general mental health. Conclusions Patients who received a percutaneous screw fixation of fragility fractures of the posterior pelvic ring reported an overall positive outcome concerning their long-term well-being. In particular, older patients appear to benefit from surgical treatment. Trial registration Functional outcome and quality of life after surgical treatment of fragility fractures of the posterior pelvic ring, DRKS00024768. Registered 8th March 2021 - Retrospectively registered. Trial registration number DRKS00024768.

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J.W.R. Young and A.R. Burgess, Radiologic Management of Pelvic Ring Fractures, Systematic Radiographic Diagnosis, Urban & Schwarzenberg, Baltimore, Munich (1987) 94 pp., 82 figs.

Clinical Radiology ◽

10.1016/s0009-9260(88)80383-0 ◽

1988 ◽

Vol 39 (2) ◽

pp. 256-256

Author(s):

P RENTON

Keyword(s):

Pelvic Ring ◽

Radiographic Diagnosis ◽

Pelvic Ring Fractures

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Low-Energy Pelvic Ring Fractures: A Care Conundrum

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459320985406 ◽

2021 ◽

Vol 12 ◽

pp. 215145932098540

Author(s):

Bailey R. Abernathy ◽

Lisa K. Schroder ◽

Deborah C. Bohn ◽

Julie A. Switzer

Keyword(s):

Acute Care ◽

Patient Population ◽

Pelvic Ring ◽

Fracture Prevention ◽

Low Energy ◽

Care Pathways ◽

Secondary Fracture ◽

Secondary Fracture Prevention ◽

Pelvic Ring Fractures ◽

Rehabilitative Care

Introduction: A need exists for improved care pathways for patients experiencing low-energy pelvic ring fractures. A review of the current literature was performed to understand the typical patient care and post-acute rehabilitation pathway within the US healthcare system. We also sought to summarize reported clinical outcomes worldwide. Significance: Low-energy pelvic ring fracture patients usually do not qualify for inpatient admission, yet they often require post-acute rehabilitative care. The Center for Medicare and Medicaid Services’ (CMS) 3-day rule is a barrier to obtaining financial coverage of this rehabilitative care. Results: Direct admission of some patients to post-acute care facilities has shown promise with decreased cost, improved patient outcomes, and increased patient satisfaction. Secondary fracture prevention programs may also improve outcomes for this patient population. Conclusions: Post-acute care innovation and secondary fracture prevention should be prioritized in the low-energy pelvic fragility fracture patient population. To demonstrate the effect and feasibility of these improved care pathways, further studies are necessary.

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