Biomechanical comparison of triangular osteosynthesis and triangular minimally invasive spinopelvic stabilization technique for pelvic fragility fractures.

CT-derived bone density as an adjunct predictor of sacral fracture complexity in older adults.

Introduction:Sacral fractures, which can occur in young individuals following road traffic accidents or falls from a height, as well as in elderly individuals with osteoporosis after minor trauma, are considered a diverse type of fracture. The incidence of non-osteoporotic sacral fractures is estimated to be 2.1/100,000 people, whereas osteoporotic fractures are estimated to affect 1–5% of elderly individuals at risk. Triangular osteosynthesis is a relatively new fixation technique used as a surgical treatment for unstable sacral fractures. It combines transverse fixation with lumbo-pelvis distraction osteosynthesis, providing stability in different planes. The subcategory of triangular osteosynthesis encompasses spinopelvic fixation, which involves the fusion of transverse sacral alar fracture fixation (such as iliosacral screw/s and sacral plate) and unilateral lumbopelvic fixation from the pedicle of L5 to the ipsilateral posterior ilium. The utilization of this technique provides a mechanically advanced approach for stabilizing unstable sacral alar fractures with vertical shear. Once the pelvic ring injury has been reduced, lumbopelvic fixation can assist in preventing the recurrence of vertical displacement in the unstable hemipelvis.Case Report:The patient, a 29-year-old male, experienced a road traffic accident resulting from a collision involving a motorcycle. As a result of the incident, he suffered from an unstable lateral compression type 1 pelvic ring injury, accompanied by an ipsilateral sacroiliac dislocation and a vertical sacral fracture on the opposite side. Computed tomography imaging revealed a right sacroiliac dissociation, a left sacral fracture classified as AO type B1, as well as fractures in both the superior and inferior pubic rami. The pelvic ring of the patient was subjected to closed reduction and percutaneous fixation, accompanied by minimally invasive spinopelvic fixation. The surgical procedure was performed in a single session, involving the reduction and fixation of the right sacroiliac dissociation, followed by lumbopelvic fixation while in the prone position. After a 1-month follow-up, the patient demonstrated the ability to walk without experiencing pain, and the X-ray revealed a stable spinopelvic and sacroiliac fixation.Conclusion:The utilization of triangular osteosynthesis fixation provides a reliable form of fixation that enables the patient to bear complete weight at an early stage of 6 weeks while also preventing any reduction loss in vertical shear transforaminal sacral fractures.

The purpose of the present article is to review the new approaches to classification and management of fragility fractures of pelvis. Fragility fractures of the pelvis (FFPs) account for approximately 7% of fragility fractures and are increasing in incidence due to the aging population, an increase in life expectancy, and a more active life-style. The FFPs are characterized by isolated bone disruption and are generally more stable than high-energy pelvic ring fractures due to intact ligaments. Due to differences in the degrees of instability, the traditional classification systems (Tile or Young and Burgess) for acute pelvic ring injuries from high-energy trauma may not be applicable to FFPs. Through a classification system based on fracture location and the degree of instability, FFPs can be appropriately managed with either conservative treatment or surgery. Fragility fractures occur in patients with primary or secondary osteoporosis from low-energy trauma or no known trauma. FFPs are different from high-energy pelvic fractures in the degree of instability and the approach to fracture management. Diagnosis of FFPs requires a high index of suspicion and the early use of CT or MRI to prevent long-term complications.

With an aging population and increasing rates of osteoporosis, fragility fractures of the pelvis (FFPs) have become increasingly common in adults, accounting for ~7% of all fragility fractures [1]. This study aims to document functional outcomes and quality of life measures in individuals with FFPs treated non-operatively and examine if a relationship exists between these parameters and healing status. This study is a retrospective analysis of a prospectively collected cohort found at a high-volume single institution (Pelvic and Acetabular Database - REB PIN 5528). All elderly patients (age ≥ 65 years) who fell from standing height and sustained a non-operative FFP as diagnosed on x-ray were identified. Functional outcomes (MFA) and quality of life measures (SF-36) were collected over a two-year period. Healing was assessed on available follow up x-ray imaging by two senior orthopaedic surgeons and two orthopaedic residents and categorized as one (less than 50% healed), two (50-75% healed) or three (>75% healed). We identified 53 elderly patients who sustained a low energy non-operative FFP. Patient MFA scores increased from baseline for all categories (except fine motor and employment) indicating worsening function. Additionally, SF-36 scores decreased from baseline, but generally maintained status from 6 to 24 months, with some variability in Role Limitation due to Physical Problems category. Follow up x-ray imaging was only available on a subset of these individuals (N=35). Substantial agreement was found between all four raters (Fleiss Kappa = 0.65) with respect to healing status. Confirmation of fracture healing on x-ray (>75% healed) was found for only 7 individuals at 12 months post-fracture. There was no relationship demonstrated between MFA and SF-36 scores with fracture healing status for patients with coincident reporting (N=16). Functional outcomes and health status in elderly patients with stable FFPs treated non-operatively did not show improvements in any MFA or SF-36 categories from baseline levels (reported within ~4 weeks post-fracture), with many categories demonstrating a steady decline out to 24 months post-fracture. Despite a limited number of follow-up x-rays, this cohort highlights impaired healing which may occur in non-operatively treated FFPs. While patient function and quality of life decreased post stable FFP, no relationship was evident between these measures and fracture healing status. Lack of routine follow-up pelvic x-ray imaging is not surprising as no current treatment exists to address delayed fracture healing or non-unions and as such management is unchanged. Fibrous non-union may also provide sufficient stability in these patients, allowing some individuals without union to report low MFA and high SF-36 scores. It is important to acknowledge that the age-related decline in health elderly patients experience may contribute to patients reporting high MFA and low SF-36 scores post pelvic fracture. These comorbidities indicate that the use of functional outcomes and quality of life measures may not be appropriate in assessing elderly populations.

Fragility fractures of the pelvis (FFPs) are an increasing entity among osteoporotic fractures. They are the result of a low-energy trauma and have specific fracture morphologies and different degrees of instability. A new classification system distinguishes between anterior and posterior, nondisplaced and displaced, and unilateral or bilateral fractures of the posterior pelvic ring. Treatment consists of adequate pain therapy and adapted physiotherapy. Anterior and nondisplaced posterior lesions are treated conservatively. In displaced lesions and in cases of unsuccessful conservative treatment, operative therapy is recommended. The surgery should be as minimally invasive as possible. Alternatives for posterior pelvic ring stabilization are iliosacral screw osteosynthesis, trans-sacral bar osteosynthesis, and internal transiliac and lumbopelvic fixation. When the posterior pelvic ring is stabilized surgically, fixation of the broken anterior pelvic ring should be considered as well. Alternatives are external fixation, retrograde transpubic fixation, plate osteosynthesis, and anterior subcutaneous internal fixation. Mobilization with full weight-bearing follows after a safety period of short transfers. Prospective studies are needed to shed light on the natural course and outcome of different treatment regimens for FFPs.

BackgroundThere is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment.Materials and methodsThe Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment.ResultsConsensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is “as early as possible”. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated.ConclusionsThis consensus collects expert opinion about this topic and may guide the surgeon in choosing the best treatment for these patients.Level of Evidence: IV.Trial registration: not applicable (consensus paper).

Gluteal muscle fatty atrophy (gMFA) might impair pelvic stability and negatively influence remobilization in patients with fragility fractures of the pelvis (FFP). This study aimed to investigate the association between gMFA and surgical indication in patients with FFP. A retrospective analysis of 429 patients (age ≥80) diagnosed with FFP was performed. gMFA of the gluteus maximus, medius, and minimus was evaluated using a standard scoring system based on computer tomography images. No significant difference was found in gMFA between genders or among FFP types. The severity of gMFA did not correlate with age. The severity of gMFA in the gluteus medius was significantly greater than in the gluteus maximus, whereas the most profound gMFA was found in the gluteus minimus. gMFA was significantly more severe in patients who underwent an operation than in conservatively treated patients with type-III FFP, and an independent correlation to surgical indication was found using logistic regression. Our findings imply that gMFA is an independent factor for surgical treatment in patients with type-III FFP. Besides focusing on the fracture pattern, the further evaluation of gMFA could be a feasible parameter for decision making toward either conservative or surgical treatment of type-III FFP.

Classifications and treatment management of fragility fracture of the pelvis: A scoping review.

Background: Due to an aging society, more and more surgeons are confronted with fragility fractures of the pelvis (FFPs). The aim of treatment of such patients should be the quickest possible mobilization with full weight-bearing. Up to now however, there are no data on loading of the lower extremities in patients suffering FFPs. We hypothesized to find differences in loading of the lower limbs. Methods: 22 patients with a mean age of 84.1 years were included. During gait analysis with insole-force sensors, loading on the lower extremities was recorded during early mobilization after index fracture. Results: Especially the average peak force showed differences in loading, as the affected limb was loaded significantly less {59.78% (SD ± 16.15%) of the bodyweight vs. 73.22% (SD ± 14.84%) (p = <0.001, effect size r = 0.58)}. Furthermore, differences in loading in between the fracture patterns of FFPs were observed. Conclusion: This study shows that it is possible to reliably detect the extremity load, with the help of an insole device, in patients presenting with fragility fractures of the pelvis. There is great potential to improve the choice and time of treatment with insole-force sensors in FFPs in future.

Short-term mobility in low-energy pelvic ring fractures after conservative treatment

ObjectiveThe incidence of fragility fractures of the pelvis (FFPs) is increasing in the elderly population, and FFPs that require fixation are a challenge for orthopedic surgeons. The insertion of implants is not risk free due to the complex anatomical and osteoporotic bones and requires a steep learning curve. This study aimed to investigate the clinical efficacy of TiRobot‐assisted percutaneous cannulated screw fixation in the treatment of elderly FFP patients.MethodThe clinical data of 46 elderly FFP patients who had been treated with percutaneous cannulated screw fixation from May 2020 to September 2022 were retrospectively analyzed. Twenty‐four patients were treated with percutaneous cannulated screw fixation assisted by the TiRobot (TiRobot‐assisted group) and 22 patients were treated with conventional freehand surgery (freehand group). Postoperative outcomes, including Matta value, excellent and good rate (EGR) of fracture reduction, and accuracy of screw placement (ASP), were compared. Changes in the Visual analog scale (VAS) pain score and the Majeed score were recorded and compared between groups before and after surgery and during the 24‐week follow‐up. Repeated‐measures analysis of variance (ANOVA) and effect sizes were used as analysis methods.ResultsA total of 90 screws were implanted, 51 screws in the TiRobot‐assisted group and 39 screws in the freehand group. The operation time of the two groups was 34.1 ± 2.67 min versus 64.5 ± 4.19 min (p < 0.001). There were no screw‐related complications or revision surgeries in any group. The Matta value of the TiRobot‐assisted group was 5.13 ± 3.52, which was significantly lower than that of the freehand group (9.00 ± 3.68, p < 0.001), while the EGR was 91.67% versus 72.73%, with statistical significance (p < 0.001). The ASP was 100% in the TiRobot‐assisted group, better than that in the freehand group, where it was 85.7% (p = 0.043). At each timepoint in the early postoperative period, the VAS score of the TiRobot‐assisted group was significantly lower than that of the freehand group and was close to consistent by the last follow‐up; the Majeed score of the former was significantly higher than that of the latter at each timepoint of follow‐up, with statistical significance (p < 0.001).ConclusionTiRobot‐assisted percutaneous cannulated screw fixation of elderly FFP patients is advantageous over conventional freehand surgery, with less invasion, more accurate screw placement, better fracture reduction, early pain relief, and rapid recovery, suggesting that Freehand method to stabilize FFP in the elderly population.

In an aging society, fragility fractures of the pelvis (FFP) have increased significantly. However, there is no clear consensus on the timing and criteria for transitioning from conservative treatment to surgery for these fractures. Thus, we aimed to investigate the effects of our treatment protocol for FFP based on conservative treatment. We conducted a retrospective study including 74 patients with FFP at our institution between 2015 and 2021. All patients were treated conservatively for the first two weeks. During this period, only wheelchair transfer was allowed. If the patient could not walk after this period, surgery was performed. Fracture type (Rommens classification), walking ability, presence of complications after admission, presence of fracture union, and surgical treatment was investigated. Patients were divided into two groups: a stable group (type I/II) and an unstable group (type III/IV). Fracture union was achieved in all patients. Thirteen patients developed complications after being admitted to our hospital; seven showed decreased walking ability, and six required surgeries. The stable and unstable groups comprised 47 and 27 patients, respectively. There were no statistically significant differences between the groups regarding the percentage of patients who developed complications or experienced decrease in walking ability. The percentage of patients who required surgery was significantly higher in the unstable group (p < 0.05). Our FFP management protocol was effective regardless of fracture type. It is important to provide a period for careful assessment of instability, and to try to prevent fracture progression.

The precision of CT-guided percutaneous sacral screw placement in 114 fragility fractures of the pelvis - a retrospective study.

Evolution of treatment of fragility fractures of the pelvic ring. An update.

PurposeVarious surgical techniques for osteosynthesis in fragility fractures of the pelvis (FFP) are described. Since 2012, a submuscularly placed internal fixator has been used to stabilize the anterior pelvic ring. Indications for this procedure are a dislocation in the anterior pelvic ring and/or severe pain with associated immobility. This technique potentially has several advantages compared to subcutaneous procedures, including improved patient comfort, less irritation, and enhanced biomechanical stability due to the deeper rod placement.MethodsDigital files of patients aged ≥ 65 years, who were treated with an internal fixator at a Level I trauma center in Germany between 2012 and 2021, were retrospectively analyzed.ResultsThirty-four patients (median age 79 years, 77% female, 61.8% ASA III) were treated. Most fractures were caused by ground-level falls (64.7%), followed by road traffic accidents (11.8%). In patients with low impact trauma, the most common fracture types were FFP IIb (37.04%) and FFP IIIc (18.52%). Complications during surgery occurred in 4 patients (11.76%) and postoperative complications in 6 patients (17.6%), with hematoseroma being the most common. Non-surgical complications occurred in 20 patients (total: 58.8%; Clavien-Dindo type 2 in 70%). After 12 months, the majority of all patients had the same mobility level as before the fracture.ConclusionThe submuscularly placed internal fixator is an effective technique for stabilizing anterior pelvic ring fractures in geriatric patients, offering advantages in cases of high dorsoventral instability or persistent severe anterior pain.