Development and Evaluation of the OF Pelvis Score for Osteoporotic Pelvic Ring Fractures - A Retrospective Assessment of Therapy Recommendations for 107 Patients. / Entwicklung und Evaluation des OF-Pelvis-Scores bei osteoporotischen Beckenringfrakturen ­ retrospektive Beurteilung der Therapieempfehlung anhand von 107 Patienten.

The aim of this study was to develop a simple and reliable score which supports decision making between non-operative and operative treatment in patients with osteoporotic pelvic fractures.Between 2018 to 2020, the OF Pelvis Score was developed during a total of 5 meetings of the Working Group on Osteoporotic Fractures of the Spine Section of the German Society of Orthopaedics and Trauma. The OF Pelvis Score as a decision aid between non-surgical and surgical treatment was developed by expert consensus after analysis of numerous geriatric sacral and pelvic ring fractures from several hospitals. Subsequently, retrospective evaluation of the score was performed on consecutive patients from three hospitals.The following parameters were considered relevant to decision making between non-surgical and surgical treatment and were incorporated into the score: fracture morphology using the OF Pelvis Classification, pain status, level of mobilisation, fracture-related neurological deficits, health status, and the modifiers already integrated into the OF Pelvis classification. If the score is < 8, non-surgical therapy is recommended; if the score is > 8, surgical therapy is recommended; if the score is 8, there is a relative indication for surgery. The OF Pelvis Score was then evaluated retrospectively in a total of 107 patients, according to records. The OF Pelvis Score was 8 points in 4 patients (3.7%), all of whom received surgical treatment. Of the remaining 103 patients, 93 received score-compliant therapy (90.3%). Among these, 4 of the patients who did not receive score-compliant care refused the recommended surgery, so the actual therapy recommendation was score-compliant in 94.2%.The OF Pelvis Score can be used to derive a therapy recommendation in many patients in clinical practice. Because of the possible change of clinical parameters during the course of the disease, the score has a dynamic character. In the retrospective evaluation, the recommendations from the OF Pelvis Score were in close accordance with the therapy actually performed.

Comparison of the zonal distribution of calcium salt density and fat marrow in bone-healthy and osteoporotic sacra: an image data analysis using quantitative computed tomography and magnetic resonance imaging.

PURPOSE: Pathogenesis of sacral fragility fractures is not fully understood. This study investigates zonal distribution of calcium salt and fat marrow in intact bone-healthy and osteoporotic pelvis. In addition, in unilateral sacral fractures, the fracture side was compared with the intact side. METHODS: CT and MRI images of 37 pelves were analyzed. Zonal calcium salt distribution by Hounsfield units (HU) was recorded for each CT dataset. Fat marrow content was measured in MRI mDixon-Quant sequence. The cohort was divided: intact pelves with (PEO, HU < 100, n = 8) and without osteoporosis (PE, HU ≥ 100, n = 14) based on the mean HU value in LWK5. A third group consisted of patients with osteoporosis and unilateral fractures (PEOFx, n = 10). CONCLUSION: The results suggest that in PEO sacral alae experience disproportionate skeletal rarefaction. This concerns the sacral ala at the S1 level (- 25 ± 55), whereby the calcium salt content is so low that it corresponds to the S3 level of healthy bone (- 20 ± 21 HU). This explains the occurrence of transalar fractures in the load-transmitting zone S1. In PEOFx, the calcium salt density was higher and the fat content was lower on the fractured side than on the intact side, indicating bony compacting due to lateral compression and fat displacement due to hematoma in the accident mechanism. This study makes an important contribution to the understanding of the development of sacral fragility fractures. Furthermore, impaction of the cancellous bone within the fracture can be demonstrated.

Georg Schmorl prize of the German spine society (DWG) 2022: current treatment for inpatients with osteoporotic thoracolumbar fractures-results of the EOFTT study.

AIM: Osteoporotic thoracolumbar fractures are of increasing importance. To identify the optimal treatment strategy this multicentre prospective cohort study was performed. PURPOSE: Patients suffering from osteoporotic thoracolumbar fractures were included. Excluded were tumour diseases, infections and limb fractures. Age, sex, trauma mechanism, OF classification, OF-score, treatment strategy, pain condition and mobilization were analysed. METHODS: A total of 518 patients' aged 75 ± 10 (41-97) years were included in 17 centre. A total of 174 patients were treated conservatively, and 344 were treated surgically, of whom 310 (90%) received minimally invasive treatment. An increase in the OF classification was associated with an increase in both the likelihood of surgery and the surgical invasiveness. RESULTS: Five (3%) complications occurred during conservative treatment, and 46 (13%) occurred in the surgically treated patients. 4 surgical site infections and 2 mechanical failures requested revision surgery. At discharge pain improved significantly from a visual analogue scale score of 7.7 (surgical) and 6.0 (conservative) to a score of 4 in both groups (p < 0.001). Over the course of treatment, mobility improved significantly (p = 0.001), with a significantly stronger (p = 0.007) improvement in the surgically treated patients. CONCLUSION: Fracture severity according to the OF classification is significantly correlated with higher surgery rates and higher invasiveness of surgery. The most commonly used surgical strategy was minimally invasive short-segmental hybrid stabilization followed by kyphoplasty/vertebroplasty. Despite the worse clinical conditions of the surgically treated patients both conservative and surgical treatment led to an improved pain situation and mobility during the inpatient stay to nearly the same level for both treatments.

Perioperative outcome of minimally invasive stabilisation of bilateral fragility fractures of the sacrum: a comparative study of bisegmental transsacral stabilisation versus spinopelvic fixation.

PURPOSE: Pelvic fragility fractures have steadily risen over the past decades. The primary treatment goal is the fastest possible mobilisation. If conservative therapy fails, surgical fixation is a promising approach. This study compares the outcome of bisegmental transsacral stabilisation (BTS) and spinopelvic fixation (SP) as minimally invasive techniques for bilateral fragility fractures of the sacrum (BFFS). METHODS: We performed a prospective, non-randomised, case-controlled study. Patients were included if they remained bedridden due to pain despite conservative treatment. Group assignment depended on sacral anatomy and fracture type. The outcome was estimated by blood loss calculation, cut-seam time, fluoroscopy time, complications, duration of stay at the intensive/intermediate care unit (ICU/IMC), and total inpatient stay. The mobility level at discharge was recorded. RESULTS: Seventy-three patients were included (SP: 49, BTS: 24). There was no difference in blood loss (BTS: 461 ± 628 mL, SP: 509 ± 354 mL). BTS showed a significantly lower cut-seam time (72 ± 23 min) than SP (94 ± 27 min). Fluoroscopy time did not differ (BTS: 111 ± 61 s vs. 103 ± 45 s). Thirteen percent of BTS and 16% of SP patients required ICU/IMC stay (BTS: 0.6 ± 1.8 days, SP: 0.5 ± 1.5 days) during inpatient stay (BTS: 9 ± 4 days, SP: 8 ± 3 days). Fourteen patients suffered from urinary tract infections (BTS: 8%; SP: 25%). In-patient mortality was low (BTS: 4.2%, SP: 4.1%). At discharge, the BTS group was almost back to the initial mobility level. In SP patients, mobility was significantly lower than before complaints (p = 0.004). CONCLUSION: Both methods allow early mobilization of BFFS patients. Blood loss can be kept low. Hence, transfusion requirement is correspondingly low. The IMC/ICU and the total inpatient stay are lower than reported in the literature. Both BTS and SP can be recommended as safe and low-complication methods for use in BFFS patients. BTS is superior to SP with respect to surgery duration and level of mobility at discharge.

Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases.

PURPOSE: The pathogenetic mechanism, progression, and instability in geriatric bilateral fragility fractures of the sacrum (BFFSs) remain poorly understood. This study investigated the hypothesis of sequential BFFS progression by analysing X-ray, computed tomography (CT), and magnetic resonance imaging (MRI) datasets. METHODS: Imaging data from 78 cases were retrospectively analysed. Fractures were categorized using the CT-based Fragility Fractures of the Pelvis classification. MRI datasets were analysed to detect relevant fracture location information. The longitudinal sacral fracture was graded as stage 1 (bone oedema) on MRI, stage 2 (recent fracture), stage 3 (healing fracture), or stage 4 (non-union) on CT. Ligamentous avulsions at the L5 transverse process and iliac crest were also captured. RESULTS: Contralateral sacral lesions were only recognized by initial bone oedema on MRI in 17/78 (22%) cases. There were 22 cases without and 56 cases with an interconnecting transverse fracture component (TFC) [between S1/S2 (n = 39) or between S2/S3 (n = 17)]. With 30/78 patients showing bilateral fracture lines at different stages (1/2: n = 13, 2/3: n = 13, 1/3: n = 4) and 38 at similar stages, Wilcoxon tests showed a significant stage difference (p < 0.001). Forty cases had a coexistent L5 transverse process avulsion, consistent with a failing iliolumbar ligament. Analysis of variance revealed significant increases in ligamentous avulsions with higher fracture stages (p < 0.001). CONCLUSION: Our results support the hypothesis of stagewise BFFS progression starting with unilateral sacral disruption followed by a contralateral lesion. Loss of sacral alar support leads to a TFC. Subsequent bone disruption causes iliolumbar ligament avulsion. MRI is recommended to detect bone oedema.