Long-Term Follow-Up after Iliosacral Screw Fixation of Unstable Pelvic Ring Fractures.

(1) Background: High-energy injuries of the pelvic ring are rare. The wide application of iliosacral screw fixation of the posterior pelvic ring is relatively new. The aim of the present study was to evaluate the long-term quality of life. (2) Methods: All patients treated with an iliosacral screw for a posterior pelvic ring stabilization after high-energy trauma at a level 1 trauma center between 2005 and 2015 were included. Pelvic ring injuries were classified according to the Tile classification adapted by AO/ASIF. The clinical evaluation included the patient-oriented questionnaires surveys of the Majeed Score, Iowa Pelvic Score (IPS), Work Ability Index (WAI), SF-36, EQ5D-5L. (3) Results: A total of 84 patients were included with a median follow-up of 130.1 months (IQR 95.0-162.0 months). The median ISS was 22.5 (IQR 16.0-29.0), mean Majeed Score 83.32 (SD ± 19.26), IPS 77.88 (SD ± 13.96), WAI 32.71 (SD ± 11.31), SF-36 PF 71.25 (SD ± 29.61) and EQ5D-5L 0.83 (SD ± 0.21). There was a notably difference between uni- and bilateral pelvic fractures (p = 0.033) as well as a correlation with the ISS (p = 0.043) with inferior functional outcome measured by IPS. (4) Conclusions: Long-term follow-up of iliosacral screw fixation of unstable pelvic ring fractures showed a good quality of life and functional outcome with equal EQ5D-5L results and inferior SF-36 physical functioning compared to the German population.

Analysis of the Spinopelvic Parameters in Patients with Fragility Fractures of the Pelvis.

BACKGROUND: We investigated the spinopelvic parameters of lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS) in patients with fragility fractures of the pelvis (FFPs). We hypothesized that these parameters differ from asymptomatic patients. METHODS: All patients treated for FFPs in a center of maximal care of the German Spine Society (DWG) between 2017 and 2021 were included. The inclusion criteria were age ≥ 60 years and the availability of a standing lateral radiograph of the spine and pelvis in which the spine from T12 to S1 and both femoral heads were visible. The baseline characteristics and study parameters were calculated and compared with databases of asymptomatic patients. The two-sample t-Test was performed with p < 0.05. RESULTS: The study population (n = 57) consisted of 49 female patients. The mean age was 81.0 years. The mean LL was 47.9°, the mean PT was 29.4°, the mean SS was 34.2° and the mean PI was 64.4°. The mean value of LLI was 0.7. LL, LLI and SS were significantly reduced, and PI and PT were significantly increased compared to asymptomatic patients. CONCLUSIONS: The spinopelvic parameters in patients with FFPs differ significantly from asymptomatic patients. In patients with FFPs, LL, LLI and SS are significantly reduced, and PI and PT are significantly increased. The sagittal spinopelvic balance is abnormal in patients with FFPs.

FFP: Indication for minimally invasive navigation technique.

An 85-year-old female patient was transferred to our clinic for surgical treatment of a complex FFP IIc. She had suffered a ground level fall 10 days ago and was still living independently. The patient was initially treated conservatively with pain medication and immobilization in an outward hospital. Due to the clinical symptoms and complex fracture pattern a physiotherapeutic assisted mobilization was not possible. The clinical examination revealed severe bilateral pain at the anterior and posterior pelvic ring. We performed a minimally invasive and an image-guided surgical stabilization. After surgical treatment the patient was mobilized with crutches for short distances. On the third day after surgical intervention the patient was discharged from our hospital into rehabilitation. This case shows the successful use of minimally invasive and modern navigation technique for treatment of a complex FFP.

[Severe injury type procedures-Influence of the cipher 11 "complications" and the COVID-19 pandemic on a center for maximum care of severe injuries]. / Schwerstverletzungsartenverfahren ­ Einfluss der Ziffer 11 "Komplikationen" sowie der COVID-19-Pandemie auf ein Haus der traumatologischen Maximalversorgung.

INTRODUCTION: Ensuring the best treatment options for injured patients (healing process, Heilverfahren, HV) is the main goal and responsibility of the German statutory accident insurance (DGUV). The injury type catalogue is the tool to guide the HV. The development of the number of cases treated in a center for severe injury type procedures, the effects of the cipher 11 "complications" of the catalogue and the effects of the COVID-19 pandemic are presented. METHODS: A retrospective study of all patients treated in the context of the DGUV from January 2019 to December 2021 was carried out. The number of cases before and during the legal lockdown actions were compared. The case mix index, the mean number of operations, the mean time in the operating room and the hospital stay were analyzed. Additionally, the cases under the cipher 11 were classified according to the specific anatomical regions. RESULTS: Out of 2007 cases 67% were classified as severe injury type procedures (SAV). Of these cases 51% were categorized to the cipher 11 of the injury type catalogue. Complications were observed particularly in the anatomical regions of the shoulder girdle, elbow, hand, knee, ankle joint and foot. These complex cases are economically not sufficiently represented. During the governmental COVID-19 lockdown actions, the number of patients treated in the context of the DGUV significantly decreased. CONCLUSION: The injury type catalogue is used effectively in the catchment area of the present trauma center. Most of the cases treated in the present trauma center are severe injury type procedures; however, more than half of these cases are classified as complications. This development might show the need for a structural change or an adjustment of the HV. The current comments on the injury type catalogue offer important definitions and specifications; however, the conciseness of the entire catalogue should be maintained.

Addition of shock wave therapy to nail dynamization increases the chance of long-bone non-union healing.

BACKGROUND: Long-bone non-unions after intramedullary nailing can be treated by nail dynamization or focused high-energy extracorporal shock wave therapy (fESWT). The objective of this study was to assess the effect of the combination therapy of nail dynamization and fESWT on long-bone non-unions. MATERIALS AND METHODS: 49 patients with long-bone non-unions (femur and tibia) after nailing were treated with nail dynamization (group D, n = 15), fESWT (group S, n = 17) or nail dynamization in addition to fESWT (group DS, n = 17). Patients were followed up for 6 months retrospectively. Furthermore, age, sex, Non-Union Scoring System (NUSS) score, time intervals from primary and last surgery until intervention and smoking status were analysed for their correlations to bone union. RESULTS: Union rates were 60% for group D, 64.7% for group S and 88.2% for group DS, with a significant difference between group D and DS (p = 0.024). Successful treatment was correlated with high age (OR 1.131; 95% CI 1.009-1.268; p = 0.034), female gender (OR 0.009; 95% CI 0.000-0.89; p = 0.039), low NUSS score (OR 0.839; 95% CI 0.717-0.081; p = 0.028) and negative smoking status (OR 86.018; 95% CI 3.051-2425.038; p = 0.009). CONCLUSIONS: Data from the present study indicate that the combination therapy of nail dynamization and fESWT leads to a higher union rate than dynamization or fESWT alone. LEVEL OF EVIDENCE: Level 3.

Does Cement Augmentation of the Sacroiliac Screw Lead to Superior Biomechanical Results for Fixation of the Posterior Pelvic Ring? A Biomechanical Study.

Background and Objectives: The stability of the pelvic ring mainly depends on the integrity of its posterior part. Percutaneous sacroiliac (SI) screws are widely implanted as standard of care treatment. The main risk factors for their fixation failure are related to vertical shear or transforaminal sacral fractures. The aim of this study was to compare the biomechanical performance of fixations using one (Group 1) or two (Group 2) standard SI screws versus one SI screw with bone cement augmentation (Group 3). Materials and Methods: Unstable fractures of the pelvic ring (AO/OTA 61-C1.3, FFP IIc) were simulated in 21 artificial pelvises by means of vertical osteotomies in the ipsilateral anterior and posterior pelvic ring. A supra-acetabular external fixator was applied to address the anterior fracture. All specimens were tested under progressively increasing cyclic loading until failure, with monitoring by means of motion tracking. Fracture site displacement and cycles to failure were evaluated. Results: Fracture displacement after 500 cycles was lowest in Group 3 (0.76 cm [0.30] (median [interquartile range, IQR])) followed by Group 1 (1.42 cm, [0.21]) and Group 2 (1.42 cm [1.66]), with significant differences between Groups 1 and 3, p = 0.04. Fracture displacement after 1000 cycles was significantly lower in Group 3 (1.15 cm [0.37]) compared to both Group 1 (2.19 cm [2.39]) and Group 2 (2.23 cm [3.65]), p ≤ 0.04. Cycles to failure (Group 1: 3930 ± 890 (mean ± standard deviation), Group 2: 3676 ± 348, Group 3: 3764 ± 645) did not differ significantly between the groups, p = 0.79. Conclusions: In our biomechanical setup cement augmentation of one SI screw resulted in significantly less displacement compared to the use of one or two SI screws. However, the number of cycles to failure was not significantly different between the groups. Cement augmentation of one SI screw seems to be a useful treatment option for posterior pelvic ring fixation, especially in osteoporotic bone.

Is Anterior Plating Superior to the Bilateral Use of Retrograde Transpubic Screws for Treatment of Straddle Pelvic Ring Fractures? A Biomechanical Investigation.

BACKGROUND: Fractures of the four anterior pubic rami are described as "straddle fractures". The aim of this study was to compare biomechanical anterior plating (group 1) versus the bilateral use of retrograde transpubic screws (group 2). METHODS: A straddle fracture was simulated in 16 artificial pelvises. All specimens were tested under progressively increasing cyclic loading, with monitoring by means of motion tracking. RESULTS: Axial stiffness did not differ significantly between the groups, p = 0.88. Fracture displacement after 1000-4000 cycles was not significantly different between the groups, p ≥ 0.38; however, after 5000 cycles it was significantly less in the retrograde transpubic screw group compared to the anterior plating group, p = 0.04. No significantly different flexural rotations were detected between the groups, p ≥ 0.32. Moreover, no significant differences were detected between the groups with respect to their cycles to failure and failure loads, p = 0.14. CONCLUSION: The results of this biomechanical study reveal less fracture displacement in the retrograde transpubic screw group after long-term testing with no further significant difference between anterior plating and bilateral use of retrograde transpubic screws. While the open approach using anterior plating allows for better visualization of the fracture site and open reduction, the use of bilateral retrograde transpubic screws, splinting the fracture, presents a minimally invasive and biomechanically stable technique.

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.

[Trends in the surgical treatment of fractures of the pelvic ring : A nationwide analysis of operations and procedures code (OPS) data between 2005 and 2017]. / Trends in der operativen Therapie von Frakturen des Beckenrings : Eine bundesweite Analyse von OPS-Daten zwischen 2005 und 2017.

AIM: The aim of this study was to analyze the epidemiological trends and incidences in inpatient pelvic surgery in the period from 2005 to 2007. METHOD: Approximately 194 million anonymized diagnosis-related groups (DRG) inpatient records were collected by the German Federal Statistical Office between 2005 and 2017. These data were screened for pelvic procedures, gender and age of the patients. Statistical testing was performed using the χ2-test and Mann-Whitney U-test (p < 0.05). RESULTS: Between 2005 and 2017 the number of closed reduction and internal fixation of the pelvic ring with screw fixation increased by +1116%. The use of screw fixation for closed reduction and internal fixation of the sacroiliac joint increased by +800%. The number of cases of open reduction and internal fixation of fractures of the pelvic ring and pelvic rim increased by +185% and reposition with external fixator increased by +188%. In 2005 more surgical procedures were undertaken in male inpatients, whereas more surgical procedures were undertaken in female inpatients in 2017. In general, a large increase in the number of pelvic procedures was observed in the group of patients >50 years old. CONCLUSION: There was an increase in the number of all analyzed pelvic procedures between 2005 and 2017. Especially the use of screw fixation increased. The introduction of new techniques (e.g. screw fixation of the sacroiliac joint) and progress and innovation in the field of three-dimensional navigation techniques, the demographic trend, greater mobility and higher demands on functionality of older patients might explain this increase in pelvic procedures.

Safety, Effect and Feasibility of Percutaneous SI-Screw with and without Augmentation-A 15-Year Retrospective Analysis on over 640 Screws.

BACKGROUND: Minimally invasive sacroiliac-screw (SI-screw) fixation of the pelvis is used in energy trauma (Arbeitsgemeinschaft für Osteosynthesefragen (AO) classified) and fragility fractures (Fragility Fracture of the Pelvis (FFP) classified). However, available clinical data are based on small case series and biomechanical data seem to be contradictory. METHODS: The present single center retrospective cohort study investigated percutaneous SI-screw fixation and augmentation over 15 years. Groups were compared concerning the general epidemiological data, mobilization, complication rates, duration of stay, and safety of SI-screw insertion. Multivariable analyses were performed using logistic regression. RESULTS: Between 2005 and March 2020, 448 patients with 642 inserted SI-screws were identified. Iatrogenic neurological impairment was documented in 2.47% and correlated with screw misplacement. There was an increased complication risk in patients with AO type C over patients with AO type B and in FFP II over FFP III/IV patients. Cement-augmented FFP patients showed a 25% reduced stay in hospital and a reduced complication risk. Cement-associated complications were seen in 22% without correlation to neurologic impairment. CONCLUSIONS: The present study confirms the safety and usability of percutaneous SI-screw fixation, despite specific risks. Cement augmentation seems to reduce the complication risk in FFP patients and shorten hospital stay for some reasons, without increased specific complications or correlated neurological impairment.

[Effects of the new injury type catalogue of the German statutory accident insurance on a center for severe injury type procedures]. / Auswirkungen des neuen Verletzungsartenverzeichnisses der DGUV auf ein SAV-Zentrum.

The development of the numbers of cases involved in accident insurance consultant procedures (DAV), injury type procedures (VAV) and severe injury type procedures (SAV) after the introduction of the new injury type catalogue from 1 July 2018 is presented. Furthermore, possible alterations to organizational aspects, such as operating room times and average duration of hospitalization are presented. A first critical assessment of the modifications in the new catalogue was carried out, particularly with reference to the newly introduced section on complications (section 11). METHODS: A retrospective study of all inpatients treated in the context of the DAV, VAV and SAV procedures at a SAV center from the 2nd and 3rd quarters of 2018 was carried out. The development of the number of cases, the case mix index (CMI), the mean number of operations, the mean time in the operating room and the length of hospitalization were analyzed. Furthermore, an assessment of the SAV cases was carried out with respect to the new developments and with particularly reference to complications. RESULTS: The total number of inpatients in the context of the DAV, VAV, SAV procedures changed only slightly. There was a clear decrease in DAV cases and a relevant increase in SAV cases. The CMI increased by 47%, the number of surgical procedures by 15%, the mean time in the operating room by 36% and the length of hospitalization by 43%. When converted to a daily operating room unit of 7 h (Tagestischeinheit, TTE) the operating room time increased from 89 to 108 TTE and the length of hospitalization increased from 1028 to 1358 days. Of the 111 SAV cases in the 3rd quarter, 52% were assigned to the catalogue number 11 "complications". In comparison to the previous version of the VAV/SAV catalogue, it was now possible to assign all inpatients to a single category. CONCLUSION: The modifications of the VAV in the observational period led to an enormous increase in SAV cases. It remains to be seen whether this development is confirmed in subsequent quarters. The increase in CMI, the number of necessary operations, operating room times and duration of hospitalization showed the necessity of these innovations on structural changes of hospitals involved in the treatment of SAV cases.