Abstract
Purpose
This retrospective multicenter study aimed to compare rates of early mobilization and survival and functional outcome of surgical treatment (S) with that of conservative treatment (C) according to each unstable fragility fracture of the pelvis (FFP) classification type with displacement of the posterior component ≥ 5 mm.
Methods
We analyzed 64 patients with unstable type III and IV FFP who could move and transfer themselves before injury and had ≥ 5 mm displacement of the posterior component. We compared survival rate, early mobilization, walking ability at final follow-up, and complications at admission for each type of surgical and conservative treatment.
Results
Most of the unstable FFP were type IIIa and IVb in the study population. Type III comprised 40 cases (group S:13/group C:27) and type IV comprised 24 cases (group S:7/group C:17). There were no significant differences in 3 month and 1 year survival rates, although group C (III) had the tendency of higher mortality rate (p = 0.08). Mobilization (transferring to a wheelchair) was enabled significantly earlier in group S (III) than in group C (III) (p = 0.02), but in type IV, most patients enabled early mobilization even without surgical intervention. There were no significant differences in hospital complications and walking ability at final follow-up.
Conclusion
In this study, the superiority of surgical treatment for unstable FFP was not proven. However, the results suggest that type IVb may be a relatively stable type compared to type III and that type IVb should be considered separately from bilaterally complete unstable sacral fractures due to high-energy trauma.
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Data available on request from the authors.
References
Andrich S, Haastert B, Neuhaus E, et al. Epidemiology of pelvic fractures in Germany: considerably high incidence rates among older people. PLoS ONE. 2015. https://doi.org/10.1371/journal.pone.0139078.
Soles GL, Ferguson TA. Fragility fractures of the pelvis. Curr Rev Musculoskelet Med. 2012;5(3):222–8. https://doi.org/10.1007/s12178-012-9128-9.
Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: recommendations for surgical treatment. Injury. 2013;44:1733–44. https://doi.org/10.1016/j.injury.2013.06.023.
Rommens PM, Wagner D, Hofmann A. Surgical management of osteoporotic pelvic fractures: a new challenge. Eur J Trauma Emerg Surg. 2012;38(5):499–509. https://doi.org/10.1007/s00068-012-0224-8.
Höch A, Özkurtul O, Pieroh P, Josten C, Böhme J. Outcome and 2 year survival rate in elderly patients with lateral compression fractures of the pelvis. Geriatr Orthop Surg Rehabil. 2017;8:3–9. https://doi.org/10.1177/2151458516681142.
Balogh Z, King KL, Mackay P, et al. The epidemiology of pelvic ring fractures: a population-based study. J Trauma. 2007;63:1066–73. https://doi.org/10.1097/TA.0b013e3181589fa4.
Grewal IS, Mir HR. Assessment of instability in type B pelvic ring fractures. J Clin Orthop Trauma. 2020;11(6):1009–15. https://doi.org/10.1016/j.jcot.2020.10.004.
Osterhoff G, Noser J, Held U, Werner CML, Pape HC, Dietrich M. Early operative versus nonoperative treatment of fragility fractures of the pelvis: a propensity-matched multicenter study. J Orthop Trauma. 2019;33(11):410–5. https://doi.org/10.5167/uzh-172550.
Bruce B, Reilly M, Sims S. OTA highlight paper predicting future displacement of nonoperatively managed lateral compression sacral fractures: can it be done? J Orthop Trauma. 2011;25(9):523–7. https://doi.org/10.1097/BOT.0b013e3181f8be33.
Weaver MJ, Bruinsma W, Toney E, Dafford E, Vrahas MS. What are the patterns of injury and displacement seen in lateral compression pelvic fractures? Clin Orthop Relat Res. 2012;470(8):2104–10. https://doi.org/10.1007/s11999-012-2364-x.
Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. J Bone Joint Surg. 1993;75:797–8. https://doi.org/10.1302/0301-620X.75B5.8376443.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83. https://doi.org/10.1016/0021-9681(87)90171-8.
Starr AJ, Walter JC, Harris RW, Reinert CM, Jones AL. Percutaneous screw fixation of fractures of the iliac wing and fracture-dislocations of the sacro-iliac joint (OTA types 61-B2.2 and 61-B2.3, or Young Burgess “lateral compression type II” pelvic fractures). J Ortho Trauma. 2002;16(2):116–23. https://doi.org/10.1097/00005131-200202000-00008.
Steer R, Balendra G, Matthews J, Wullschleger M, Reidy J. The use of anterior subcutaneous internal fixation (INFIX) for treatment of pelvic ring injuries in major trauma patients, complications and outcomes. SICOT J. 2019;5:22. https://doi.org/10.1051/sicotj/2019019.
Rommens PM, Ossendorf C, Pairon P, Dietz SO, Wagner D, Hoffman A. Clinical pathways for fragility fractures of pelvic ring: personal experience and review of literature. J Ortho Sci. 2015;20(1):1–11. https://doi.org/10.1007/s00776-014-0653-9.
Miyai I, Sonoda S, Nagai S, et al. Results of new policies for inpatient rehabilitation coverage in Japan. Neurorehabil Neural Repair. 2011;25:540–7. https://doi.org/10.1177/1545968311402696.
Hill RM, Robinson CM, Keating JF. Fractures of the pubic rami epidemiology and five-year survival. J Bone Joint Surg Br. 2001;83(8):1141–4. https://doi.org/10.1302/0301-620X.83B8.0831141.
Rapp K, Cameron ID, Kurrle S, et al. Excess mortality after pelvic fractures in institutionalized older people. Osteoporos Int. 2010;21(11):1835–9. https://doi.org/10.1007/s00198-009-1154-0.
Yoshida M, Tajima K, Saito Y, Sato K, Uenishi N, Iwata M. Mobility and mortality of 340 patients with fragility fracture of the pelvis. Eur J Trauma Emerg Surg. 2021;47(1):29–36. https://doi.org/10.1007/s00068-020-01481-3.
Majeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg Br. 1989;71(2):304–6. https://doi.org/10.1302/0301-620X.71B2.2925751.
Kanda Y. Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplant. 2013;48(3):452–8. https://doi.org/10.1038/bmt.2012.244.
Taillandier J, Langue F, Alemanni M, Taillandier-Heriche E. Mortality and functional outcomes of pelvic insufficiency fractures in older patients. Joint Bone Spine. 2003;70:287–9. https://doi.org/10.1016/S1297-319X(03)00015-0.
Koval KJ, Aharonoff GB, Schwartz MC, et al. Pubic rami fracture: a benign pelvic injury? J Orthop Trauma. 1997;11:7–9. https://doi.org/10.1097/00005131-199701000-00003.
Krappinger D, Struve P, Schmid R, Kroesslhuber J, Blauth M. Fractures of the pubic rami: a retrospective review of 534 cases. Arch Orthop Trauma Surg. 2009;129:1685–90. https://doi.org/10.1007/s00402-009-0942-5.
Hagino H, Nakamura T, Fujiwara S, Oeki M, Okano T, Teshima R. Sequential change in quality of life for patients with incident clinical fractures: a prospective study. Osteoporos Int. 2009;20:695–702. https://doi.org/10.1007/s00198-008-0761-5.
Bliuc D, Nguyen ND, Milch VE, et al. Mortality risk associated with low-trauma osteoporotic fracture and subsequent fracture in men and women. JAMA. 2009;301:513–21. https://doi.org/10.1001/jama.2009.50.
Johnell O, Kanis JA, Odén A, et al. Mortality after osteoporotic fractures. Osteoporos Int. 2004;15:38–42. https://doi.org/10.1007/s00198-003-1490-4.
Ueda Y, Inui T, Kurata Y, Tsuji H, Saito J, Shitan Y. Prolonged pain in patients with fragility fractures of the pelvis may be due to fracture progression. Eur J Trauma Emerg Surg. 2019;47(2):507–13. https://doi.org/10.1007/s00068-019-01150-0.
Linstrom NJ, Heiserman JE, Kortman KE, et al. Anatomical and biomechanical analyses of the unique and consistent locations of sacral insufficiency fractures. Spine. 2009;34:309–15. https://doi.org/10.1097/brs.0b013e318191ea01.
Committee of Japanese Guidelines for the Prevention and Treatment of Osteoporosis. The Japanese guidelines for the prevention and treatment of osteoporosis. 2015th ed. Tokyo: Life Science Publishing; 2015.
Sullivan MP, Baldwin KD, Donegan DJ, Mehta S, Ahn J. Geriatric fractures about the hip: divergent patterns in the proximal femur, acetabulum, and pelvis. Orthopedics. 2014;37:151–7. https://doi.org/10.3928/01477447-20140225-50.
Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302:1573–9. https://doi.org/10.1001/jama.2009.1462.
Petersen MB, Jørgensen HL, Hansen K, Duus BR. Factors affecting postoperative mortality of patients with displaced femoral neck fracture. Injury. 2006;37:705–11. https://doi.org/10.1016/j.injury.2006.02.046.
Goldacre MJ, Roberts SE, Yeates D. Mortality after admission to hospital with fractured neck of femur: database study. BMJ. 2002;325:868–9. https://doi.org/10.1136/bmj.325.7369.868.
Leibson CL, Tosteson AN, Gabriel SE, Ransom JE, Melton LJ. Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc. 2002;50:1644–50. https://doi.org/10.1046/j.1532-5415.2002.50455.x.
Morris RO, Sonibare A, Green DJ, Masud T. Closed pelvic fractures: characteristics and outcomes in older patients admitted to medical and geriatric wards. Postgrad Med J. 2000;76(900):646–50. https://doi.org/10.1136/pmj.76.900.646.
Marrinan S, Pearce MS, Jiang XY, Waters S, Shanshal Y. Admission for osteoporotic pelvic fractures and predictors of length of hospital stay, mortality and loss of independence. Age Ageing. 2015;44(2):258–61. https://doi.org/10.1093/ageing/afu123.
Clement ND, Court-Brown CM. Elderly pelvic fractures: the incidence is increasing and patient demographics can be used to predict the outcome. Eur J Orthop Surg Traumatol. 2014;24(8):1431–7. https://doi.org/10.1007/s00590-014-1439-7.
Studer P, Suhm N, Zappe B, Bless N, Jakob M. Pubic rami fractures in the elderly—a neglected injury? Swiss Med Wkly. 2013;143: w13859. https://doi.org/10.4414/smw.2013.13859.
Rommens PM. Paradigm shift in geriatric fracture treatment. Eur J Trauma Emerg Surg. 2019;45:181–9. https://doi.org/10.1007/s00068-019-01080-x.
Acknowledgments
We thank So Mitsuya, Tokumi Kanemura, Masahiro Hanabayashi, Osamu Ito, Yasuhide Kanayama, Koji Maruyama, Hiroaki Yoshida, and Toshihiro Ando for data collection.
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Conceptualization: YT and KT, methodology, formal analysis and investigation: YS, TO, writing—original draft preparation: YS, writing—review and editing: KT, resources: MY, supervision: SI.
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Saito, Y., Tokutake, K., Takegami, Y. et al. Does surgical treatment for unstable fragility fracture of the pelvis promote early mobilization and improve survival rate and postoperative clinical function?. Eur J Trauma Emerg Surg 48, 3747–3756 (2022). https://doi.org/10.1007/s00068-021-01729-6
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DOI: https://doi.org/10.1007/s00068-021-01729-6