Does surgical treatment for unstable fragility fracture of the pelvis promote early mobilization and improve survival rate and postoperative clinical function?

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.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3

Availability of data and materials

Data available on request from the authors.

References

  1. 1.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    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.

    Article  PubMed  Google Scholar 

  4. 4.

    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.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    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.

    Article  PubMed  Google Scholar 

  6. 6.

    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.

    Article  Google Scholar 

  7. 7.

    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.

    Article  PubMed  Google Scholar 

  8. 8.

    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.

    Article  Google Scholar 

  9. 9.

    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.

    Article  PubMed  Google Scholar 

  10. 10.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    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.

    CAS  Article  Google Scholar 

  12. 12.

    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.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    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.

    Article  Google Scholar 

  14. 14.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    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.

    Article  Google Scholar 

  16. 16.

    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.

    Article  PubMed  Google Scholar 

  17. 17.

    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.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    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.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    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.

    Article  PubMed  Google Scholar 

  20. 20.

    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.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    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.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    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.

    Article  PubMed  Google Scholar 

  23. 23.

    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.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    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.

    Article  PubMed  Google Scholar 

  25. 25.

    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.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    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.

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    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.

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    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.

    Article  PubMed  Google Scholar 

  29. 29.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    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.

    Google Scholar 

  31. 31.

    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.

    Article  PubMed  Google Scholar 

  32. 32.

    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.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    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.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    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.

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    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.

    Article  PubMed  Google Scholar 

  36. 36.

    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.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    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.

    Article  PubMed  Google Scholar 

  38. 38.

    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.

    Article  PubMed  Google Scholar 

  39. 39.

    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.

    Article  PubMed  Google Scholar 

  40. 40.

    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.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank So Mitsuya, Tokumi Kanemura, Masahiro Hanabayashi, Osamu Ito, Yasuhide Kanayama, Koji Maruyama, Hiroaki Yoshida, and Toshihiro Ando for data collection.

Author information

Affiliations

Authors

Contributions

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.

Corresponding author

Correspondence to Katsuhiro Tokutake.

Ethics declarations

Conflicts of interest

The authors declare no competing interests.

Ethical approval

The approval number from our institution is 2020–0549.

Consent to participate

All patients provided written informed for their data to be used.

Consent for publication

All patients provided written informed for their data to be published.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

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 (2021). https://doi.org/10.1007/s00068-021-01729-6

Download citation

Keywords

  • Fragility fracture
  • Pelvis
  • Trauma
  • Rommens classification