Introduction and Aims: Surgical correction of pelvic obliquity is an important component of spinal instrumentation for neuromuscular scoliosis, though instrumentation to the pelvis has high reported complication rates. This study evaluates the results of pelvic fixation during surgical correction of neuromuscular scoliosis in a consecutive series of 62 children and adolescents. Method: A retrospective chart and radiographic review of 62 consecutive patients treated with spinal fusions to the pelvis as treatment for neuromuscular scoliosis was performed. Follow-up ranged from two to seven years. Diagnoses included cerebral palsy (36 patients), muscular dystrophy (16 patients), myelomeningocele (three patients), spinal muscular atrophy (three patients) and other disorders (four patients). Mean age at surgery was 13.5 years. Pelvic fixation techniques used included Luque-Galveston or iliosacral screw fixation. Correction of deformity in each patient was assessed with Cobb angle measurements of scoliosis, thoracic kyphosis, and lumbar lordosis. Pelvic obliquity and coronal decompensation was also assessed. Results: The Luque-Galveston spinal instrumentation technique was used in 54 patients and iliosacral screw fixation was used in eight patients. Seventeen patients had an additional anterior release and fusion without instrumentation. The mean Cobb angle measured 73 degrees pre-operatively and 31 degrees (mean correction 59%) post-operatively. The mean Cobb angle on latest follow-up was 33 degrees (loss of correction 12%). Thoracic kyphosis remained essentially unchanged, as did lumbar lordosis (56 pre-op and 61 on follow-up). Pelvic obliquity corrected from a mean of 16 degrees pre-operatively to eight degrees on most recent follow-up. Mean pre-operative coronal decompensation measured 135mm, and follow-up decompensation measured 46mm. Eleven patients with Galveston fixation exhibited the ‘windshield-wiper’ sign, with a radiolucency of 2mm or more, though most were asymptomatic. Wound infection was observed in 6% (3/54) of the patients who underwent Galveston instrumentation and 50% (4/8) who had iliosacral screws. In patients treated with Galveston fixation, three had symptomatic prominant hardware and one had hardware breakage for an overall mechanical failure rate of 7% (4/54). In contrast, two patients with iliosacral screws had construct breakage and pseudoarthrosis for a mechanical failure rate of 25% (2/8), though the numbers in the iliosacral screw group are small. Conclusions: In this series, Galveston pelvic fixation during spinal instrumentation treatment of neuromuscular scoliosis was associated with satisfactory results and with less complications than generally reported in the literature. This technique is recommended as the preferred method for pelvic fixation in severe neuromuscular scoliosis associated with pelvic obliquity

Purpose: Posterior spinal fusion (PSF), with or without anterior spinal fusion (ASF), in conjunction with Luque rod instrumentation (LRI) and Galveston technique is a common procedure in neuromuscular spinal deformity. However, few studies have specifically studied the long-term results and complications of Galveston technique. The purpose of this study was to analyze the long-term results of Galveston technique in combination with PSF, with or without ASF, and LRI in the correction of neuromuscular spinal deformity. We were specifically interested in the stability of the distal foundation, lumbosacral fusion, correction of the associated pelvic obliquity, and complications.

Method: Analyzing our Pediatric Orthopaedic Spine Database between 1992–2006, we identified 107 consecutive patients with a neuromuscular spinal deformity who underwent a PSF, with or without ASF, and LRI including Galveston technique, who had a minimum of 2 years postoperative follow-up. There were 55 females and 52 males with a mean age at surgery of 13.5 ± 3.5 years. The mean follow-up was 7.8 ± 3.7 years. We analyzed the coronal and sagittal plane alignment and pelvic obliquity preoperatively, postoperatively, and at last follow-up. We recorded any complications directly related to the Galveston technique.

Results: The mean preoperative major curve was 76 ± 21 degrees. At last postoperative follow-up, this measured 33 ± 16 degrees. The mean preoperative pelvic obliquity was 17 ± 10 degrees and at last follow-up 7 ± 6 degrees. Seven patients (6.5%) had Galveston technique complications: three rod breakages, three implant distal migrations and one patient with both rod breakage and distal migration. These occurred late and only one patient required revision surgery.

Conclusion: The Galveston technique is an excellent procedure for lumbosacral stabilization in patients with neuromuscular spinal deformity. It provides a solid distal foundation for a lumbosacral fusion and for correction of spinal deformity and pelvic obliquity, with minimal complications.

The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta. There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication. The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation. This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study. The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection. Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003). This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection

Background: There are various sites for pin placement in the pelvis. Recent studies have suggested that the supra acetabular pin placement is mechanically stronger and has been recommended as an alternative. The aim of this study is to analyse the morbidity of the most commonly used pin placement sites namely, conventional pin placement into the anterior iliac crest versus the low pin placement into the supra acetabular region. Methods: Sixty one patients who required pelvic external fixation as part of their management between April 1998 and December 2001 were identified. Three patients died and were excluded from the study. Of the remaining 58 patients, 33 were treated with a supra-acetabular external fixator and 25 had an iliac crest external fixator. The majority of patients sustained the pelvic fracture as a result of road traffic accident. There were no statistically significant differences in the number of patients, mean age, length of stay, ISS or type of fractures for the two patient groups. Results: Fewer complications were noted in the supra-acetabular group versus the iliac crest group (21.2% vs. 56.0%, p< 0.05). In particular, infection rates were significantly lower in the supra-acetabular group (15.1% vs. 36%, p< 0.05). There were no significant differences between the two groups in the number of pin cut-outs or misplacements, injury to the lateral femoral cutaneous nerve or loss of reduction. Conclusion: The supra-acetabular technique of pin insertion for pelvic external fixation has fewer complications and should be utilised if an image intensifier is available. The lower rate of pin tract infection is a favourable outcome when secondary pelvic reconstructive procedures are necessary

Objectives. Osteosynthesis of anterior pubic ramus fractures using one large-diameter screw can be challenging in terms of both surgical procedure and fixation stability. Small-fragment screws have the advantage of following the pelvic cortex and being more flexible. The aim of the present study was to biomechanically compare retrograde intramedullary fixation of the superior pubic ramus using either one large- or two small-diameter screws. Materials and Methods. A total of 12 human cadaveric hemipelvises were analysed in a matched pair study design. Bone mineral density of the specimens was 68 mgHA/cm. 3. (standard deviation (. sd). 52). The anterior pelvic ring fracture was fixed with either one 7.3 mm cannulated screw (Group 1) or two 3.5 mm pelvic cortex screws (Group 2). Progressively increasing cyclic axial loading was applied through the acetabulum. Relative movements in terms of interfragmentary displacement and gap angle at the fracture site were evaluated by means of optical movement tracking. The Wilcoxon signed-rank test was applied to identify significant differences between the groups. Results. Initial axial construct stiffness was not significantly different between the groups (p = 0.463). Interfragmentary displacement and gap angle at the fracture site were also not statistically significantly different between the groups throughout the evaluated cycles (p ⩾ 0.249). Similarly, cycles to failure were not statistically different between Group 1 (8438, . sd. 6968) and Group 2 (10 213, . sd. 10 334), p = 0.379. Failure mode in both groups was characterised by screw cutting through the cancellous bone. Conclusion. From a biomechanical point of view, pubic ramus stabilisation with either one large or two small fragment screw osteosynthesis is comparable in osteoporotic bone. However, the two-screw fixation technique is less demanding as the smaller screws deflect at the cortical margins. Cite this article: Y. P. Acklin, I. Zderic, S. Grechenig, R. G. Richards, P. Schmitz, B. Gueorguiev. Are two retrograde 3.5 mm screws superior to one 7.3 mm screw for anterior pelvic ring fixation in bones with low bone mineral density? Bone Joint Res 2017;6:8–13. DOI: 10.1302/2046-3758.61.BJR-2016-0261

Background

Venous thromboembolism (VTE) is a common complication of pelvic and acetabular fracture fixation. There is, however, currently limited data to guide clinical decisions on thromboprophylaxis choice in these patients.

Determine the infection risk of nonoperative versus operative repair of extraperitoneal bladder ruptures in patients with pelvic ring injuries. Pelvic ring injuries with extraperitoneal bladder ruptures were identified from a prospective trauma registry at two level 1 trauma centers from 2014 to 2020. Patients, injuries, treatments, and complications were reviewed. Using Fisher's exact test with significance at P value < 0.05, associations between injury treatment and outcomes were determined. Of the 1127 patients with pelvic ring injuries, 68 (6%) had a concomitant extraperitoneal bladder rupture. All patients received IV antibiotics for an average of 2.5 days. A suprapubic catheter was placed in 4 patients. Bladder repairs were performed in 55 (81%) patients, 28 of those simultaneous with ORIF anterior pelvic ring. The other 27 bladder repair patients underwent initial ex-lap with bladder repair and on average had pelvic fixation 2.2 days later. Nonoperative management of bladder rupture with prolonged Foley catheterization was used in 13 patients. Improved fracture reduction was noted in the ORIF cohort compared to the closed reduction external fixation cohort (P = 0.04). There were 5 (7%) deep infections. Deep infection was associated with nonoperative management of bladder rupture (P = 0.003) and use of a suprapubic catheter (P = 0.02). Not repairing the bladder increased odds of infection 17-fold compared to repair (OR 16.9, 95% CI 1.75 – 164, P = 0.01). Operative repair of extraperitoneal bladder ruptures substantially decreases risk of infection in patients with pelvic ring injuries. ORIF of anterior pelvic ring does not increase risk of infection and results in better reductions compared to closed reduction. Suprapubic catheters should be avoided if possible due to increased infection risk later. Treatment algorithms for pelvic ring injuries with extraperitoneal bladder ruptures should recommend early bladder repair and emphasize anterior pelvic ORIF

Objective: This study investigates whether fixation down to lumbar spine only can prevent pelvic tilt compared to pelvic fixation, in the surgical treatment of Duchenne Muscular Dystrophy (DMD). Design: Retrospective and prospective clinical outcome study, with long-term follow up. Materials and Methods: Nineteen cases of DMD with scoliosis had early stabilisation (mean age 11.5 years, range 9–16) with sublaminar wires and rods, and pedicle screws up to the lumbar spine. This cohort was followed up for a mean 4.2 years (3–10 years). 31 cases in another centre had late stabilisation (mean age 14.5 years, range 10–17), with Luque rod and sublaminar wire fixation, and pelvic fixation using L-rod (22 cases) configuration or Galveston technique (9 cases) and were followed up for 4.6 years (0.5–11.5 years). Post-op morbidity, Cobb angle correction and pelvic obliquity data were collected retrospectively and prospectively for comparison. Results: In the lumbar fixation group FVC was 58%, the mean Cobb angle and pelvic obliquity were 19.8° and 9° preoperative, 3.2° and 2.2° direct postoperative, and 5.2° and 2.9° at final follow up respectively. The mean estimated blood loss was 3.3 litres and average hospital stay 7.7 days. In the pelvic fixation group FVC was 44%, the mean Cobb angle and pelvic obliquity were 48° and 19.8° preoperative, 16.7° and 7.2° direct postoperative, and 22° and 11.6° at final follow up respectively. The mean blood loss (4.1 litres) and the average hospital stay (17 days) were significantly higher (p< 0.05) compared to the lumbar fixation group. The pelvic fixation group had higher complication rate at the lower end of fixation. No progression of the pelvic obliquity was noted in the lumbar fixation group during follow up. Conclusion: Lumbar fixation may be adequate for scoliosis in DMD, if the stabilisation is performed early, before the pelvis becomes tilted, and scoliosis becomes significant. The caudal pedicular fixation in the lumbar spine stops rotation of the spine around the rods, and prevent pelvic tilt to occur. Pelvic fixation may be necessary in presence of established pelvic obliquity and larger scoliosis, but is associated with higher morbidity and complications

Introduction: Pelvic fixation is undertaken in order to restore stability to an unstable pelvis or correct severe scoliotic degeneration of the spine. Instability of the pelvic ring can result from resection of tumours, fractures of the pelvis or infection of the pelvic joints and bones. A number of methods for stabilising the pelvis have been described in the literature including the Galveston Reconstruction (GR). 1. and the triangular frame reconstruction (TFR). 2. These are associated with an improvement in functional ability, however failure of instrumentation or loosening often occurs. 3. A recent mechanical analysis of these techniques has found the technique used in this hospital (GR) performed most poorly. 2. Methods: A scoring system was developed from a retrospective analysis of 8 patients. The patients were categorised into two groups (high score and low score) based on age, presence of infection and serious non-associated comorbidities. A patient aged 60 years or over scored 5 points. Patients with bony infection scored 10 points. The presence of serious comorbidity including osteoporosis scored 5 points with minor comorbidities scoring 1 point. Results: Eight patients who underwent pelvic fixation for varied indications (2 after resection of tumours, 1 fracture, 2 scoliotic degeneration, 3 for infection) were analysed. Three patients had a good functional improvement without loosening of screws beyond 1 year after surgery. These patients were otherwise healthy, relatively young and had no disease processes that affected local bone quality at the site of fixation or serious comorbidities. The other 5 patients all showed evidence of early screw loosening within one year. Of these patients, 2 had a number of serious comorbidities well recognised to compromise bone quality (osteoporosis, long term steroid use) and 3 had pre-existing extensive bony infection. Discussion: Bone quality of the pelvic bones appears to be the primary predictor of long term functional outcome after pelvic fixation. The 5 patients who had a number of comorbidities well recognised to compromise bone quality all saw early screw loosening within 1 year. Since fixation of the pelvis requires extensive surgery necessitating both posterior and anterior approach and has a number of severe complications such as alteration of urinary, sexual and recto-sigmoid functions the benefit of pelvic fixation should be considered in light of these factors which appear to predict long term outcomes. Further prospective studies of patients undergoing pelvic fixation are required to validate our scoring system

Introduction. Many methods are available for distal anchoring of spine-based and rib-based growing rod systems for early-onset scoliosis. One of these methods, pelvic S-hooks, was initially recommended for patients with spina bifida or for those with severe thoracolumbar curves. No study has yet analysed the clinical and radiographic effects of S-hooks on patients with rib-based instrumentation. The purpose of this study is to retrospectively review the results of S-hook pelvic fixation in patients with rib-based instrumentation. Methods. A multicentre, retrospective study, approved by the institutional review board, was undetaken in all patients treated with rib-based constructs using S-hooks for pelvic fixation. Preoperative and postoperative clinical variables, radiological measurements, and the incidence and management of complications were evaluated in patients with a minimum follow-up of 2 years. Results. 44 patients, 26 of whom were girls, were studied and had a mean age at surgery of 71 months. The most common surgical indication was progressive neuromuscular scoliosis. The average preoperative Cobb angle was 64° and at most recent follow-up (mean 45 months) was 53°. The most common construct was dual rods resting over the iliac crest without suture to the iliac crest extending from T3/T4 ribs to the pelvis using domino connectors. 45% of the patients had complications, of which S-hook migration after the initial procedures was the most common. S-hook migration was corrected at the next lengthening with repositioning of the hook to the iliac crest. No correlation was detected between the complication rates and the clinical, radiographic, and surgical technique variables evaluated. Conclusions. Control of spinal deformities without fusion presents several challenges. S-hooks can migrate off the iliac crest, requiring repositioning of implants during subsequent lengthening. This finding highlights the need to explore different fixation techniques with a stronger attachment to the iliac crest

Purpose of the study. To investigate the efficacy of pedicle screw instrumentation in correcting spinal deformity in patients with quadriplegic cerebral palsy. Also to assess quality of life and functional improvement after deformity correction as perceived by the parents of our patients. Summary of Background Data. All pedicle screw constructs have been commonly used to correct adolescent idiopathic scoliosis. There is limited information on their effectiveness in treating patients with cerebral palsy and neuromuscular scoliosis. Methods. We reviewed the medical records and serial radiographs of 45 consecutive patients with quadriplegia who underwent spinal arthrodesis using pedicle screw/rod instrumentation and a standardised surgical technique (prospectively collected single surgeon's series). All patients were wheelchair bound with collapsing thoracolumbar scoliosis and pelvic obliquity. Twenty-eight patients had associated sagittal deformities. A telephone survey was performed by an independent investigator to assess parents' perception on surgical outcome. Results. Thirty-eight patients underwent posterior-only and 7 staged anteroposterior spinal arthrodesis. Mean age at surgery was 13.4 years (range 9-18.3) and mean postoperative follow-up 3.5 years (range 2.8-5). Pedicle screw instrumentation extended from T2/T3 to L5 with bilateral pelvic fixation using iliac bolts. Scoliosis was corrected from mean 82.5° to 21.4° (74.1%). Pelvic obliquity was corrected from mean 24° to 4° (83.3%). In posterior-only procedures, average blood loss was 0.8 blood volumes, ICU stay 3.5 days, and hospital stay 17.6 days. In anteroposterior procedures, average blood loss was 0.9 blood volumes, ICU stay 8.9 days, and hospital stay 27.4 days. Major complications included one deep infection and one re-operation to remove prominent implants but no deaths, no neurological deficit and no detected pseudarthrosis. Parents' survey demonstrated 100% satisfaction rate. Conclusion. Pedicle screw instrumentation can achieve excellent correction of spinopelvic deformity in quadriplegic cerebral palsy with low complication and re-operation rates and high parent satisfaction. Our study has demonstrated that spinal correction using segmental pedicle screw/rod constructs can be performed safely and with lesser major complications and reoperations compared to the traditionally used Unit rod or hybrid instrumentation. The greater degree of deformity correction and lesser rate of complications and reoperations due to non-union, prominent instrumentation or failed pelvic fixation using a pedicle screw compared to the Unit rod technique should be balanced against the increased implant cost

Simulation in surgical training has become a key component of surgical training curricula, mandated by the GMC, however commercial tools are often expensive. As training budgets become increasingly pressurised, low-cost innovative simulation tools become desirable. We present the results of a low-cost, high-fidelity simulator developed in-house for teaching fluoroscopic guidewire insertion. A guidewire is placed in a 3d-printed plastic bone using simulated fluoroscopy. Custom software enables two inexpensive web cameras and an infra-red led marker to function as an accurate computer navigation system. This enables high quality simulated fluoroscopic images to be generated from the original CT scan from which the bone model is derived and measured guidewire position. Data including time taken, number of simulated radiographs required and final measurements such as tip apex distance (TAD) are collected. The simulator was validated using a DHS model and integrated assessment tool. TAD improved from 16.8mm to 6.6mm (p=0.001, n=9) in inexperienced trainees, and time taken from 4:25s to 2m59s (p=0.011). A control group of experienced surgeons showed no improvement but better starting points in TAD, time taken and number of radiographs. We have also simulated cannulated hip screws, femoral nail entry point and SUFE, but the system has potential for simulating any procedure requiring fluoroscopic guidewire placement e.g. pedicle screws or pelvic fixation. The low cost and 3D-printable nature have enabled multiple copies to be built. The software is open source allowing replication by any interested party. The simulator has been incorporated successfully into a higher orthopaedic surgical training program

The treatment of the multi-trauma, hemodynamically unstable patient, with pelvic fractures is a major challenge for the trauma team. The use of selective embolization, in early stage when hemodynamic instability persists despite control of other sources of bleeding, is well established. In these cases bleeding from an injured artery, cannot be controlled through indirect means such as an external fixation device, and must be directly addressed, through laparotomy and retroperitoneal packing or direct embolization of the bleeding artery. This procedure is part of the C phase of the ATLS, and therefore must be carried out in an emergency setup requiring a well trained team that can be alerted 24 hours a day. We present our experience and preferred protocol for the treatment of these complex injuries. Material and Methods: Between the years 2000 and 2004, 732 patients with pelvic fractures were treated in our center. Of these, 11 patients with complex pelvic fractures required emergency arteriography and embolization. All the cases involved high energy injuries, eight motor vehicle accidents, two falls from height and one crush injury. The average age was 32 (range 21 to 78). The pelvic fracture type was an anterior posterior mechanism in eight cases where the artery injured was the pudendal artery. In three cases iliac wing injury in a lateral compression or sheer mechanism, caused a gluteal artery injury. Timing of treatment: in 5 cases angiography was performed directly after an initial CT, in 4 cases the embolization was performed following an emergent laparotomy. In the remaining two cases, instability was recognized later in the course of treatment, one following amputation of a mangled leg and the second after secondary deterioration in a head injured multi-trauma patient. Five patients went through pelvic fixation by an external fixation device, applied prior to angiography of which two were surgically applied and three were treated with a pelvic belt. In five patients no pelvic fixation was needed either initially or definitively. Discussion: When available angiographic embolization can be used affectively in these selected cases. Pelvic fractures can present with arterial injury even with a clinically stable pelvic ring. An arterial injury must be considered in all severe pelvic injuries regardless of the pelvic ring stability. We recommend strongly to use the belt as an intermittent way of controlling the hemodynamic instability and not to delay direct means of hemorrhage control such as laparotomy or embolization – if there is a team ready in the hospital. We must consider that the delay in treatment, short as it may be, needed for application the external fixation devices, may be crucial for the survival of the patient

There has been a trend towards operative management of pelvic injuries. Posterior pelvic integrity is more important for functional recovery. Percutaneous iliosacral screw fixation is being increasingly preferred for posterior pelvic stabilisation. Outcome reporting for this procedure remains inconsistent and un-standardised. Retrospectively, all percutaneous iliosacral screw fixations done at this institute during a 5-year period (2008–2012) were reviewed. 28 patients, who had had at least 12 months follow-up, were contacted and clinical scoring was done by postal correspondence. Radiographs were measured for displacements and leg-length discrepancy. Possible factorial associations and correlations were investigated. Mean Majeed score was 83 (median 87), mean EQ-Visual Analog Score (EQ-VAS) was 75.5 (median 80) and the two scores were correlated with statistical significance. Tile AO type C injuries produced worse outcomes and patients who'd anterior pelvic fixation did better. Our results show high patient-reported outcomes, excellent radiologically measured reductions and unions. The incidence of complications is very low. There is a significant correlation between the EQ-VAS arm of the EQ5D instrument and the Majeed score in this patient population. Incidence of non-pelvic surgical procedures in these patients was significantly associated with worse outcomes. Leg length discrepancies appeared to increase after patients were fully weight bearing

Aim. Evaluate the outcome and complications of anterior pubic symphysis plating in the stabilisation of traumatic anterior pelvic ring injuries. Methods. All patients who underwent pubic symphysis plating in a tertiary referral unit were studied. Fracture classification, type of fixation, complications, and incidence of metalwork failure were recorded. Results. Out of 178 consecutive patients, 159 (89%) were studied for a mean of 41 months. There were 121 males and 38 females (mean age 38 years). Symphysis pubic fixation was performed in 105 AO-OTA type B and 54 type C injuries using a Matta symphyseal plate (n = 92), reconstruction plate (n = 65), or DCP (n = 2). Supplementary posterior pelvic fixation was performed in 103 patients. 6 patients required revision for failure of fixation or symptomatic instability of the pubic symphysis. A further 7 patients had metalwork removed for other reasons. Metalwork breakage occurred in 66 patients (42%), at a mean of 17 months. 64 of these 66 patients were asymptomatic and metalwork was left in situ. Conclusions. Plate fixation of the symphysis pubis is an effective method of stabilising anterior pelvic ring injuries with a low complication rate. There is a high rate of late metalwork breakage, but this is not clinically significant

There is controversy regarding the optimum method of stabilising traumatic anterior pelvic ring injuries. This study aimed to evaluate the role of pubic symphysis plating. Methods. All patients who underwent pubic symphysis plating in a regional pelvic and acetabular unit were studied. Fracture classification, type of fixation, complications, and incidence of metalwork failure were recorded. Results. Out of 178 consecutive patients, 159 (89%) were studied for a mean of 37.6 months. There were 121 males and 38 females (mean age 43 years). Symphysis pubic fixation was performed in 100 AO-OTA type B and 59 type C injuries using a Matta symphyseal plate (n=92), reconstruction plate (n=65), or DCP (n=2). Supplementary posterior pelvic fixation was performed in 102 patients. 5 patients required revision for failure of fixation or symptomatic instability of the pubic symphysis. A further 7 patients had metalwork removed for other reasons. Metalwork breakage occurred in 63 patients (40%). 62 of these 63 patients were asymptomatic and metalwork was left in situ. Conclusions. Plate fixation of the symphysis pubis is an effective method of stabilising anterior pelvic ring injuries with a low complication rate. There is a high rate of late metalwork breakage, but this is not clinically significant

Aim. To evaluate the outcome and complications of pubic symphysis plating in the stabilisation of traumatic anterior pelvic ring injuries. Methods. All patients who underwent anterior pelvic ring stabilisation with a pubic symphysis plate in a tertiary referral pelvic and acetabular reconstruction unit were studied. Patients were followed up annually for five years with AP, inlet and outlet radiographs at each visit. The fracture classification, type of fixation (including additional posterior fixation), and incidence of metalwork failure were recorded. Results. In a series of 178 consecutive patients, 159 (89%) were studied for a mean of 41 months (range 3 months to 13 years). There were 121 males and 38 females, with a mean age of 38 years (9-80yrs). Symphysis pubic fixation was performed in 105 AO-OTA type B and 54 AO-OTA type C injuries using a Matta symphyseal plate in 92, a reconstruction plate in 65, or a DCP in two patients. Supplementary posterior pelvic fixation was performed in 103 patients. Six patients (3.8%) required revision for failure of fixation or symptomatic instability of the pubic symphysis. A further seven patients (4%) had metalwork removed for other reasons. Metalwork breakage occurred in 66 patients (42%). 64 of these 66 patients were asymptomatic and metalwork was left in situ. Conclusion. Plate fixation of the symphysis pubis is an effective method of stabilising anterior pelvic ring injuries with a low rate of complications. There is a high rate of late metalwork breakage, but this is often not clinically significant

The development of spinal deformity in children with underlying neurodisability can affect their ability to function and impact on their quality of life, as well as compromise provision of nursing care. Patients with neuromuscular spinal deformity are among the most challenging due to the number and complexity of medical comorbidities that increase the risk for severe intraoperative or postoperative complications. A multidisciplinary approach is mandatory at every stage to ensure that all nonoperative measures have been applied, and that the treatment goals have been clearly defined and agreed with the family. This will involve input from multiple specialities, including allied healthcare professionals, such as physiotherapists and wheelchair services. Surgery should be considered when there is significant impact on the patients’ quality of life, which is usually due to poor sitting balance, back or costo-pelvic pain, respiratory complications, or problems with self-care and feeding. Meticulous preoperative assessment is required, along with careful consideration of the nature of the deformity and the problems that it is causing. Surgery can achieve good curve correction and results in high levels of satisfaction from the patients and their caregivers. Modern modular posterior instrumentation systems allow an effective deformity correction. However, the risks of surgery remain high, and involvement of the family at all stages of decision-making is required in order to balance the risks and anticipated gains of the procedure, and to select those patients who can mostly benefit from spinal correction.

Objectives. The additive use of an external modular device may improve dorsal compression forces in pelvic external fixation. This would improve the efficiency of indirect reduction and stabilization with an anterior pelvic external fixator. The purpose of this study was to determine the forces of the posterior pelvis achieved by a new device improving the application of a supraacetabular anterior external fixator compared with other constructs. Material and Method. Synthetic pelvic models were used. Complete pelvic ring instability was created by symphyseal and unilateral sacroiliac joint disruption. Four different constructs of fixation were tested. A pressure-sensitive film was placed in the sacroiliac joint. The constructs were applied in a standardized way. The maximum sacroiliacal compression loads (N) of each trial was recorded. Statistics was performed with the student t-test. Results. Standard supraacetabular two-pin external fixator achieved a dorsal compression load of 13.84 (SD 8.13). The new dorsal pelvic compression device delivered 177.05N (SD 32.32) of load across the sacroiliac joint when the pins were inserted half way and 183.58N (SD 46.64) with full pin insertion. Both the half- and full-pin construct demonstrated a significant dorsal load improvement with the pelvic compressor (p<0.05) compared with the standard supraacetabular fixator group. The C-clamp revealed compression forces of 384.88N (SD 22.95), which was significantly greater than all the other groups (p<0.05). Conclusion. We tested a simple and new modular device for improved application of pelvic external fixation. The centres of rotation of supra-acetabular pins were determined and used to achieve greater dorsal compression forces in disrupted pelvic ring injuries. The compression load is less than with a C-Clamp, but significantly greater than the familiar technique of standard external supra-acetabular fixation. This improves the initial stability in acute management of unstable, disrupted and life threatening pelvic ring fractures

The safety and efficacy of bone-healing enhancement with Bone Morphogenetic Protein-7 (BMP) has been studied in the clinical setting of persistent post-traumatic and post-partum pelvic instability. Prospective collection and analysis of all cases with pelvic ring instability after trauma or childbirth, treated with reconstruction and local application of BMP-7. Patient demographics, hospitalisation, operative interventions before and after the BMP-7 grafting, and follow-up data were recorded and evaluated. The median follow-up period was 1 year (range 12 to 18 months). Over a two-year period (March 2005 – January 2007) nine patients (8 females) with median age of 39 years (31–62) were operated for persistent pelvic instability and pain. The mean number of previous operations was 1,6 procedures. Reconstruction of the pelvic ring included 4 cases of post-partum pubic symphysis instability, 2 traumatic non-unions of pubis symphysis and 3 sacroiliatis (1-septic and 2-aseptic). Reconstruction included double plating of pubis symphysis (4-cases), external pelvic fixation (2-cases), sacroiliac screw fixation (1-case) and anterior sacroiliac plating (2-cases). In 4 cases BMP-7 was used alone; in 5 it was used together with iliac crest autograft. All patients were mobilizing with a wheelchair for a period of 8 weeks (6–12) before progressing to full weight bearing. Clinical and radiological union occurred in 8/9 cases at a median time of 14 weeks (range 12–20). One female patient with post-partum pubic symphysis instability and a chronic psychiatric disorder is still complaining of pain despite the radiological evidence of progress of fusion. The rest reported resolution of symptoms. No local or systemic complications or adverse events associated with the use of BMP-7 were recorded. The application of BMP-7 alone or supplementing autografting has been proven to be radiologically 100% and clinically 90% successful and safe following pelvic ring reconstruction as seen in this series of patients