The royal victoria hospital is a tertiary trauma centre receiving pelvic injury referrals for a population of 1.7 million. The use of ilio-sacral screw fixation with low anterior frame stabilisation has been adopted as the principle treatment for unstable pelvic ring injuries in our institution. We aim to describe our practice and outcomes following the use of percutaneous screw fixation of the pelvis. The review included standardised assessment of health-related quality of life (SF-36) as well as the Iowa pelvic score and Majeed pelvic injury outcome scores. Data was also collected on associated injuries, post-operative complications, nerve injury and pain scores. A total case series of 45 patients undergoing percutaneous ilio-sacral screw fixation following traumatic pelvic injury were identified over a 5 year period. Of these 23 were contactable to follow-up or responded to questionnaire review. The mean follow up was 680 days (range 151–1962). The mean age was 33 (range 18–57). The mean SF-36 physical and mental scores were 38 and 46 respectively. The mean Majeed score was 69 and Iowa pelvic score was 65. The mean pain score was 3.5 (range 0–7). There were no incidences of deep infection, post-operative PE or nerve injury related to screw insertion. Patients with isolated pelvic injuries performed better on outcome scoring however the low SF-36 scores highlight the severity of pelvic injuries

To evaluate efficacy and outcome of embolisation following pelvic ring injuries in patients presented with ongoing hypovolaemic shock. Between 2000 and 2003, 200 poly-trauma patients presented in our institutions following pelvic ring injuries. Those with ongoing hypovolaemic shock who were treated within 24h of admission with embolisation were included in this study. Demographics, mechanism of injury, ISS, type of pelvic ring fracture, arterial source of bleeding, hours from injury to embolisation, and outcome were all recorded prospectively. Out of the 200 treated in our institutions 17 (8.5%) underwent angio-embolisation. The mean age of the patients was 37 (14-70) and the mean ISS was 29. Distribution of pelvic ring injuries included: 3LC, 7APC, 7VS. The mean time from injury to embolisation was 15 hours. 8/17 patients were initially treated with an external fixator. The distribution of arterial injuries was: 7 superior gluteal arteries, 8 internal iliac arteries, 1 obturator artery and 1 internal pudental artery. The mean number of units transfused prior to embolisation was 22 (range 6-50). Mortality rate was 4 (23%) out of 17 embolised patients. Angio-embolisation for pelvic ring injuries occurred in 8.5% of our study population. This study indicates that only a small proportion of patients required embolisation secondary to arterial bleeding. The overall survival rate was in accordance to published international experience. Embolisation should be considered as a valid adjunct in some selected group of patients with pelvic fractures where ongoing bleeding refractory to other treatment modalities is present

Traditionally, unstable anterior pelvic ring injuries have been stabilised with an external fixator or by internal fixation. Recently, a new percutaneous technique of placement of bilateral supraacetabular polyaxial screws and subcutaneous connecting bar to assemble an “internal fixator” has been described. We present the surgical technique and early clinical results of using this technique in twenty-five consecutive patients with a rotationally unstable pelvic ring injury and no diastasis of the symphysis pubis treated between April 2010 and December 2013. Additional posterior pelvic stabilisation with percutaneous iliosacral screws was used in 23 of these patients. The anterior device was routinely removed after three months. Radiological evidence of union of the anterior pelvic ring was seen in 24 of 25 patients at a minimum 6 month follow-up. Thirteen patients developed sensory deficits in the lateral femoral cutaneous nerve (five bilateral) and only one fully recovered. The anterior pelvic internal fixator is a reliable, safe and easy percutaneous technique for the treatment of anterior pelvic ring injuries, facilitating the reduction and stabilisation of rotational displacement. However, lateral femoral cutaneous nerve dysfunction is common. The technique is recommended in cases with bilateral or unilateral pubic rami fractures and no diastasis of the symphysis pubis

Sacral fractures are often underdiagnosed, but are frequent in the setting of pelvic ring injuries. They are mostly caused by high velocity injuries or they can be pathological in aetiology. We sought to assess the clinical outcomes of the surgically treated unstable sacral fractures, with or without neurological deficits. unstable sacral fractures were included in the study. Single centre, prospectively collected data, retrospective review of patients who sustained vertically unstable fractures of the sacrum who underwent surgical fixation. out of a total of 432 patients with pelvis and acetabulum injuries. fifty six patients met the inclusion criteria. 18 patients had sustained zone one injuries. 14 patients had zone 2 injuries and 10 patients had zone 3 injurie. Operative fixation was performed percutaneously using cannulated screws in 18 patients.. Open fixation of the sacrum using the anterior approach in 6 patients. Posterior approach was indicates in all 10 of the zone 3 injuries of the sacrum. While in 4 patients, combined approaches were used. 3 patients had decompression and spinopelvic fixation. Neurological deficits were present in 16% of the patients. 2 patients presented with neurgenic bladder. Of the 4 patients who had neurological fall out, 3 resolved with posterior decompression and posterior fixation. All 4 neurological deficits were due to taction or compression of the nerve roots. No hardware failures or non unions observed. The rate of neurological deficit was related more to the degree of pelvic ring instability than to a particular fracture pattern. Low rates of complications and successful surgical treatment of sacral fractures is achiavable. Timeous accurate diagnosis mandatory

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

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

Deep infection after acetabular fracture surgery is a serious complication, ranging between 1.2% and 2.5% and has been a challenge for patients and surgeons. It increases length of hospital stay by three to four times due to the need of extra surgeries for debridement, impairs future patient's mobility, and increases the overall costs of care. Aim: We aim to identify pre- and intra-operative risk factors associated with deep infections in surgically treated acetabular fractures. Methods: In a single-center retrospective case-control study, 447 consecutive patients who underwent open reduction and internal fixation of acetabular fractures were included in the study. Diagnosis of surgical site infections required a combination of clinical signs and positive tissue culture or histological signs of tissue infection according to Lipsky et al (2010) and Fleischer et al (2009). To evaluate risk factors from SSI we performed uni- and multivariate analysis by multiple logistic regression. Results: Among 447 patients studied, 23 (5.1%) presented diagnosis of postoperative infection. 349 (78.1%) were male with a mean age of 33.3 years old. Posterior wall fractures accounted for 119 cases (26.6%) followed by 102 (22.8%) double column fractures and 57 (12.8%) T fractures. Factors associated with a significantly risk of infection were patient-related: older age and alcoholism (OR = 5.15, 95% CI = 1.06 to 21.98; p=0.036); trauma-related: fractures of the lower limb (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.8 to 6.78; p=0.017), comminution (OR = 3.6, 95% CI = 1.19 to 8.09; p=0.009), pelvic ring injuries (OR = 2.89, 95% CI = 1.07 to 7.63; p=0.037); and surgical-related: peri- operative complications (OR = 5.12, 95% CI = 1.85 to 13.8; p=0.001), and dislocation (OR = 0.21, 95% CI = 0.03 to 0.96; p=0.023). Duration of surgery longer than 300 min (p=0.002), and type of surgical approach (p<0.001) were also associated with infection. Conclusion: Deep infections after acetabular fracture surgery were mainly associated with prolonged duration of surgery and the interrelation with the complexity of the fracture such as double column fractures, combined surgical approach, comminution and intra operative complications. Pelvic ring injuries, lower limb fractures, mean age, no dislocations at the time of accident and alcoholism is others associations

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

Purpose of study. Unstable pelvic ring injuries usually occur in polytrauma patients and are associated with high mortality and morbidity. Percutaneous screw fixation of sacro-iliac joint dislocations, fracture-dislocations and sacral fractures is a well-recognised technique first described by Routt and is increasingly gaining popularity. This method is biomechanically comparable to open reduction and internal fixation with plates and screws but offers the advantages of minimally invasive surgical techniques. It is however a technically demanding procedure with reported complications including hardware failure, misplacement of screws, nerve injury and poor posterior reduction. The purpose of the study is to report clinical results of patients treated with closed reduction and percutaneous ilio-sacral screw fixation for unstable pelvic ring fractures by a single surgeon. Methods. A review of prospectively collected data was performed on all patients who had percutaneous sacro-iliac fixation between 2009 and 2012. Thirty five percutaneus sacro-iliac screws were inserted in 30 patients with a mean age of 25.6 years (range 17–62). Fracture types included 10 AO type B, and 20 AO type C. The mean follow-up period was 11.6 months (range 3–38). The complications assessed were screw misplacement, neurovascular complications, hardware breakage and loss of reduction. Results. All patients had a satisfactory initial reduction. One patient (2.8%) had misplacement of a screw with resultant temporary neurological fallout. One patient (2.8%) had screw misplacement without neurological fallout. Both of these patients initially had two screws inserted and the misplaced screws were removed and not reinserted. One patient (2.8%) had screw cut-out with loss of reduction. This screw was removed, open reduction peformed and the screw was re-inserted. Conclusion. The use of percutaneous sacro-iliac screws provides a safe and effective technique for the management of unstable posterior pelvic ring injuries. Our combined complication rate is comparable to published literature. NO DISCLOSURES

Aim. Posttraumatic pelvic-osteomyelitis is one of the most serious complications after pelvic-fractures. The necessary extensive surgical debridement as part of interdisciplinary treatment is complicated by the possible persistence of pelvic instability. The aim of this study was to determine the outcome and outline the course of treatment after early posttraumatic pelvic bone infections due to type-C pelvic ring injuries. Method. In a retrospective cohort study (2005–2015) all patients with pelvic-osteomyelitis within six weeks of surgical stabilization of a type-C pelvic-fracture were assessed. Microbiological results, risk factors, course of treatment and functional long-term outcome using the Orlando-Pelvic-Score were analyzed. Results. A total of 18 patients (age 43.7 years; Body-Mass-Index 27.9 kg/m2; ASA-physical-status 1.8; Injury-Severity-Score 38) developed a pelvic-osteomyelitis within an average of 27 days after internal surgical stabilization of a type-C pelvic injury (AO-type C1: 10, C2: 4, C3: 4). Os pubis was affected in 7 and Os ilium in 11 cases. In addition to the pelvic-fracture, major vascular injuries occurred in 8, nerve injuries in 9, and intestinal and/or bladder ruptures in 11 cases. In 14 cases a mass transfusion was necessary. In addition to clinical signs of inflammation, (10 × redness, 12 × wound secretion, 6 × fistula) elevated levels of c-reactive-protein (7.7 mg/dl) and white-blood-cells (10.5/nl) were found. Bacterial cultures harvested during the initial surgical revision demonstrated mixed cultures in 17/18 cases, with an average of 3 different organisms isolated per case (61% intestinal bacteria). During the scheduled repetitive debridement a reduction of the initial mixed cultures into a single organism was observed. Overall 6.8 surgical interventions, including implant removal, were necessary until osteomyelitis was eradicated. In no cases was re-osteosynthesis performed. In 6/18 cases recurrence of infection occurred after an average of 5 months, followed by an additional repetitive debridement. An average 3-year-follow-up after the initial osteomyelitis-diagnosis demonstrated eradication of infection in 17/18 cases combined with an Orlando-Pelvic-Score of 21.9 points (best possible function: 40 points). Despite significant pelvic malalignment the ability to walk was achieved in all patients, with one exception due to a spinal cord injury. Conclusions. Despite no new surgical stabilization of the initial unstable pelvic injury, the early removal of implants combined with extensive debridement and antibiotic therapy led to sufficient long-term outcomes in patients with early posttraumatic pelvic-osteomyelitis. In particular, due to the severity of the initial injury and the complex interdisciplinary approach, early diagnosis of the osteomyelitis is essential

The aim of this study was to assess the incidence, management and survival of unstable pelvic ring injuries in patient aged 65 years or older. Prospectively kept data was analysed from April 2008 to October 2016. Information regarding the mechanism, fracture type, associated injuries, treatment and complications of the treatment were collected. Annual incidence was calculated and a Kaplan Meier survival analysis for carried out at 30 days, 1 year and 5 years. 404 patient records were available. 125 were 65 years or older (60 males and 65 females). 24 (19%) patients required surgical stabilisation to permit mobilisation the remaining 101 patients, treated conservatively were mobilised with immediate weight-bearing under the supervision of a physical therapist with assistive devices. Mean age was 73.5 years (SD 9.9 yrs). Fracture types were − 61.B2 47(37.6%), 61.B1 24(32%), 61.A2 17(13.6%), 61.C1 16(12.8%), 61.C2 5(4%), 61.A1 2(1.6%) and 61.C3 3(2.4%). Mechanisms of injury included fall from standing height − 41 (32%), road traffic collisions − 46(36.8%), fall from higher than standing height − 10(8%), fall from horse − 6(4.8%), jumped from bridge − 3(2.4%) & others 19(15%). Complications in surgical group included 1 death from PE and 1 wound infection treated with vacuum assisted dressing. Survivorship was 91.7%(30 days), 82.5%(1 year) and 49.7%(5 years). Most common fracture type is 61.B2. Over one third of fractures resulted from low energy mechanism. The majority 81% could be managed conservatively. One-year survival figure closely resembles the fracture neck of femur group, highlighting the frailty of this population

Purpose of study:. The presence of an L5 transverse process fracture is reported in many texts to be a marker of pelvis fracture instability. There is paucity of literature to support this view. Available studies have been performed on patients who were already known to have a pelvis fracture. No study has attempted to document the presence of this lesion in the absence of a pelvis fracture. Primary aim: To identify the correlation between the presence of a L5 transverse process fracture and an unstable pelvic ring injury. Secondary aim: To establish whether a L5 transverse process fracture can occur in the absence of a pelvis fracture. Methods:. We conducted a retrospective review of all CT scans performed in patients who presented to a Level 1 Trauma Unit for blunt abdomino-pelvic trauma between January 1, 2012 and August 28, 2013. A total of 203 patients met our inclusion criteria. Results:. Fifty four of these 203 patients (26%) sustained a pelvis fracture. Of these 54 patients 26 (48%) had an unstable fracture pattern according to the AO classification. Five of these 26 patients (19%) had an associated L5 transverse process fracture. Seven (12%) had an L5 transverse process fracture associated with a stable fracture pattern. Three patients (1.4%) had an isolated L5 transverse process fracture in the absence of a pelvis fracture. Conclusion:. This study confirms the association between the presence of a L5 transverse process fracture and an unstable pelvis fracture pattern. This injury is rarely seen in the absence of a pelvis fracture so its presence should alert the treating clinicians to the existence of a pelvis fracture

Stoppa approach has recently been adapted for pelvic surgery as it allows direct intra-pelvic reduction and fixation of the quadrilateral plate and anterior column. We report our early experience, indications and complications with this exposure introduced in 2010 in our tertiary unit. A Retrospective review of all Stoppa approaches in pelvic-acetabular fixations was performed from a prospectively maintained database. Of the 25 patients, mean age 40 years (range 15–76), who underwent pelvic-acetabular fixation using Stoppa approach, 21 patients had mean follow up of 7.3 months (1–48 months). All except 24% of patients had one or more additional systemic injury some requiring additional surgery. There were 6 acetabular fractures, 13 pelvic ring injuries and 6 combined fractures. Mean injury-surgery interval was 9 days (range 3–20). 8 patients had an isolated Stoppa approach whilst the remaining others also had an additional approach. Mean surgical time was 239 minutes. Anatomical reduction was achieved in 96% (24/25) cases. There was 1 minor intra-operative vascular injury, repaired immediately successfully, and no late wound infections, or other visceral complications. One patient reported new onset sensory numbness which resolved after the first review. Two patients reported erectile dysfunction thought to be caused by the initial injury. One patient had asymptomatic plate loosening. None required revision surgery. Despite the obvious learning curve, we found this approach safe and it did not compromise accuracy of reduction in well selected patients, but early surgery within 10–14 days is recommended to aid optimal reduction

Background. Acetabular or pelvic ring injuries are invariably associated with high-energy trauma that could lead to a significant degree of disability. The purpose of this study was to investigate whether patients who had surgical treatment of isolated acetabular or pelvic injuries were able to return to their previous sporting activities. Patients and method. Between January 2001 and January 2002 90 patients were treated in our institution with pelvic (PF) and acetabular (AF) fractures. We excluded 22 of them who had sustained other associated injuries in order to eliminate the potential bias that the associated injuries could have on the results. Demographics, fracture classification, rehabilitation, outcome and complications were documented prospectively. Frequency, level of activity and sports participation before and after surgery, as well as EuroQol (EQ-5D) were also recorded. Results. There were 58 male and 10 female patients, with a mean age of 42 years (16-80) and mean follow-up of 30 months (24-36). 43 out of 53 (81%) patients in AF group and 13 out of 15 patients in PF group (83%) returned to a variable level of sports activity. Significant reduction was observed in those who sustained both column (BC) (p<0.04) and posterior wall (PW) (p<0.0009) fractures in the AF group. Significant reduction in frequency of sports practice was also found in the PW subgroup (p<0.0001). Patients <25 and >40 years of age in PF group and <40 or >65 in AF group had significant reduction in EQ-5D scores in comparison to the normal UK population. Conclusion. The majority of patients returned back to sports activities following surgery. The worst prognosis lies with BC and PW acetabular fractures. Middle aged patients do better as compared to younger or elderly patients in both groups