Aims

The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture.

We performed a systematic review of the literature to evaluate the use and interpretation of generic and disease-specific functional outcome instruments in the reporting of outcome after the surgical treatment of disruptions of the pelvic ring. A total of 28 papers met our inclusion criteria, with eight reporting only generic outcome instruments, 13 reporting only pelvis-specific outcome instruments, and six reporting both. The Short-Form 36 (SF-36) was by far the most commonly used generic outcome instrument, used in 12 papers, with widely variable reporting of scores. The pelvis-specific outcome instruments were used in 19 studies; the Majeed score in ten, Iowa pelvic score in six, Hannover pelvic score in two and the Orlando pelvic score in one. Four sets of authors, all testing construct validity based on correlation with the SF-36, performed psychometric testing of three pelvis-specific instruments (Majeed, IPS and Orlando scores). No testing of responsiveness, content validity, criterion validity, internal consistency or reproducibility was performed.

The existing literature in this area is inadequate to inform surgeons or patients in a meaningful way about the functional outcomes of these fractures after fixation.

Aims. The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization. Patients and Methods. The study used data from the German Pelvic Trauma Registry and compared patients undergoing conservative management (n = 2394), surgical treatment (n = 1345) and transpubic surgery, including posterior stabilization (n = 730) with isolated posterior osteosynthesis (n = 405) in non-complex Type B and C fractures that only involved the obturator ring anteriorly. Calculated odds ratios were adjusted for potential confounders. Outcome criteria were intraoperative and general short-term complications, the incidence of nerve injuries, and mortality. Results. Operative stabilization reduced mortality by 36% (odds ratio (OR) 0.64, 95% confidence interval (CI) 0.42 to 0.98) but the incidence of complications was twice as high (OR 2.04, 95% CI 1.57 to 2.64). Mortality and the incidence of neurological deficits at discharge were no different after isolated posterior or combined anteroposterior fixation. However, the odds of both surgical (98%, OR 1.98, 95%CI 1.22 to 3.22) and general complications (43%, OR 1.43, 95% CI 1.02 to 2.00) were higher in the group with the more extensive surgery. Conclusion. Operative stabilization is recommended for non-complex unstable pelvic fractures. The need for anterior fixation of obturator ring fractures should, however, be considered critically. Cite this article: Bone Joint J 2018;100-B:973–83

We report the incidence and location of deep-vein thrombosis in 312 patients who had sustained high-energy, skeletal trauma. They were investigated using magnetic resonance venography and Duplex ultrasound. Despite thromboprophylaxis, 36 (11.5%) developed venous thromboembolic disease with an incidence of 10% in those with non-pelvic trauma and 12.2% in the group with pelvic trauma. Of patients who developed deep-vein thrombosis, 13 of 27 in the pelvic group (48%) and only one of nine in the non-pelvic group (11%) had a definite pelvic deep-vein thrombosis. When compared with magnetic resonance venography, ultrasound had a false-negative rate of 77% in diagnosing pelvic deep-vein thrombosis. Its value in the pelvis was limited, although it was more accurate than magnetic resonance venography in diagnosing clots in the lower limbs. Additional screening may be needed to detect pelvic deep-vein thrombosis in patients with pelvic or acetabular fractures

We describe the impact of a targeted performance improvement programme and the associated performance improvement interventions, on mortality rates, error rates and process of care for haemodynamically unstable patients with pelvic fractures. Clinical care and performance improvement data for 185 adult patients with exsanguinating pelvic trauma presenting to a United Kingdom Major Trauma Centre between January 2007 and January 2011 were analysed with univariate and multivariate regression and compared with National data. In total 62 patients (34%) died from their injuries and opportunities for improved care were identified in one third of deaths. Three major interventions were introduced during the study period in response to the findings. These were a massive haemorrhage protocol, a decision-making algorithm and employment of specialist pelvic orthopaedic surgeons. Interventions which improved performance were associated with an annual reduction in mortality (odds ratio 0.64 (95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction in error rates (p = 0.024) and significant improvements in the targeted processes of care. Exsanguinating patients with pelvic trauma are complex to manage and are associated with high mortality rates; implementation of a targeted performance improvement programme achieved sustained improvements in mortality, error rates and trauma care in this group of severely injured patients. Cite this article: Bone Joint J 2014;96-B:1090–7

There are unacceptable delays in the management of pelvic trauma in the United Kingdom. In 2003 this became a political issue after TV and radio coverage. Changes to the service were introduced, including trauma coordinators and a special tariff, but has it made a difference?

Four patients with injuries of the acetabular triradiate cartilage are presented. In three of them premature fusion of the cartilage occurred; two of these developed acetabular deformity and subluxation of the hip. In all patients the sacroiliac joint also was injured; in two, the joint was completely disrupted, leading to fusion and growth disturbance of the ilium. As injury of the triradiate cartilage is easily missed on the initial radiograph, it is advised that all patients with pelvic trauma should be followed clinically and radiographically for at least one year

Aims

Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA).

Aims

This study sought to establish the prevalence of the cross over sign (COS) and posterior wall sign (PWS) in relation to the anterior pelvic plane (APP) in an asymptomatic population through reliable and accurate 3D-CT based assessment.

Aims

We performed a retrospective, comparative study of elderly patients with an increased risk from anaesthesia who had undergone either anterior screw fixation (ASF) or halo vest immobilisation (HVI) for a type II odontoid fracture.

The open blast fracture of the pelvis is considered to be the most severe injury within the spectrum of battlefield trauma. We report our experience of 29 consecutive patients who had sustained this injury in Afghanistan between 2008 and 2010. Their median new injury severity score (NISS) was 41 (8 to 75), and mean blood requirement in the first 24 hours was 60.3 units (0 to 224). In addition to their orthopaedic injury, six had an associated vascular injury, seven had a bowel injury, 11 had a genital injury and seven had a bladder injury. In all, eight fractures were managed definitively with external fixation and seven required internal fixation. Of those patients who underwent internal fixation, four required removal of metalwork for infection. Faecal diversion was performed in nine cases. The median length of hospital stay following emergency repatriation to the United Kingdom was 70.5 days (5 to 357) and the mean total operating time was 29.6 hours (5 to 187). At a mean follow-up of 20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk and 26 (89.7%) had clinical and radiological evidence of stability of the pelvic ring.

As a result of the increase in terrorism, injuries that were previously confined exclusively to warfare can now occur anywhere, with civilian surgeons who are involved in trauma care potentially required to manage similar injuries. Our study demonstrates that the management of this injury pattern demands huge resources and significant multidisciplinary input. Given the nature of the soft-tissue injury, we would advocate external fixation as the preferred management of these fractures. With the advent of emerging wound and faecal management techniques, we do not believe that faecal diversion is necessary in all cases.

Unstable pelvic injuries in young children with an immature pelvis have different modes of failure from those in adolescents and adults. We describe the pathoanatomy of unstable pelvic injuries in these children, and the incidence of associated avulsion of the iliac apophysis and fracture of the ipsilateral fifth lumbar transverse process (L5-TP). We retrospectively reviewed the medical records of 33 children with Tile types B and C pelvic injuries admitted between 2007 and 2014; their mean age was 12.6 years (2 to 18) and 12 had an immature pelvis. Those with an immature pelvis commonly sustained symphyseal injuries anteriorly with diastasis, rather than the fractures of the pubic rami seen in adolescents. Posteriorly, transsacral fractures were more commonly encountered in mature children, whereas sacroiliac dislocations and fracture-dislocations were seen in both age groups. Avulsion of the iliac apophysis was identified in eight children, all of whom had an immature pelvis with an intact ipsilateral L5-TP. Young children with an immature pelvis are more susceptible to pubic symphysis and sacroiliac diastasis, whereas bony failures are more common in adolescents. Unstable pelvic injuries in young children are commonly associated with avulsion of the iliac apophysis, particularly with displaced SI joint dislocation and an intact ipsilateral L5-TP.

Cite this article: Bone Joint J 2015; 97-B:696–704.

We prospectively studied the outcome of a protocol of prophylaxis for deep vein thrombosis (DVT) in 103 consecutive patients undergoing surgical stabilisation of pelvic and acetabular fractures. Low-molecular-weight heparin (LMWH) was administered within 24 hours of injury or on achieving haemodynamic stability. Patients were screened for proximal DVT by duplex ultrasonography performed ten to 14 days after surgery.

The incidence of proximal DVT was 10% and of pulmonary embolus 5%. Proximal DVT developed in two of 64 patients (3%) who had received LMWH within 24 hours of injury, but in eight of 36 patients (22%) who received LMWH more than 24 hours after the injury (p < 0.01). We conclude that LMWH, when begun without delay, is a safe and effective method of thromboprophylaxis in high-risk patients with major pelvic or acetabular fractures.

The types of explosive devices used in warfare and the pattern of war wounds have changed in recent years. There has, for instance, been a considerable increase in high amputation of the lower limb and unsalvageable leg injuries combined with pelvic trauma.

The conflicts in Iraq and Afghanistan prompted the Department of Military Surgery and Trauma in the United Kingdom to establish working groups to promote the development of best practice and act as a focus for research.

In this review, we present lessons learnt in the initial care of military personnel sustaining major orthopaedic trauma in the Middle East.

The aim of this study was to assess the accuracy of placement of pelvic binders and to determine whether circumferential compression at the level of the greater trochanters is the best method of reducing a symphyseal diastasis.

Patients were identified by a retrospective review of all pelvic radiographs performed at a military hospital over a period of 30 months. We analysed any pelvic radiograph on which the buckle of the pelvic binder was clearly visible. The patients were divided into groups according to the position of the buckle in relation to the greater trochanters: high, trochanteric or low. Reduction of the symphyseal diastasis was measured in a subgroup of patients with an open-book fracture, which consisted of an injury to the symphysis and disruption of the posterior pelvic arch (AO/OTA 61-B/C).

We identified 172 radiographs with a visible pelvic binder. Five cases were excluded due to inadequate radiographs. In 83 (50%) the binder was positioned at the level of the greater trochanters. A high position was the most common site of inaccurate placement, occurring in 65 (39%). Seventeen patients were identified as a subgroup to assess the effect of the position of the binder on reduction of the diastasis. The mean gap was 2.8 times greater (mean difference 22 mm) in the high group compared with the trochanteric group (p < 0.01).

Application of a pelvic binder above the level of the greater trochanters is common and is an inadequate method of reducing pelvic fractures and is likely to delay cardiovascular recovery in these seriously injured patients.

This study was designed to provide normal reference values for the centre-edge angle of Wiberg in the Chinese population by measuring 1494 radiographs according to the criteria of Tönnis. The mean angle was 23.1° (4.7° to 46.4°) in childhood (four to nine years), increasing to 28.9° (6° to 48°) in adolescence (10 to 18 years) and reaching 32.8° (13.7° to 58.8°) in adults. The angle was positively correlated with age, increasing by a mean of 0.78° annually before adulthood and by 0.070° annually in adults. A relative upward tendency after middle age might contribute to degenerative changes. No gender difference was discovered. The change in the angle with age was similar to that observed in other ethnic groups, showing moderate differences in the average of individual age groups, but the ethnic differences are not sufficient to explain the variation of incidence of developmental dysplasia of the hip in different races.

The purpose of this study was to assess the stability of a developmental pelvic reconstruction system which extends the concept of triangular osteosynthesis with fixation anterior to the lumbosacral pivot point. An unstable Tile type-C fracture, associated with a sacral transforaminal fracture, was created in synthetic pelves. The new concept was compared with three other constructs, including bilateral iliosacral screws, a tension band plate and a combined plate with screws. The pubic symphysis was plated in all cases. The pelvic ring was loaded to simulate single-stance posture in a cyclical manner until failure, defined as a displacement of 2 mm or 2°. The screws were the weakest construct, failing with a load of 50 N after 400 cycles, with maximal translation in the craniocaudal axis of 12 mm. A tension band plate resisted greater load but failure occurred at 100 N, with maximal rotational displacement around the mediolateral axis of 2.3°.

The combination of a plate and screws led to an improvement in stability at the 100 N load level, but rotational failure still occurred around the mediolateral axis. The pelvic reconstruction system was the most stable construct, with a maximal displacement of 2.1° of rotation around the mediolateral axis at a load of 500 N.

We have examined the accuracy of reduction and the functional outcomes in elderly patients with surgically treated acetabular fractures, based on assessment of plain radiographs and CT scans. There were 45 patients with such a fracture with a mean age of 67 years (59 to 82) at the time of surgery. All patients completed SF-36 questionnaires to determine the functional outcome at a mean follow-up of 72.4 months (24 to 188). All had radiographs and a CT scan within one week of surgery. The reduction was categorised as ‘anatomical’, ‘imperfect’, or ‘poor’.

Radiographs classified 26 patients (58%) as anatomical,13 (29%) as imperfect and six (13%) as poor. The maximum displacement on CT showed none as anatomical, 23 (51%) as imperfect and 22 (49%) as poor, but this was not always at the weight-bearing dome. SF-36 scores showed functional outcomes comparable with those of the general elderly population, with no correlation with the radiological reduction.

Perfect anatomical reduction is not necessary to attain a good functional outcome in acetabular fractures in the elderly.

Bleeding is a major complication of revision total hip replacement. We report a case where the inflated balloon of a urinary catheter was used to temporarily control intrapelvic bleeding from the superior gluteal artery, while definitive measures for endovascular embolisation were made.

Payments by the NHS Litigation Authority continue to rise each year, and reflect an increase in successful claims for negligence against NHS Trusts. Information about the reasons for which Trusts are sued in the field of trauma and orthopaedic surgery is scarce.

We analysed 130 consecutive cases of alleged clinical negligence in which the senior author had been requested to act as an expert witness between 2004 and 2006, and received information on the outcome of 97 concluded cases from the relevant solicitors. None of the 97 cases proceeded to a court hearing. Overall, 55% of cases were abandoned by the claimants’ solicitors, and the remaining 45% were settled out of court. The cases were settled for sums ranging from £4500 to £2.7 million, the median settlement being £45 000. The cases that were settled out of court were usually the result of delay in treatment or diagnosis, or because of substandard surgical technique.