Axel Gänsslen

Epidemiology of pelvic ring injuries

3260 patients with pelvic and acetabular fractures were assessed using a standardized documentation form by collating the data on 1905 patients treated at the Department of Traumatology of the Hannover Medical School together with those patients treated between 1991 and 1993 in the German Multicentre Study Group (Pelvis) of the German Trauma Society and the German Section of the AO International. 2551 patients had pelvic ring injuries. 61.7% of the patients were multiply injured. 12.2% were suffering a complex pelvic trauma defined as a pelvic injury with concomitant soft tissue injury. The pelvic ring fracture was classified as stable in 54.8% (type A injury), as rotationally unstable in 24.7% (type B injury), and as unstable in translation in 20.5% (type C injury). There were concomitant acetabular fractures in 15.7%. The most frequent single lesions affecting the pelvic girdle were fractures of the ischiopubic bones (transpubic instability), injuries involving the sacroiliac joint (transiliosacral instability), and sacral fractures (transsacral instability). The overall rate of operative stabilizations was 21.6%. Type B injuries were stabilized in 28.9% and type C injuries in 46.7%. The overall mortality rate was 13.4%, depending significantly on the associated extrapelvic trauma. In complex pelvic injuries, the mortality rate was 31.1% whereas for pelvic fractures without concomitant soft tissue injury the rate was only 10.8%.

Hemorrhage in pelvic fracture: who needs angiography?

Pelvic fractures are rare but potentially devastating injuries. An understanding of the bony and peripelvic anatomy along with common patterns and the classification of the injury are of critical importance in their management. These form the basis for a general treatment algorithm for pelvic fracture patients. Angiographic embolization is time-consuming and often delayed. Hemodynamic instability with unstable pelvic fracture is therefore best approached with a combination of pelvic emergency stabilization (C-clamp) and surgical hemostasis by pelvic tamponade. This is especially true for critically injured patients in extremis.

Outcome after pelvic ring injuries

Open reduction and internal fixation of unstable pelvic ring fractures provides the best stability of fixation as well as the best late clinical results. Whereas several studies have supported this both in biomechanical studies and clinical trials, there is still controversy about the long-term outcome of these injuries. A series of 58 patients who had received surgical stabilization of Tile B- and C-type fractures between 1985 and 1990 were followed up for an average of 28 months. The follow-up included a detailed clinical and radiological examination, an evaluation of the patients general social status and a detailed neurological and urological screening. The data were summarized in a new scoring system rating radiological, clinical and social results independently. Patients suffering B-type fractures showed 79% good and excellent results. Despite the fact that after C-type fractures 50% healed anatomically and 30% healed with a 5 mm or less residual posterior displacement, only 27% of the patients were rated good or excellent. Further studies must be conducted for closer evaluation of risk factors influencing the results after anatomical reconstruction of the pelvic ring.

Survival trends and predictors of mortality in severe pelvic trauma: Estimates from the German Pelvic Trauma Registry Initiative

STUDY OBJECTIVE To determine longitudinal trends in mortality, and the contribution of specific injury characteristics and treatment modalities to the risk of a fatal outcome after severe and complex pelvic trauma. METHODS We studied 5048 patients with pelvic ring fractures enrolled in the German Pelvic Trauma Registry Initiative between 1991 and 1993, 1998 and 2000, and 2004 and 2006. Complete datasets were available for 5014 cases, including 508 complex injuries, defined as unstable fractures with severe peri-pelvic soft tissue and organ laceration. Multivariable mixed-effects logistic regression analysis was employed to evaluate the impact of demographic, injury- and treatment-associated variables on all-cause in-hospital mortality. RESULTS All-cause in-hospital mortality declined from 8% (39/466) in 1991 to 5% (33/638) in 2006. Controlling for age, Injury Severity Score, pelvic vessel injury, the need for emergency laparotomy, and application of a pelvic clamp, the odds ratio (OR) per annum was 0.94 (95% confidence interval [CI] 0.91-0.96). However, the risk of death did not decrease significantly in patients with complex injuries (OR 0.98, 95% CI 0.93-1.03). Raw mortality associated with this type of injury was 18% (95% CI 9-32%) in 2006. CONCLUSION In contrast to an overall decline in trauma mortality, complex pelvic ring injuries remain associated with a significant risk of death. Awareness of this potentially life-threatening condition should be increased amongst trauma care professionals, and early management protocols need to be implemented to improve the survival prognosis.

Heterotopic ossifications in patients after severe blunt trauma with and without head trauma: incidence and patterns of distribution.

Objective To investigate the incidence and distribution of heterotopic ossifications in patients with blunt multiple trauma with and without associated head trauma. Design Retrospective. Setting Level I trauma center. Patients Patients were included if they were treated between August 1987 and September 1995. Inclusion criteria included age between 16 and 65 years, injury severity score (ISS) of more than twenty points, and clinical reexamination performed more than three years after the initial injury. Methods The records of each patient were abstracted to determine the ISS, the Glasgow coma score (GCS), and parameters describing the course of intensive care. For each patient, a reexamination was performed between January and September 1998. Patients with multiple trauma and associated head trauma (Group PTH, polytrauma, GCS less than nine points, and head computed tomography scan abnormalities) and patients with multiple trauma without associated head trauma (Group PT, polytrauma, GCS of at least nine points, and normal head computed tomography scans) were compared. A clinical reexamination was performed to evaluate functional outcome. Results Sixty-four patients belonged to Group PTH and 124 patients belonged to Group PT. There were no differences in the age (Group PTH, 28.9 ± 1.6 years; Group PT, 29.2 ± 2.1 years) or severity of injury (ISS Group PTH, 31.0 ± 5.3 points; ISS Group PT, 33.0 ± 6.1 points) among patients in the two groups. The overall incidence of periarticular heterotopic ossification was comparable in patients with multiple trauma with and without head injury (Group PTH, 30 of 64 patients [46.9 percent]; Group PT, 53 of 124 patients [42.7 percent]). The duration of ventilation was significantly higher in Group PT (Group PTH, 9.3 ± 2.4 days; Group PT, 14.2 ± 3.1 days;p = 0.02). In the subgroups in which heterotopic ossification developed (PT-HO and PTH-HO), patients in PT-HO had a significantly higher incidence of heterotopic ossification, as compared with patients in PTH-HO at initially uninjured joints (Group PTH-HO, 1 of 30 patients [3.3 percent]; Group PT-HO, 10 of 53 patients [18.9 percent];p = 0.04). Conclusions There was a high incidence of heterotopic ossification around those joints that were initially classified as uninjured in patients without head trauma. This finding suggests that pathogenic pathways independent of head trauma, such as long-term ventilation, play a main role. Causative factors for the development of heterotopic ossification at initially uninjured joints in long-term ventilated patients with multiple trauma with and without head trauma remain to be elucidated.

Percutaneous iliosacral screw fixation of unstable pelvic injuries by conventional fluoroscopy.

ZusammenfassungOperationszielGeschlossene Reposition und Retention von translatorisch instabilen Verletzungen des Beckenrings (Typ-C-Verletzungen) zur Wiederherstellung der Form und Funktion des dorsalen Beckenrings durch perkutane iliosakrale Schraubenosteosynthese mit Hilfe konventioneller Bildwandlertechnik.IndikationenDefinitive Behandlung des dorsalen Beckenrings bei Typ-C-Verletzungen (AO-Klassifikation) mit kompletter Sakrumfraktur, Luxation des Sakroiliakalgelenks (SI-Gelenk), transiliakaler oder transsakraler Luxationsfraktur des SI-Gelenks mit unbedeutend kleinem Fragment und Sakrumausbruchverletzungen, die sich geschlossen nahezu anatomisch reponieren lassen.KontraindikationenSchlechter Allgemeinzustand, lokaler Weichteilschaden, rotationsinstabile Beckenverletzungen vom Typ B sowie Typ-C-Verletzungen, die sich geschlossen nur unzureichend reponieren lassen.OperationstechnikGeschlossene Reposition, Stichinzision und perkutane Stabilisierung des hinteren Beckenrings durch transiliosakrale Schraubenosteosynthese unter Bildwandlerkontrolle.WeiterbehandlungTeilbelastung der verletzten Seite mit 15 kg für 8–12 Wochen mit zwei Unterarmgehstützen.Implantatentfernung 6–12 Monate nach der Verletzung.ErgebnisseBei 20 Patienten mit transforaminaler Sakrumfraktur im Rahmen einer Beckenverletzung vom Typ C wurde unter Bildwandlerkontrolle eine transiliosakrake Fixation mit kanülierten 7,3-mm-Schrauben in den Wirbelkörper S1 durchgeführt. Die durchschnittliche präoperative Fehlstellung von 3,8 mm konnte im Rahmen der geschlossenen Reposition postoperativ auf 1,6 mm reduziert werden. Die mittlere Operationszeit betrug 55 min, die mittlere Durchleuchtungszeit 2,22 min. Eine Schraubenfehllage ohne Konsequenz wurde bei drei Patienten beobachtet; iatrogene Nervenverletzungen lagen nicht vor. Alle Frakturen heilten innerhalb von 3 Monaten aus.AbstractObjectiveClosed reduction and retention of translatory unstable pelvic injuries (type C injuries), in order to restore the form and function of the posterior pelvis by percutaneous iliosacral screw osteosynthesis, using conventional fluoroscopy.IndicationsDefinitive treatment of the posterior pelvis in type C injuries (AO classification) with complete sacral fracture, sacroiliac joint (SI joint) dislocation, transiliac or transsacral dislocation fracture of the SI joint with insignificant small fragment and sacroiliac avulsion injuries which can be reduced almost anatomically in closed technique.ContraindicationsPoor general health, local soft-tissue damage, rotationally unstable type B pelvic injuries as well as type C injuries which cannot be reduced satisfactorily in closed technique.Surgical TechniqueClosed reduction, stab incision and percutaneous stabilization of the posterior pelvis by transiliosacral screw osteosynthesis, guided by fluoroscopy.Postoperative ManagementPartial loading of the injured side with 15 kg for 8–12 weeks with two underarm crutches.Implant removal 6–12 months after injury.Results20 patients with a transforaminal sacral fracture consistent with a type C pelvic injury underwent screw fixation with fluoroscopy with 7.3-mm cannulated screws, placed in a transiliosacral position in the vertebral body of S1. The average preoperative displacement of 3.8 mm was decreased by closed reduction to 1.6 mm postoperatively. The average operating time was 55 min, the average screening time 2.22 min. Incorrect screw position with no consequences was observed in three patients; iatrogenic nerve damage was not found. All fractures healed within 3 months.

Die bildwandergestützte, perkutane transiliosakrale Schraubenfixation instabiler Beckenverletzungen

ZusammenfassungOperationszielGeschlossene Reposition und Retention von translatorisch instabilen Verletzungen des Beckenrings (Typ-C-Verletzungen) zur Wiederherstellung der Form und Funktion des dorsalen Beckenrings durch perkutane iliosakrale Schraubenosteosynthese mit Hilfe konventioneller Bildwandlertechnik.IndikationenDefinitive Behandlung des dorsalen Beckenrings bei Typ-C-Verletzungen (AO-Klassifikation) mit kompletter Sakrumfraktur, Luxation des Sakroiliakalgelenks (SI-Gelenk), transiliakaler oder transsakraler Luxationsfraktur des SI-Gelenks mit unbedeutend kleinem Fragment und Sakrumausbruchverletzungen, die sich geschlossen nahezu anatomisch reponieren lassen.KontraindikationenSchlechter Allgemeinzustand, lokaler Weichteilschaden, rotationsinstabile Beckenverletzungen vom Typ B sowie Typ-C-Verletzungen, die sich geschlossen nur unzureichend reponieren lassen.OperationstechnikGeschlossene Reposition, Stichinzision und perkutane Stabilisierung des hinteren Beckenrings durch transiliosakrale Schraubenosteosynthese unter Bildwandlerkontrolle.WeiterbehandlungTeilbelastung der verletzten Seite mit 15 kg für 8–12 Wochen mit zwei Unterarmgehstützen.Implantatentfernung 6–12 Monate nach der Verletzung.ErgebnisseBei 20 Patienten mit transforaminaler Sakrumfraktur im Rahmen einer Beckenverletzung vom Typ C wurde unter Bildwandlerkontrolle eine transiliosakrake Fixation mit kanülierten 7,3-mm-Schrauben in den Wirbelkörper S1 durchgeführt. Die durchschnittliche präoperative Fehlstellung von 3,8 mm konnte im Rahmen der geschlossenen Reposition postoperativ auf 1,6 mm reduziert werden. Die mittlere Operationszeit betrug 55 min, die mittlere Durchleuchtungszeit 2,22 min. Eine Schraubenfehllage ohne Konsequenz wurde bei drei Patienten beobachtet; iatrogene Nervenverletzungen lagen nicht vor. Alle Frakturen heilten innerhalb von 3 Monaten aus.AbstractObjectiveClosed reduction and retention of translatory unstable pelvic injuries (type C injuries), in order to restore the form and function of the posterior pelvis by percutaneous iliosacral screw osteosynthesis, using conventional fluoroscopy.IndicationsDefinitive treatment of the posterior pelvis in type C injuries (AO classification) with complete sacral fracture, sacroiliac joint (SI joint) dislocation, transiliac or transsacral dislocation fracture of the SI joint with insignificant small fragment and sacroiliac avulsion injuries which can be reduced almost anatomically in closed technique.ContraindicationsPoor general health, local soft-tissue damage, rotationally unstable type B pelvic injuries as well as type C injuries which cannot be reduced satisfactorily in closed technique.Surgical TechniqueClosed reduction, stab incision and percutaneous stabilization of the posterior pelvis by transiliosacral screw osteosynthesis, guided by fluoroscopy.Postoperative ManagementPartial loading of the injured side with 15 kg for 8–12 weeks with two underarm crutches.Implant removal 6–12 months after injury.Results20 patients with a transforaminal sacral fracture consistent with a type C pelvic injury underwent screw fixation with fluoroscopy with 7.3-mm cannulated screws, placed in a transiliosacral position in the vertebral body of S1. The average preoperative displacement of 3.8 mm was decreased by closed reduction to 1.6 mm postoperatively. The average operating time was 55 min, the average screening time 2.22 min. Incorrect screw position with no consequences was observed in three patients; iatrogenic nerve damage was not found. All fractures healed within 3 months.

A simple supraacetabular external fixation for pelvic ring fractures

ZusammenfassungOperationszielGeschlossene Reposition und Retention von Beckenringverletzungen durch äußere Stabilisierung.IndikationenNotfallversorgung instabiler Beckenringfrakturen vom Typ B und C.Definitive Behandlung von Typ-B-Verletzungen.Definitive Behandlung des ventralen Beckenrings bei Typ-C-Verletzungen mit transpubischer Instabilität nach dorsaler interner Stabilisierung.Unterstützende Stabilisierung interner Osteosynthesen.Stabilisierung kindlicher Beckenringfrakturen.KontraindikationenSchlechter Allgemeinzustand.Lokaler Weichteilschaden.Lokale Infektion.OperationstechnikBeidseitig perkutanes Einbringen von Schanz-Schrauben in den supraazetabulären Knochen. Geschlossene Reposition und Stabilisierung des Beckenrings durch Kompression und Anbringen eines Verbindungsstabs unter Bildwandlerkontrolle.WeiterbehandlungIn Abhängigkeit von der Gesamtsituation des Patienten und der Beckenringinstabilität, ggf. Wechsel auf interne Osteosynthesetechniken.Mobilisation des Patienten unter Teilbelastung der am dorsalen Beckenring verletzten Körperseite mit einem Fünftel des Körpergewichts an Unterarmgehstützen, unabhängig vom Stabilitätsgrad des Beckens.ErgebnisseRetrospektive Analyse von 64 supraazetabulären Fixateur-externe-Applikationen zur Stabilisierung des vorderen Beckenrings bei 20 Typ-B- und 44 Typ-C-Verletzungen.Die Rate iatrogener Läsionen des Nervus cutaneus femoris lateralis lag bei 4,5%; alle Sensibilitätsstörungen waren innerhalb 1 Jahres komplett reversibel. Die Eintrittsstellen techniinfizierten sich in keinem Fall. Bei zwei Patienten (3%) wurde eine primäre Perforation der Schanz-Schraube in das kleine Becken ohne therapeutische Konsequenz beobachtet.Bei Typ-B-Verletzungen wurden keine sekundäre Dislokationen des vorderen oder hinteren Beckenrings beobachtet. Für Typ-C-Verletzungen wurden Sakrumfrakturen mit begleitenden Frakturen des Schambeinasts analysiert. Sekundäre Fehlstellungen wurden nicht beobachtet. In einem Fall kam es zu einer behandlungswürdigen Pseudarthrose der Schambeinäste.AbstractObjectiveClosed reduction and maintenance of pelvic ring injuries by external stabilization.IndicationsEmergency management of unstable type B and type C pelvic ring fractures.Definitive treatment of type B injuries.Definitive treatment of the anterior pelvic ring in type C injuries with transpubic instability after posterior internal stabilization.Adjunct stabilization of internal fixation.Stabilization of pelvic ring fractures in children.ContraindicationsPoor general condition.Local soft-tissue damage.Local infection.Surgical TechniqueBilateral percutaneous insertion of Schanz screws into the supraacetabular area of iliac bone. Closed reduction and stabilization of the pelvic ring by compression and application of a connecting rod under image intensification.Postoperative ManagementDepending on the patient’s condition and the degree of pelvic instability, a change to an open procedure may become necessary.Mobilization of the patient with partial weight bearing (one fifth of body weight) on the side of the injured posterior pelvic ring using forearm crutches, irrespective of the degree of stability of the pelvis.ResultsRetrospective analysis of 64 supraacetabular external fixator applications to stabilize the anterior pelvic ring in 20 type B and 44 type C injuries.Iatrogenic lesions of the lateral femoral cutaneous nerve: 4.5%; all sensory disturbances completely reversed within 1 year. No pin site infection. In two patients (3%) primary perforation of the Schanz screw into the small pelvis not necessitating any treatment.No secondary displacements of the anterior or posterior pelvic ring in type B injuries nor for type C injuries, sacral fractures associated with fractures of the pubic ramus. One pseudarthrosis of the pubic and ischial rami requiring surgical treatment.

Erectile dysfunction in relation to traumatic pelvic injuries or pelvic fractures

Because the interdisciplinary management of patients who sustain multiple trauma has improved, the survival of patients with pelvic fractures has increased in recent decades. This has resulted in a notable increase in the number of patients with lifelong disabilities from associated injuries to the urogenital organs, and with erectile dysfunction (ED). There is controversy as to whether ED develops as a result of the disruption caused by the primary pelvic trauma, or from the subsequent repair processes, or from iatrogenic lesions during the surgical repair of bony and soft tissue lesions. However, a comprehensive interdisciplinary evaluation of these patients shows autonomic neurogenic lesions to be the predominant cause for post-traumatic ED. This aetiology is of practical importance for the treatment options offered to the patient.

Computer Assisted Pelvic Surgery: Registration Based on a Modified External Fixator

A fundamental step in Computer Assisted Surgery (CAS) is the registration, when the preoperative virtual data and the corresponding operative anatomy of the region of interest are merged. To provide exact landmarks for anatomical registration, a tubular external fixator was modified. Two intact pelvic bones (one artificial foam pelvis and one cadaver specimen) were used for the experimental setup. Registration was carried out using a standardized protocol for anatomy-based registration in the control group; anatomical registration was achieved using a modified external fixator in the study group. This external fixator had titanium fiducials wedged into the fixator carbon tubes serving as landmarks for paired-point registration. The tubes were used for surface registration. The standard anterior pelvis fixator assembly was augmented with additional bilateral tubes oriented towards the posterior, enabling registration of the sacroiliac areas. The accuracy of registration was checked by “reversed verification”, where the examiner used only the screen display to control the virtual position of the pointer tip in relation to selected landmarks. By virtual matching, the real distance was measured with a digital caliper. We defined the verification as “accurate” when the residual distance was less than 1 mm; “acceptable” when it was between 1 mm and 2 mm; and “insufficient” when it exceeded 2 mm. The paired T-test with significance levels of p < 0.05 was used for statistical analysis. The anatomical registration based on the external fixator landmarks was statistically as accurate as that obtained using anatomical landmarks on the pelvic bone. This study concludes that the external fixator, a conventional tool in the management of acute traumatic pelvic instability, can also be useful for landmark registration in CAS.