G. Tosounidis

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.

Different stabilisation techniques for typical acetabular fractures in the elderly—A biomechanical assessment

OBJECTIVES The tremendous increase of acetabular fractures in the elderly provides new challenges for their surgical treatment. The aim of this study was to evaluate the biomechanical properties of conventional and newly developed implants for the stabilisation of an anterior column combined with posterior hemitransverse fracture (ACPHTF), which represents the typical acetabular fracture in the elderly. METHODS Using a single-leg stance model we analysed four different implant systems for the stabilisation of ACPHTFs in synthetic and cadaveric pelvises. Applying an increasing axial load, fracture dislocation was analysed with a new multidirectional ultrasonic measuring system. Results of the different implant systems were compared by Scheffé post hoc test and one-way ANOVA. RESULTS In synthetic pelvises, the standard reconstruction plate fixed by 3 periarticular long screws and a new titanium fixator with multidirectional interlocking screws were associated with significantly less dislocation of the fractured quadrilateral plate of the acetabulum when compared to a standard reconstruction plate fixed by only one periarticular long screw and a locking reconstruction plate. No significant differences between the different osteosynthesis techniques could be observed in cadaver pelvises, probably due to a heterogeneous bone quality. CONCLUSIONS We conclude that the plate fixation by positioning of periarticular long screws as well as the multidirectional positioning of interlocking screws account for the most sufficient fracture stabilisation of ACPHTFs under experimental conditions.

Versorgungskonzept der Beckenringverletzung des alten Patienten

Whereas pelvic injuries in patients in their 20s and 30s are typically caused by high energy trauma, another group suffering this injury are elderly patients between the seventh and eighth decades of life. Due to osteoporosis and co-morbidities females are particularly affected by low energy trauma. After examining the medical history a physical examination of the pelvis is performed. This is followed by imaging with X-ray and CT scanning with 3D reconstruction if necessary. If there are concomitant injuries additional diagnostics are essential (e.g. sonography, MRI, retrograde ureterography, cystography and excretion urogram). The standard AO/ATO classification (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association) has been well proven and does not depend on the age of the patient. Three different fracture types are differentiated, types A, B and C. This classification in combination with the description of the affected anatomical region (e.g. transsymphysis, transpubic, etc.) is sufficient in the daily clinical practice to decide on the necessary treatment. Often there are diagnostic difficulties in elderly patients (so-called differentiation of the A-B problem). In these patients a type A fracture is initially diagnosed and treated conservatively but due to persistent pain the imaging is repeated and an additional (insufficiency) fracture is found. With this new information the therapeutic regime has to be changed. The reconstruction of the pelvic ring is of major importance especially for elderly patients. This reduces the pain and the primary objective, an earliest possible rehabilitation without prolonged immobilization, can be achieved. In elderly patients external fixation with supra-acetabular screw positioning is an effective procedure and secondary insufficiency-instability (mostly dorsal) can be avoided. Whereas type A fractures can almost exclusively be treated non-surgically, types B and C fractures usually need surgery. As in young patients type B fractures are stabilized ventrally and C fractures dorsoventrally. In an emergency supra-acetabular external fixation and when required extraperitoneal tamponade has been established as the standard treatment for elderly patients in Germany. For the definitive surgical management standard procedures are used, but they often have to be modified depending on the bone structure.

Concept for treatment of pelvic ring injuries in elderly patients. A challenge

Whereas pelvic injuries in patients in their 20s and 30s are typically caused by high energy trauma, another group suffering this injury are elderly patients between the seventh and eighth decades of life. Due to osteoporosis and co-morbidities females are particularly affected by low energy trauma. After examining the medical history a physical examination of the pelvis is performed. This is followed by imaging with X-ray and CT scanning with 3D reconstruction if necessary. If there are concomitant injuries additional diagnostics are essential (e.g. sonography, MRI, retrograde ureterography, cystography and excretion urogram). The standard AO/ATO classification (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association) has been well proven and does not depend on the age of the patient. Three different fracture types are differentiated, types A, B and C. This classification in combination with the description of the affected anatomical region (e.g. transsymphysis, transpubic, etc.) is sufficient in the daily clinical practice to decide on the necessary treatment. Often there are diagnostic difficulties in elderly patients (so-called differentiation of the A-B problem). In these patients a type A fracture is initially diagnosed and treated conservatively but due to persistent pain the imaging is repeated and an additional (insufficiency) fracture is found. With this new information the therapeutic regime has to be changed. The reconstruction of the pelvic ring is of major importance especially for elderly patients. This reduces the pain and the primary objective, an earliest possible rehabilitation without prolonged immobilization, can be achieved. In elderly patients external fixation with supra-acetabular screw positioning is an effective procedure and secondary insufficiency-instability (mostly dorsal) can be avoided. Whereas type A fractures can almost exclusively be treated non-surgically, types B and C fractures usually need surgery. As in young patients type B fractures are stabilized ventrally and C fractures dorsoventrally. In an emergency supra-acetabular external fixation and when required extraperitoneal tamponade has been established as the standard treatment for elderly patients in Germany. For the definitive surgical management standard procedures are used, but they often have to be modified depending on the bone structure.

[Application of the pelvic C-clamp].

ZusammenfassungDie instabile Beckenringverletzung in Kombination mit der schweren beckenbedingten Blutung geht mit hoher Letalität einher. Durch den Einsatz der Notfall-Beckenzwinge nach Ganz kann die Prognose verbessert werden. Sie kann schon während der lebensrettenden Maßnahmen durchgeführt werden und sollte gegebenenfalls mit einer pelvinen Tamponade kombiniert werden. Wegen der geringen Patientenzahlen verfügen vor allem die Traumazentren der Maximalversorgung über Erfahrung mit der Methode. In dem vorliegenden Beitrag wird eine im eigenen Vorgehen entwickelte, standardisierte Anlagetechnik dargestellt. Sie ermöglicht die sichere Anwendung des Verfahrens durch die Verwendung von gut definierten klinisch erkennbaren Orientierungspunkten im Schockraum.AbstractUnstable pelvic girdle injury combined with severe pelvis related haemorrhage has a high mortality rate. This prognosis can be improved by using the C-clamp according to Ganz. This can be applied while the life saving measures are in progress, and should, if necessary, be combined with a pelvic tamponade. Due to the limited number of patients, trauma centres have the most experience with this technique. In this contribution, we present our standardised application technique, which allows the use of the procedure through well defined clinically recognisable orientation points in the emergency room.

Die Anlage der Notfall-Beckenzwinge

ZusammenfassungDie instabile Beckenringverletzung in Kombination mit der schweren beckenbedingten Blutung geht mit hoher Letalität einher. Durch den Einsatz der Notfall-Beckenzwinge nach Ganz kann die Prognose verbessert werden. Sie kann schon während der lebensrettenden Maßnahmen durchgeführt werden und sollte gegebenenfalls mit einer pelvinen Tamponade kombiniert werden. Wegen der geringen Patientenzahlen verfügen vor allem die Traumazentren der Maximalversorgung über Erfahrung mit der Methode. In dem vorliegenden Beitrag wird eine im eigenen Vorgehen entwickelte, standardisierte Anlagetechnik dargestellt. Sie ermöglicht die sichere Anwendung des Verfahrens durch die Verwendung von gut definierten klinisch erkennbaren Orientierungspunkten im Schockraum.AbstractUnstable pelvic girdle injury combined with severe pelvis related haemorrhage has a high mortality rate. This prognosis can be improved by using the C-clamp according to Ganz. This can be applied while the life saving measures are in progress, and should, if necessary, be combined with a pelvic tamponade. Due to the limited number of patients, trauma centres have the most experience with this technique. In this contribution, we present our standardised application technique, which allows the use of the procedure through well defined clinically recognisable orientation points in the emergency room.

Biomechanical comparison of different stabilisation devices for transforaminal sacral fracture. Is an interlocking device advantageous

Background. Reliable osteosynthesis for fractures in the different regions of the human pelvis are described in the literature while there is no common and satisfying treatment for unstable sacral fractures. Because of the posterior pelvic ring’s special anatomic conditions a local plate osteosynthesis seems to be advantageous. In many fields of modern fracture treatment locking implants show superior results. The prototype of a local locking plate osteosynthesis was compared to a common local plate and two sacroiliac screws. Methods. The implants were tested using six plastic models of the pelvis and three embalmed human specimens. A Tile C1 fracture was created by disruption of the pubic symphysis and a transforaminal osteotomy. The specimens were exposed to axial loading in an upright single-leg stance with a maximum of 800 N for the plastic models and 200 N for the human specimens. An ultrasonic-based measuring system recorded translations (X, Y, Z) and rotations (α, β, γ). Parameters such as pattern of motion, translation/rotation, load to failure and remaining dislocation were evaluated. Results. Concerning most of the evaluated parameters the local plate osteosynthesis was inferior compared with two sacroiliac screws. There were no significant differences between the locking implant and the local plate osteosynthesis. Compared with the two sacroiliac screws the locking implant shows biomechanically equal results but allows greater anterior rotation and remaining dislocation. Because of the lower bone quality, the results from the anatomic specimen tested were not utilisable. Conclusions. The locking implant is biomechanically an alternative compared with two sacroiliac screws. Problems occurred due to the preset direction of the locking head screws.

Das komplexe Beckentrauma des älteren Patienten

The definition of complex pelvic trauma has allowed a selection of those pelvic fracture patients with the highest mortality rate. The term complex pelvic trauma is used as a definition for pelvic fractures which are associated with serious soft tissue lesions in the pelvic region. These may include visceral and neurovascular, as well as extensive skin and muscle injuries. Haemodynamic instability particularly related to vascular injuries raises the mortality dramatically. Traumatic hemipelvectomy, which represents the worst case of a complex pelvic trauma, is associated with mortality rates of up to 60%. The pelvic study groups 1-3 of the German trauma association (DGU) and the Association for Osteosynthesis (AO) provide the worldwide largest database on pelvic injuries (group 1, 1991-1993: 1,722 patients from 10 hospitals; group 2, 1998-2002: 2,569 patients from 22 hospitals; and group 3, 2005-2007: 2,704 patients from 23 hospitals). Using this database this article reviews epidemiological data, therapy concepts, associated injuries as well as the incidence and mortality rates related to complex pelvic trauma over a 16-year time period. Special attention has been paid to complex trauma in the elderly (patients >60 years of age). An additional aim of this article is to analyze the correlation between different treatment modalities and the mortality rate of complex pelvic trauma and to investigate whether changes in the treatment of complex pelvic trauma have improved the outcome of these injuries. Taken together an increase in measures for an initial mechanical stabilization of the pelvic ring, such as the use of the pelvic C clamp, the external fixator or primary osteosynthesis was found over the 16-year observation period. In addition to stabilization of the pelvic ring, pelvic tamponade for mechanical haemostasis has been proven to be one of the most effective measures to control haemorrhaging. These treatment regimes did not differ between young patients and patients >60 years of age. Regarding the outcome of these treatment strategies only slight decreases in the mortality rate were found (pelvic study group 1: 21%; pelvic study group 2: 22%; pelvic study group 3: 18%). In all pelvic study groups the mortality rate in patients >60 years of age was found to be significantly higher than in individuals <60 years of age (pelvic study group 1: 57% versus 29.6%, pelvic study group 2: 33% versus 22.6%, pelvic study group 3: 41% versus 10.4%, p <0.05, respectively).

The posterior two-portal approach for reconstruction of scapula fractures: results of 39 patients.

The purpose of this study was to describe the so-called posterior two-portal approach to the scapula in detail and to investigate the clinical outcome of patients with displaced glenoid and scapular neck fractures who were surgically treated using this approach. From February 1992 to August 2008, 39 patients (30 men and nine women; mean age: 53 years) with scapular fractures underwent surgical fixation at our institution. Thirty-three patients had glenoid fractures and six had unstable scapular neck fractures. All patients were treated via the two-portal approach. The reduction was evaluated radiographically, and the clinical results were analysed using the Constant score. The mean follow-up period was 78 months (range: 6-168). In 24 of the 33 glenoid fractures, the reduction was anatomical. The mean Constant score was 82.3 (range: 35-100) points. In one case, an early postoperative wound infection was cured by local revision, and one patient developed posttraumatic osteoarthritis of the acromioclavicular joint after 2 years. Only one patient developed specific glenohumeral degeneration after non-anatomical reduction. The posterior two-portal approach allows for a good visualisation of the posterior scapular neck and the glenoid area, facilitating the reduction and safe internal fixation of dislocated scapular neck and glenoid fractures.

Complex pelvic trauma in elderly patients

The definition of complex pelvic trauma has allowed a selection of those pelvic fracture patients with the highest mortality rate. The term complex pelvic trauma is used as a definition for pelvic fractures which are associated with serious soft tissue lesions in the pelvic region. These may include visceral and neurovascular, as well as extensive skin and muscle injuries. Haemodynamic instability particularly related to vascular injuries raises the mortality dramatically. Traumatic hemipelvectomy, which represents the worst case of a complex pelvic trauma, is associated with mortality rates of up to 60%. The pelvic study groups 1-3 of the German trauma association (DGU) and the Association for Osteosynthesis (AO) provide the worldwide largest database on pelvic injuries (group 1, 1991-1993: 1,722 patients from 10 hospitals; group 2, 1998-2002: 2,569 patients from 22 hospitals; and group 3, 2005-2007: 2,704 patients from 23 hospitals). Using this database this article reviews epidemiological data, therapy concepts, associated injuries as well as the incidence and mortality rates related to complex pelvic trauma over a 16-year time period. Special attention has been paid to complex trauma in the elderly (patients >60 years of age). An additional aim of this article is to analyze the correlation between different treatment modalities and the mortality rate of complex pelvic trauma and to investigate whether changes in the treatment of complex pelvic trauma have improved the outcome of these injuries. Taken together an increase in measures for an initial mechanical stabilization of the pelvic ring, such as the use of the pelvic C clamp, the external fixator or primary osteosynthesis was found over the 16-year observation period. In addition to stabilization of the pelvic ring, pelvic tamponade for mechanical haemostasis has been proven to be one of the most effective measures to control haemorrhaging. These treatment regimes did not differ between young patients and patients >60 years of age. Regarding the outcome of these treatment strategies only slight decreases in the mortality rate were found (pelvic study group 1: 21%; pelvic study group 2: 22%; pelvic study group 3: 18%). In all pelvic study groups the mortality rate in patients >60 years of age was found to be significantly higher than in individuals <60 years of age (pelvic study group 1: 57% versus 29.6%, pelvic study group 2: 33% versus 22.6%, pelvic study group 3: 41% versus 10.4%, p <0.05, respectively).