Fragility Fractures of the Pelvis (eBook)

Professor Pol M. Rommens and Professor Alexander Hofmann are well-known and respected pelvic and acetabular surgeons. They have published numerous papers on the treatment and outcome of pelvic fractures, and developed a comprehensive classification of fragility fractures of the pelvis, combined with recommendations for treatment.

Foreword 7
Preface 9
Contents 11
Part I: General Aspects 14
1: Epidemiology and Demographics 15
1.1 Introduction 15
1.2 Osteoporosis 15
1.3 Fragility Fractures in General 16
1.4 Fragility Fractures of the Pelvis 16
References 19
2: Personality of Fragility Fractures of the Pelvis 21
2.1 Introduction 21
2.2 Trauma Mechanism 22
2.3 Clinical Picture 24
2.4 Hemodynamic Condition 24
2.5 Emergency Stabilization 25
2.6 Strength of Bone and Stiffness of Ligaments 29
2.7 Unique Fracture Morphology 30
2.8 Progress of Instability 31
References 32
3: Sacral Morphology 35
3.1 Introduction 35
3.2 Sacral Morphology 35
3.3 Corridors 36
3.4 Radiographic Assessment of the Corridor 39
3.5 Author’s Preferred Method 43
References 44
4: Bone Mass Distribution in the Sacrum 46
4.1 Introduction 46
4.2 Osteoporosis in Statistical Bone Models 46
4.3 Bone Structure of the Sacrum 47
4.4 Statistical Model of the Sacral Bone Mass 47
4.5 Implications on Fracture Morphology 50
4.6 Implications for Operative Treatment 50
4.7 Sacroplasty in the Light of Sacral Bone Mass Distribution 50
References 51
Part II: Clinical and Radiological Aspects 54
5: Clinical Presentation 55
5.1 Introduction 55
5.2 Mechanism of Injury and Patient History 55
5.3 Non-traumatic Fractures 56
5.4 Site of Pain and Fracture Localization 56
5.5 Comorbidities and General Condition 57
5.6 Fracture Patterns 58
5.7 Massive Arterial Hemorrhage 60
5.8 Pelvic Nonunion 61
5.9 Summary 62
References 62
6: Radiological Assessment 65
6.1 Introduction 65
6.2 Plain Radiography 65
6.3 Computed Tomography 68
6.4 Magnetic Resonance Imaging 71
6.5 Bone Scintigraphy 72
6.6 Differential Diagnosis 72
6.7 Diagnostic Algorithm 74
References 74
Part III: Classification 76
7: Classification of Fragility Fractures of the Pelvis 77
7.1 Introduction 77
7.2 Classification Systems 77
7.3 Classification Systems for Pelvic Ring Lesions 78
7.4 Comprehensive Classification of Fragility Fractures of the Pelvic Ring 80
References 87
Part IV: Treatment of Fragility Fractures of the Pelvis 89
8: Non-Operative Treatment 90
8.1 Introduction 90
8.2 Elements of Non-operative Management 91
8.2.1 Bed Rest 91
8.2.2 Pain Management 92
8.2.3 Mobilization 92
8.2.4 Medication with Influence on Bone Metabolism 92
8.2.4.1 Vitamin D and Calcium 92
8.2.4.2 Antiresorptive Agents 92
Bisphosphonates 92
Calcitonin 93
Raloxifene 93
Teriparatide 93
8.2.5 Low Intensity Pulsed Ultrasound (LIPUS) 94
8.3 Failure of Conservative Treatment 94
8.4 Finite Element Analysis of Stress Distribution in the Posterior Pelvis 99
References 101
9: Operative Management 103
9.1 General Considerations 103
9.2 Different Phases of Operative Management 103
9.2.1 Initial Assessment and Resuscitation 103
9.2.2 Post-Resuscitation Phase 104
9.2.3 Operative Reconstruction 104
9.2.4 Mobilization Phase 105
9.3 Indications for Surgery and Operative Techniques 106
9.3.1 FFP Type II: Non-displaced Posterior Ring Injuries 106
9.3.2 FFP Type III: Unilateral Displaced Posterior Ring Injuries 107
9.3.3 FFP Type IV: Bilateral Displaced Posterior Ring Injuries 107
References 110
10: Sacroplasty 111
10.1 Introduction 111
10.2 History and Definition 112
10.3 Rationale 113
10.4 Procedure 113
10.4.1 Patient Selection 113
10.4.2 Surgical Technique 114
10.4.3 Imaging 115
10.4.4 Cement Application 116
10.5 Complications and Outcome 118
10.5.1 Cement Leakage 118
10.5.2 Clinical Results 118
10.6 Summary and Conclusion 119
References 121
Part V: Stabilization Techniques for the Posterior Pelvic Ring 124
11: Iliosacral Screw Osteosynthesis 125
11.1 Introduction 125
11.2 Rationale 126
11.3 The Iliosacral Corridor 128
11.4 Biomechanical Studies 129
11.5 Surgical Technique 133
11.5.1 Supine Position 134
11.5.2 Prone Position 138
11.6 Results 138
References 140
12: Iliosacral Screw Fixation with Cement Augmentation 142
12.1 Introduction 142
12.2 Surgical Technique 143
12.3 Results 147
References 147
13: Transsacral Bar Osteosynthesis 148
13.1 Introduction 148
13.2 Rationale and Development 149
13.3 Preoperative Planning 150
13.4 Surgical Technique 150
13.4.1 General Remarks 150
13.4.2 Patient Positioning 151
13.4.3 Surgical Steps 151
13.4.4 Pitfalls 152
13.5 After-Treatment 155
13.6 Outcomes 156
References 158
14: Bridging Plate Osteosynthesis 160
14.1 Introduction 160
14.2 Indications 163
14.3 Surgical Technique 164
14.4 Results and Personal Experience 165
References 167
15: Transiliac Internal Fixator 168
15.1 Indications 168
15.2 Biomechanical Data 168
15.3 Surgical Technique 169
15.3.1 The Transiliac Internal Fixator with Screws in Cranio-Caudal Direction 169
15.3.2 The Transiliac Internal Fixator with Screws in Dorso-Ventral Oblique Direction 169
15.4 Postoperative Care 174
15.5 Results 174
References 177
16: Triangular Osteosynthesis and Lumbopelvic Fixation 178
16.1 Introduction 178
16.2 General Considerations 178
16.3 Indications 181
16.4 Patient Evaluation 183
16.5 Surgical Management and Technical Aspects 185
16.6 Surgical Technique 186
16.7 Postoperative Treatment 190
References 192
17: Plate and Screw Fixation of the Ilium 193
17.1 Introduction 193
17.2 Anatomical Considerations 194
17.3 Clinical Presentation and Diagnostic Evaluation 194
17.4 Indications for Surgery 194
17.5 Preparation for Surgery and Surgical Approach 195
17.6 Fracture Reduction and Internal Fixation 197
17.7 After Treatment 202
References 202
Part VI: Stabilization Techniques for the Anterior Pelvic Ring 204
18: External Fixation 205
18.1 Biomechanical Considerations 205
18.2 Indications for External Fixation 205
18.3 Surgical Technique 207
18.4 Aftercare and Removal 210
References 210
19: Retrograde Transpubic Screw Fixation 211
19.1 Introduction 211
19.2 Rationale 212
19.3 The Anterior Column Corridor 213
19.4 Biomechanical Studies 215
19.5 Surgical Technique 216
19.6 Results 220
References 222
20: Plate Osteosynthesis, Subcutaneous Internal Fixation and Anterior Pelvic Bridge Fixation 224
20.1 General Considerations 224
20.2 Plate Osteosynthesis 227
20.2.1 Surgical Technique 229
20.2.2 Results 231
20.3 Subcutaneous Internal Fixation 231
20.3.1 General Description 231
20.3.2 INFIX: Anterior Subcutaneous Crossover Internal Pelvic Fixator 231
20.3.2.1 Surgical Technique 232
20.3.2.2 Results 234
20.3.3 Anterior Pelvic Bridge 235
20.3.3.1 Surgical Technique 236
20.3.3.2 Results 236
20.3.3.3 Own Results 238
20.4 Anterior Subcutaneous Three-Point Pelvic Fixator 239
20.4.1 Introduction 239
20.4.2 The Anterior Subcutaneous Three-Point Pelvic Fixator 239
20.4.2.1 Operative Procedure 240
20.4.2.2 Advantages and Disadvantages of the Procedure 241
20.4.2.3 Risks and Limitations 243
20.4.3 Indications 244
References 245
Part VII: Adjuvant Drug Therapy 248
21: Anti-Resorptive Therapy 249
21.1 Introduction 249
21.2 Calcium and Vitamin D 249
21.3 Hormone Replacement Therapy (HRT) and Selective Estrogen Receptor Modulators (SERMs) 250
21.4 Bisphosphonates 251
21.5 Denosumab 251
21.6 Strontium Ranelate 252
21.7 New Therapeutic Targets for Osteoporosis 253
21.7.1 Cathepsin K Inhibitors 253
21.7.2 Anti-Sclerostin Therapy 254
References 254
22: Parathyroid Hormone 258
22.1 Introduction 258
22.2 Parathyroid Hormone Physiology 258
22.3 Genetic Variations of PTH with Bone Mineral Density and Fracture Risk 259
22.4 PTH—The Paradox Effect 259
22.5 Fracture Healing 260
22.6 Experimental Studies 260
22.7 Clinical Studies 261
22.8 Delayed-Unions and Non-Unions 261
22.9 Fracture Healing in Osteoporotic Fractures 261
22.10 Stress Fractures 262
22.11 Atypical Fractures Associated with Bisphosphonate Therapy 263
References 263
Part VIII: Aftertreatment 265
23: Aftercare 266
23.1 Non-operative Treatment 266
23.1.1 Introduction 266
23.1.2 Setting of Care 266
23.1.3 The Fracture Pattern, Presence of a Sacral Fracture 266
23.1.4 Comorbidities and Their Management 267
23.1.5 Acute Medical Conditions 267
23.1.6 Chronic Medical Conditions 269
23.1.7 Osteoporosis Work-Up and Management 269
23.1.8 Pain Management 270
23.1.9 Supportive Care 270
23.1.9.1 Rehabilitation 270
23.1.9.2 Discharge Destination 270
23.1.9.3 System of Care and Its Importance 270
23.1.10 Outcomes 270
23.2 Operative Treatment 272
23.2.1 Indications and Techniques of Operative Treatment 272
23.2.2 Soft Tissue Management 273
23.2.3 Rehabilitation After Surgery 274
23.2.4 Anticoagulation 274
23.2.5 Healing Time and Outcome 274
References 275
Part IX: Outcome 276
24: Outcome 277
24.1 Outcome Measurement 277
24.2 Outcome 278
24.2.1 Mortality 278
24.2.2 Length of Hospital Stay 279
24.2.3 Medical Complications 279
24.2.4 Surgical Complications 280
24.2.5 Pain 280
24.2.6 Mobility and Independence 281
24.2.7 Functional Outcome 281
24.2.8 Bony Union 282
24.3 Recommendations and Level of Evidence 282
References 283
Part X: Case Presentations 286
25: Case Presentations 287
25.1 Introduction 287
Index 308