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Commentary and Perspective

Confirmation of a Reproducible Therapeutic Protocol

Commentary on an article by Frank R. Avilucea, MD, et al.: “Fixation Strategy Using Sequential Intraoperative Examination Under Anesthesia for Unstable Lateral Compression Pelvic Ring Injuries Reliably Predicts Union with Minimal Displacement”

Mears, Dana C. MD, PhDa

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The Journal of Bone and Joint Surgery: September 5, 2018 - Volume 100 - Issue 17 - p e119
doi: 10.2106/JBJS.18.00582
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Commentary

The management of unstable pelvic ring fractures remains a highly complex clinical problem in view of the difficulties in accurately documenting the sites and degree of pelvic instability, the relative rarity of the injuries, and the potential presence of multiple traumatic disruptions and life-threatening complications. One example is a lateral compression fracture of the pelvis with the presence of an unstable sacral or posterior iliac fracture, a potential contralateral sacroiliac disruption, and ramus fractures. Previous studies documented a considerable likelihood of unacceptable late pelvic deformity with symptomatic nonunion or malunion of the pelvic ring1,2. The present study represents a multicenter investigation involving the use of a predefined algorithm of surgical management that was devised on the basis of prior work and the considerable clinical experience of the investigators. For 74 patients who were managed for unstable lateral compression fractures, multistaged fluoroscopic examination of the pelvic ring during the application of a rotational stress permitted documentation of the sites of pelvic instability. In a sequential fashion, the ipsilateral and, subsequently, contralateral posterior pelvic anatomy were evaluated and stabilized, as necessary, with percutaneous screws. This process was repeated for the pelvic ring anteriorly. The fluoroscopic images provided guidance for the insertion of fixation screws. Postoperative computed tomography (CT) and late radiographs confirmed the accuracy of pelvic realignment for all of the posterior stabilizations. The only sites of late deformity pertained to 9 patients with concomitant bilateral anterior rami disruptions in which anterior fixation was not undertaken. This article provides an enlightening message for pelvic surgeons in terms of a realistic algorithm of intraoperative management of these complex pelvic disruptions. The authors outline the use of examination under anesthesia (EUA) to confirm the unstable sites of pelvic disruption and to identify the optimal sequence for stabilization. The critical need to initiate fixation in the posterior pelvic ring is confirmed. The authors conclude that the presence of concomitant bilateral rami disruptions may merit supplementary anterior fixation. As the authors acknowledge, an investigation including an assessment of late clinical outcomes would be valuable, although no doubt difficult to successfully complete.

In view of the complexity and relative rarity of these injuries and for the likelihood of concomitant serious injuries, the management of major pelvic trauma is best suited to trauma centers that possess the necessary experienced surgeons, nurses, and supplementary health-care specialists. Following the acute resuscitation and stabilization of the patient3,4, the next consideration is pelvic imaging to document sites of injury, the vectors and magnitude of the pelvic deformities, and the degree of instability of the injuries. While the underlying principles of the management of complex pelvic injuries are numerous, historically, a diverse array of conventional pelvic images was combined with a transaxial CT scan. Currently, after an anteroposterior pelvic radiograph to document a complex pelvic disruption, the use of a standard CT scan and a 3-dimensional CT assessment provides the optimal appreciation of multiple pelvic deformities along with the detailed resolution of the standard CT5. The potentially subtle displacement of a sacral body fracture neighboring the cauda equina or a sacral nerve root is optimally appreciated by the CT scan. The rationale for a supplementary dynamic fluoroscopic assessment of the pelvis under anesthesia is confirmed in the current manuscript. While Avilucea and colleagues focus on a particular comminuted pattern of pelvic trauma for which percutaneous fixation of the several injury sites may be preferred, many patients present with alternative injury patterns that may violate the sacral body, the posterior aspect of the ilium, or the acetabulum6. In such a situation, open reduction of the sacrum, ilium, and/or acetabulum may be necessary. Proficiency in open reduction and stabilization of this injury site is required7. Such concomitant injury influences the preferred sequence of reducing the several injury sites. Currently, for most pelvic ring disruptions, percutaneous screw fixation performed under fluoroscopic guidance is a minimally invasive technique with limited blood loss that is suitable for the majority of the injuries. The surgeon requires knowledge of the essential intraoperative multiplanar fluoroscopic images and the corresponding closed reduction strategies that are necessary for the various types of pelvic disruption. A detailed appreciation of the relevant osseous anatomy of each site of fixation is required along with an understanding of the anatomical variants.

Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest form is provided with the online version of the article (http://links.lww.com/JBJS/E877).

References

1. Weaver MJ, Bruinsma W, Toney E, Dafford E, Vrahas MS. What are the patterns of injury and displacement seen in lateral compression pelvic fractures? Clin Orthop Relat Res. 2012 Aug;470(8):2104-10.
2. Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, Bathon GH, Brumback RJ. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990 Jul;30(7):848-56.
3. Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 1. Evaluation, classification, and resuscitation. J Am Acad Orthop Surg. 2013 Aug;21(8):448-57.
4. Lefaivre K, O’Brien PJ, Tile M. Pathoanatomy, mechanisms of injury and classification. In: Tile M, Helfet DL, Kellam JF, Vrahas M, editors. Fractures of the pelvis and acetabulum. 4th ed. Davos Platz: AO Foundation; 2015. p 39-60.
5. Mauffrey C, Stacey S, York PJ, Ziran BH, Archdeacon MT. Radiographic evaluation of acetabular fractures: review and update on methodology. J Am Acad Orthop Surg. 2018 Feb 1;26(3):83-93.
6. Halvorson JJ, Lamothe J, Martin CR, Grose A, Asprinio DE, Wellman D, Helfet DL. Combined acetabulum and pelvic ring injuries. J Am Acad Orthop Surg. 2014 May;22(5):304-14.
7. Lee M, Routt T, Achor S. Internal fixation of unstable fractures. In: Tile M, Helfet DL, Kellam JF, Vrahas M, editors. Fractures of the pelvis and acetabulum. 4th ed. Davos Platz: AO Foundation; 2015. p 187-234.

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