Eur J Orthop Surg Traumatol DOI 10.1007/s00590-015-1631-4
ORIGINAL ARTICLE • PELVIS - TRAUMA
Isolated pelvic ring injuries: functional outcomes following percutaneous, posterior fixation Matthew P. Sullivan1
•
John A. Scolaro2 • Andrew H. Milby1 • Samir Mehta1
Received: 13 January 2015 / Accepted: 29 March 2015 Springer-Verlag France 2015
Abstract Objectives To characterize pelvic-specific functional outcomes in patients with isolated, partially unstable (AO/ OTA 61-B), pelvic ring injuries treated with posterior only percutaneous screw fixation of the pelvic ring. Patients and methods Between September 2007 and October 2011, 16 subjects (mean age 42.4 years; range 18–90 years) with isolated, partially unstable pelvic ring injuries (AO/OTA 61-B) were treated with percutaneous, posterior pelvic ring fixation. Subjects underwent an evaluation of pelvic ring function with a modification of Majeed’s pelvic functional outcome assessment tool. Subjects were excluded if they sustained a concomitant long-bone fracture, visceral injury requiring surgery, spinal cord injury, and an injury to the anterior pelvic ring or acetabulum requiring additional fixation. Result Mean follow-up was 30.8 (range 14–55) months. Eleven subjects sustained unilateral posterior ring injuries, and five subjects sustained bilateral posterior ring injuries.
All fractures healed uneventfully, and no hardware failures were noted. Average pelvic functional outcome score at final follow-up was 85.3 % (good). All but subjects required assistive walking devices and gait and sitting comfort scored ‘‘excellent.’’ High rates of sexual dysfunction and persistent difficulty with daily activities were noted in this series. Conclusions This series demonstrates that activity-specific dysfunction persists years after definitive percutaneous posterior fixation of isolated pelvic ring injuries. Radiographic outcomes were excellent as were subjects’ ability to ambulate independently and sit comfortably without pain. Many complained of persistent discomfort with both daily activities and sexual activity, suggesting persistent pathology to the non-osseous structures about the pelvis. Keywords Pelvic ring Pelvic trauma Posterior pelvic ring Functional outcomes Percutaneous pelvic fixation
Introduction & Matthew P. Sullivan [email protected] John A. Scolaro [email protected] Andrew H. Milby [email protected] Samir Mehta [email protected] 1
Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
2
Department of Orthopaedic Surgery, University of California Irvine Medical Center, 101 The City Drive South, Orange, CA 92868, USA
Percutaneous fixation of posterior pelvic ring injuries has gained popularity over the past two decades as a safe and effective way to definitively stabilize the posterior ring while limiting surgical complications [1–4]. Injuries to the posterior pelvic ring are commonly due to high-energy mechanisms, such as motor vehicle and pedestrian-struck accidents. These patients tend to be polytraumatized with associated long-bone, visceral, and central nervous system injuries [5]. Due to the high rate of wound complications related to open surgery about the traumatized pelvis, less invasive techniques were developed in which percutaneous screw fixation is performed in either the prone or the supine position. This has been made possible with advances in
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intra-operative fluoroscopic imaging and pre- and postoperative CT reconstructions in both two- and three-dimensions [4]. There are several reports in the literature, primarily case series, of patients treated with percutaneous fixation of posterior ring injuries [1, 2, 6–10]. These series demonstrate that percutaneous techniques work well and that radiographic union following posterior ring injures is achievable. Many of the published series describe surgical complications and radiographic outcomes [1, 2, 6–8]. Far fewer describe both radiographic and clinically significant pelvic outcomes [9, 10]. Of those that describe pelvic functional outcomes, nearly all patients included suffered from concomitant longbone or visceral injuries, which, no doubt, affect clinical pelvic outcome measures, such as pain with ambulation, sexual dysfunction, and gait abnormalities. Consequently, our understanding of the effects that percutaneous management of posterior ring injuries have on pelvic pain and function is likely confounded by comorbid injuries. The primary goal of this analysis is to investigate functional outcomes in patients with isolated AO/OTA 61-B (partially unstable) pelvic ring injuries treated surgically with posterior only closed reduction and percutaneous fixation techniques in the supine position, as described by Routt et al. [1]. We attempted to study a cohort of subjects without confounding injuries, such as long-bone fractures, spinal cord injuries, or additional pelvic or acetabular fractures requiring surgery. Majeed first proposed his ‘‘System for functional assessment after pelvic fractures’’ in 1989 [11]. This grading system has been used numerous times in its native form as well as in modified forms [10, 12–17]. We utilized a modification of Majeed’s pelvic outcomes grading scale to assess functional outcomes related to pelvic pain with various activities, including sitting, walking, and sexual intercourse, as well as other parameters. Polytraumatized patients with confounding injuries and anterior pelvic fixation were excluded in an effort to specifically target pelvic function after posterior fixation only.
Patients and methods All subjects included in the investigation underwent surgical management between 9/6/2007 and 10/17/2011 at our institution (Urban, Level One Trauma Center). The senior author (SM) performed all procedures. Inclusion criteria for involvement in this analysis were as follows: surgical management of the pelvis using percutaneous posterior fixation techniques (Current Procedure Terminology code 27216: Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring), ability and willingness to participate in a telephone survey, preoperative and
123
postoperative CT scans of the pelvis, and preoperative and postoperative stress examination under anesthesia. Exclusion criteria were as follows: concomitant long-bone fracture(s), visceral injury requiring surgery, spinal cord injury, and death at the time of outcomes survey. Additionally, subjects were excluded if they had any internal or external anterior pelvic ring or acetabular fixation. The Institutional Review Board (IRB) at our institution approved our protocol for this analysis. Subjects were identified by searching our internal trauma database. The electronic medical record was then utilized to identify subjects that failed exclusion criteria. All subjects had postoperative plain radiographic follow-up to union. Fracture classification was based on the AO/OTA classification of acute pelvic fractures. All subjects included in this series had exam-under-anesthesia-stress-test-positive 61-B posterior ring injuries. As described by the AO/OTA classification system, 61-B injuries are partially unstable, incomplete disruptions of the posterior ring. 61-B injuries are sub-grouped into B1, B2, and B3. 61-B1 injuries are anterior–posterior compression. 61-B2 injuries are lateral compression. 61-B3 injuries are bilateral [18]. After percutaneous posterior ring fixation, all injuries were stressed in the operating room, demonstrating stable posterior ring fixation. Pre- and postoperative posterior ring displacement was measured at the point of maximal displacement of the sacroiliac joint on axial CT images. Once all appropriate subjects were identified, they were asked to participate in a telephone survey administered by the first author (MPS) based on Majeed’s pelvic outcomes grading scale. This scale was modified slightly in order to limit socioeconomic, cultural, and psychological confounders. For example, we removed all questions related to return to pre-injury occupation, as we believed return to work is likely confounded by psychological and financial factors. The functional survey consisted of six multiplechoice questions with answers graded along a continuum, Table 1. Each answer was given a point value, and points were summed to give a raw total. The raw total was then converted to a percentage, and functional outcome was based on the subject’s percentage score. We felt this was the most reliable way to standardize point values in the setting of three subjects who declined to answer questions pertaining to sexual intercourse.
Results During the study period, 470 patients were treated surgically with pelvic ring injuries. Of these subjects, 78 treated with percutaneous posterior ring fixation were initially identified from our internal trauma database as meeting the inclusion criteria for this study. Forty-six of these subjects
Eur J Orthop Surg Traumatol Table 1 Pelvic functional assessment survey modified from Majeed’s pelvic outcomes grading scale [11]
(1) In terms of your pelvic pain as it relates to activity, would you describe it as Intense and continuous at rest
5
Intense with activity
10
Tolerable but limits activity Pain with moderate activity but goes away with rest
15 20
Mild and intermittent with normal activity
25
No pain
30
(2) In terms of your pelvic pain as it relates to sitting, would you describe it as Painful with any sitting
4
Painful if prolonged
6
Uncomfortable but not painful
8
No pain
10
(3) In terms of your pelvic pain as it relates to sexual intercourse, would you describe it as Painful with any attempt
1
Painful if prolonged
2
Uncomfortable but not painful
3
No pain
4
(4) In terms of your ability to ambulate as a result of pelvic pain, do you ever use Unable to ambulate (i.e., bedridden) Wheelchair
2 4
Two crutches
6
One crutch
8
One cane
10
Nothing
12
(5) Which of the following best describes your gait, with or without assistance Cannot walk
2
Shuffle small steps
4
Major limp
6
Moderate limp
8
Slight limp
10
No limp
12
(6) In terms of the distance you are able to walk, would you describe it as Bedridden
2
Very limited in time and distance with assistance (cane, crutch)
4
Very limited in time and distance with out assistance 1 h continuous but require assistance
6 8
1 h continuous without assistance but slight pain and/or limp
10
Normal for age and general condition
12
Sum Total Grade = (sum total___/80) 9 100 Grading scale (%) Excellent: 90–100 Good: 80–89 Fair: 70–79 Poor: \70
were excluded based on exclusion criteria, leaving 32 subjects preliminarily available to participate in the questionnaire. One subject died from unrelated causes, two subjects refused to participate, and 13 subjects could not be located, leaving 16 subjects, all of whom participated in
and completed the survey. There were 13 females and three males. Mean age at the time of injury was 42.4 years (female 44.8 years and males 32 years). Injury mechanisms are as follows: road traffic accident 11 (69 %), fall 3 (19 %), and pedestrian struck 2 (13 %). Fourteen (88 %)
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subjects sustained associated traumatic injuries such as shoulder dislocation, clavicle fracture, retroperitoneal hematoma, and lung contusion. Seven (43 %) subjects required additional surgeries. No subjects had neurologic injuries. No subjects had urologic injuries. Mean time from injury to surgery was 4.2 days (range 0–12 days), and mean length of stay was 11.7 days (range 3–27 days). Mean time from injury to functional assessment was 31 months (range 14–55 months), and mean radiographic follow-up was 7.8 months (Table 2). All fractures were closed 61-B injuries (incomplete disruptions of the posterior arch that allow rotation of the hemipelvis) that were stress positive preoperatively under anesthesia with static displacement noted on CT scan ranging 0–7 mm prior to stress intra-operative stress examination. According to the Matta’s criteria for pelvic reduction, all injuries were acceptably reduced [19]. Average postoperative displacement was 0.3 mm (range 0–2 mm). All 11 unilateral injuries (61-B1 and 61-B2) were treated with single, unilateral upper sacral segment screw fixation (7.0 mm fully threaded, cannulated screws, Synthes, West Chester, PA). All five bilateral injuries (61-B3) were treated with bilateral percutaneous fixation (7.0 mm fully threaded, cannulated screws, Synthes, West Chester, PA, USA, and Zimmer, Warsaw, IN, USA). Table 2 Study cohort
Complications were limited. There were no intra-operative complications related to screw placement. One of twenty-one screws (4.8 %) breached the anterior cortex of the upper sacral segment, but did not require revision. This subject had no neurologic sequelae, and the functional score was 94 % (excellent). There were no hardware failures at follow-up or postoperative infections. There were no iatrogenic nerve root injuries. No screws loosened or had to be removed for any reason. At final radiographic follow-up, there were no findings of non-union. At final follow-up, 16 patients completed the functional assessment survey. The overall average pelvic functional assessment score for the entire cohort was 85 % (good function). A total of 37.5 % of subjects scored excellent, 25 % scored good, 18.75 % scored fair, and 18.75 % scored poor. 61-B3 injuries (bilateral) had the highest average functional score, 89.4 %. This was followed by 61-B1 injuries (Anterior–posterior compression), 87.5 %. 61-B2 injuries (Lateral compression) were the poorest, with an average functional score of 81.1 %. Overall the average score for the bilateral injuries was 89.4 % and for unilateral injuries was 83.4 %, Table 3. A breakdown of outcomes by each functional assessment question is described in Table 4. Subjects performed highest with respect to their lack of reliance of assistive devices, such
Seventy-eight met inclusion criteria ? 46 failed exclusion criteria ? 16 unavailable Sixteen subjects for analysis Mean age: 42.4 years (18–90 years) Mechanism: road traffic accident (11/16), fall (3/16), and pedestrian struck (2/16) Mean time from injury to surgery: 4.2 days Mean length of hospitalization: 11.7 days Mean follow-up: clinical 31 months; radiographic 7.8 months Preoperative displacement: 0–7 mm (prior to stress examination) Postoperative displacement: 0.3 mm (CT scan after internal fixation and stress examination) Injury pattern Unilateral: 61-B1 and 61-B2 ? 11/16 Bilateral: 61-B3 ? 5/16
Table 3 Functional outcome scores by fracture pattern
Average overall functional score—85 % 37.5 %—Excellent: 90–100 % (6/16) 25 %—Good: 80–89 % (4/16) 18.75 %—Fair: 70–79 % (3/16) 18.75 %—Poor: \70 % (3/16) 61-B1 injuries (4/16—unilateral external rotation) —mean functional score—87.5 % 61-B2 injuries (7/16—unilateral internal rotation)—mean functional score—81.1 % 61-B3 injuries (5/16—bilateral)—mean functional score—89.4 %
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Unilateral injuries (61-B1 and B2)
Bilateral injuries (61-B3)
mean functional score—83.4 %
mean functional score—89.4 %
Eur J Orthop Surg Traumatol Table 4 Functional assessment outcomes by question Question
Average score/ (total)
Interpretation
Description of pelvic pain with activity
23.8/(30) = 79 %
Between pain with moderate activity and mild pain that goes away with rest
2
Pain related to sitting
8.6/(10) = 86 %
Between uncomfortable but not painful and no pain with sitting at all
3
Pain with sexual intercourse
3.3/(4) = 83 %
Uncomfortable but not painful
1
4
Assistive devices for ambulation
11.8/(12) = 98 %
No subjects required assistive devices
5
Description of gait
11.3/(12) = 94 %
Nearly all subjects ambulating with no assistance
6
Walking distance
9.8/(12) = 82 %
1 h continuous without assistance but slight pain and/or limp
Summary of responses, average scores, and interpretation of each score of the six questions of the pelvic functional assessment survey
as cane/crutches. Two subjects (12.5 %) required a single cane for walking assistance, while all other subjects require no assistance. All subjects described gait as either with slight limp or with no limp. Sitting comfort also scored well with an average score of 86 % with just over half of all subjects describing no pain with sitting. Conversely, subjects described their comfort during sexual activity relatively poorly, with an average description of ‘‘uncomfortable but not painful’’ as well as pain or limp with walking significant distances. Comfort with daily activities scored poorest. All but three subjects reported at least some pelvic pain with daily activities and an average score of 79 % (fair).
Discussion The goal of this series was to assess pelvic-specific function in patients with isolated 61-B pelvic ring injuries treated with posterior only closed reduction and percutaneous screw fixation. To our knowledge, this is the first of its kind in which all confounding injuries were excluded in an attempt to look specifically at pelvic outcomes. Radiographic outcomes of percutaneously treated posterior pelvic ring injuries have been extensively published in the literature. Routt published the first series describing the results of patients undergoing percutaneous iliosacral screw fixation for iliosacral disruptions and sacral fractures in the supine position. Sixty-eight consecutive patients were included and 50 % required concomitant surgical fixation of anterior pelvic or acetabular fractures. There was 4 % hardware failure rate [1]. Routt later published a series of 60 consecutive sacral fractures treated with percutaneous posterior fixation. A total of 72 % had concomitant anterior pelvic or acetabular fixation. There were two non-unions and five hardware failures [7]. Radiographic outcome series has similarly been published with respect to percutaneous posterior screw fixation of U-type sacral fractures and vertically unstable sacral fractures [6, 8]. To a lesser degree, there are a number of investigations in the literature examining clinical outcomes in patients
undergoing percutaneous fixation of posterior ring injuries. Cole et al. published their extensive Pelvic Outcomes Scale based on pain, ambulation, work and activity status, clinical examination, and radiographic outcome. They examined 64 patients with C-type (unstable) posterior pelvic fractures. A total of 78 % of patients underwent percutaneous posterior ring fixation, and 58 % of patients underwent both anterior and posterior internal fixation. Nearly all patients had concomitant long-bone or neurological injury, and 22 % of patients reported significant long-term sequelae of their comorbid injuries. Overall, the average outcome score for all patients was 29 out of 40 total points [9]. Schweitzer et al. likewise described clinical outcomes in patients undergoing percutaneous fixation of posterior ring injuries. Seventy-three patients were included. A total of 81 % required provisional or definitive anterior pelvic fixation in addition to posterior percutaneous screw fixation. At final assessment, 26 % reported some degree of sacroiliac joint pain or discomfort [10]. As a consequence of comorbid injuries, varying operative techniques, and high rates of surgical complications, functional outcomes specific to pelvic ring injuries in isolation have been difficult to assess [11, 14, 20]. Concomitant injuries may negatively impact gait, contribute to chronic pin, and cause sexual dysfunction [5, 9, 10, 21–23]. In these multiply injured patients, there is often no way of assessing our ability to restore normal pelvic function in the face of simultaneous injuries. With respect to functional outcomes, our strict inclusion and exclusion criteria allowed for the controlled assessment of posterior pelvic ring injuries without additional confounding injuries. The data presented here suggest several important findings referable to radiographic and functional outcomes of percutaneously managed, isolated, partially unstable posterior pelvic ring injuries. With respect to radiographic outcomes, our average radiographic follow-up was 7.8 months. Neither radiographic non-unions nor hardware failures were identified in this series. The average length of follow-up was excellent (30.8 months). When considering all subjects, regardless of injury pattern, mean functional outcome score at final follow-up was good (85 %).
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A comparison of unilateral to bilateral injuries suggests similar long-term results between cohorts. Mean functional score for unilateral injury was 83.4 % and for bilateral injury was 89.4 %, suggesting an element of persistent disability in all fracture patterns. Intuitively, one would expect unilateral injuries to perform better than bilateral injuries. This was not seen. Reasons for this finding are unclear; however, they are perhaps related to significant pelvic floor soft tissue injury that is not addressed with bony fixation alone. This point is highlighted by the finding that all subjects in our series had stable examination before leaving the operating room, and no non-unions or malunions were found at follow-up. A breakdown of questions related to specific tasks shows interesting trends as well. Pain with sitting, reliance of assistive devices, and gait abnormality all showed excellent outcomes across fracture patterns. On the other hand, pain with sexual activity on average was reported as fair. Dyspareunia has been reported in the literature as an expected outcome of pelvic ring injuries [21–23]. This, however, is the first series to show sexual dysfunction when concomitant injuries are absent, and postoperative fracture reduction is anatomic, suggesting a persistent consequence of pelvic soft tissue trauma. The differences identified in activity-specific domains suggest the importance of different pelvic structures for specific pelvic demands. This is an area of potential future investigation. There are a number of limitations of this investigation. The most significant of which is the small study size. This is a result of both our strict inclusion/exclusion criteria and the difficulty encountered with following trauma patients post-injury. Additionally, we retrospectively examined radiographs and operative reports, which lend itself to interpretation error. In summary, our series of isolated posterior pelvic ring injuries treated with percutaneous posterior screw fixation demonstrates excellent radiographic union and good overall functional results; however, both unilateral and bilateral injuries demonstrated some element of persistent clinical pelvic dysfunction and neither laterality nor stable internal fixation predicted functional outcomes. Future considerations may be aimed at a better understanding of pelvic soft tissue injury, reconstructive options, and operative criteria. Conflict of interest
None.
References 1. Routt ML, Kregor PJ, Simonian PT et al (1995) Early results of percutaneous iliosacral screws placed with the patient in the supine position. J Orthop Trauma 9(3):207–214 2. Shuler TE, Boone DC, Gruen GS et al (1995) Percutaneous iliosacral screw fixation: early treatment for unstable posterior pelvic ring disruptions. J Trauma 38(3):453–458
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3. Routt ML, Simonian PT, Mills WJ (1997) Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma 11(8):584–589 4. Routt ML, Nork SE, Mills WJ (2000) Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res 375:15–29 5. Lindahl J, Hirvensalo E (2005) Outcome of operatively treated type-C injuries of the pelvic ring. Acta Orthop 76(5):667–678 6. Nork SE, Jones CB, Harding SP et al (2001) Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma 15(4):238–246 7. Routt ML, Simonian PT (1996) Closed reduction and percutaneous skeletal fixation of sacral fractures. Clin Orthop Relat Res 329:121–128 8. Griffin DR, Starr AJ, Reinert CM et al (2006) Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure? J Orthop Trauma 20(1 Suppl):S30–S36 discussion S36 9. Cole JD, Blum DA, Ansel LJ (1996) Outcome after fixation of unstable posterior pelvic ring injuries. Clin Orthop Relat Res 329:160–179 10. Schweitzer D, Zylberberg A, Co´rdova M et al (2008) Closed reduction and iliosacral percutaneous fixation of unstable pelvic ring fractures. Injury 39(8):869–874 11. Majeed SA (1989) Grading the outcome of pelvic fractures. J Bone Joint Surg Br 71(2):304–306 12. Suzuki T, Hak DJ, Ziran BH et al (2009) Outcome and complications of posterior transiliac plating for vertically unstable sacral fractures. Injury 40(4):405–409 13. Dujardin FH, Hossenbaccus M, Duparc F et al (1998) Long-term functional prognosis of posterior injuries in high-energy pelvic disruption. J Orthop Trauma 12(3):592–593 14. Lindahl J, Hirvensalo E, Bo¨stman O, Santavirta S (1999) Failure of reduction with an external fixator in the management of injuries of the pelvic ring. Long-term evaluation of 110 patients. J Bone Joint Surg Br 81(6):955–962 15. Van den Bosch EW, Van der Kleyn R, Hogervorst M et al (1999) Functional outcome of internal fixation for pelvic ring fractures. J Trauma 47(2):365–371 16. Suzuki T, Shindo M, Soma K et al (2007) Long-term functional outcome after unstable pelvic ring fracture. J Trauma 63(4):884–888 17. Mullis BH, Sagi HC (2008) Minimum 1-year follow-up for patients with vertical shear sacroiliac joint dislocations treated with iliosacral screws: does joint ankylosis or anatomic reduction contribute to functional outcome? J Orthop Trauma 22(5):293–298 18. Marsh J, Slongo T, Agel J et al (2007) Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database, and outcomes committee. J Orthop Trauma 21(10):S1–S133 19. Tornetta P, Matta JM (1996) Outcome of operatively treated unstable posterior pelvic ring disruptions. Clin Orthop Relat Res 329(329):186–193 20. Oliver CW, Twaddle B, Agel J et al (1996) Outcome after pelvic ring fractures: evaluation using the medical outcomes short form SF-36. Injury 27(9):635–641 21. Vallier HA, Cureton BA, Schubeck D (2012) Pelvic ring injury is associated with sexual dysfunction in women. J Orthop Trauma 26(5):308–313 22. Copeland CE, Bosse MJ, McCarthy ML, MacKenzie EJ et al (1997) Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function. J Orthop Trauma 11(2):73–81 23. Kiely N, Williams N (1996) Sexual dysfunction in women following pelvic fractures with sacro-iliac disruption. Injury 27(1):45–46
ORIGINAL ARTICLE • PELVIS - TRAUMA
Isolated pelvic ring injuries: functional outcomes following percutaneous, posterior fixation Matthew P. Sullivan1
•
John A. Scolaro2 • Andrew H. Milby1 • Samir Mehta1
Received: 13 January 2015 / Accepted: 29 March 2015 Springer-Verlag France 2015
Abstract Objectives To characterize pelvic-specific functional outcomes in patients with isolated, partially unstable (AO/ OTA 61-B), pelvic ring injuries treated with posterior only percutaneous screw fixation of the pelvic ring. Patients and methods Between September 2007 and October 2011, 16 subjects (mean age 42.4 years; range 18–90 years) with isolated, partially unstable pelvic ring injuries (AO/OTA 61-B) were treated with percutaneous, posterior pelvic ring fixation. Subjects underwent an evaluation of pelvic ring function with a modification of Majeed’s pelvic functional outcome assessment tool. Subjects were excluded if they sustained a concomitant long-bone fracture, visceral injury requiring surgery, spinal cord injury, and an injury to the anterior pelvic ring or acetabulum requiring additional fixation. Result Mean follow-up was 30.8 (range 14–55) months. Eleven subjects sustained unilateral posterior ring injuries, and five subjects sustained bilateral posterior ring injuries.
All fractures healed uneventfully, and no hardware failures were noted. Average pelvic functional outcome score at final follow-up was 85.3 % (good). All but subjects required assistive walking devices and gait and sitting comfort scored ‘‘excellent.’’ High rates of sexual dysfunction and persistent difficulty with daily activities were noted in this series. Conclusions This series demonstrates that activity-specific dysfunction persists years after definitive percutaneous posterior fixation of isolated pelvic ring injuries. Radiographic outcomes were excellent as were subjects’ ability to ambulate independently and sit comfortably without pain. Many complained of persistent discomfort with both daily activities and sexual activity, suggesting persistent pathology to the non-osseous structures about the pelvis. Keywords Pelvic ring Pelvic trauma Posterior pelvic ring Functional outcomes Percutaneous pelvic fixation
Introduction & Matthew P. Sullivan [email protected] John A. Scolaro [email protected] Andrew H. Milby [email protected] Samir Mehta [email protected] 1
Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
2
Department of Orthopaedic Surgery, University of California Irvine Medical Center, 101 The City Drive South, Orange, CA 92868, USA
Percutaneous fixation of posterior pelvic ring injuries has gained popularity over the past two decades as a safe and effective way to definitively stabilize the posterior ring while limiting surgical complications [1–4]. Injuries to the posterior pelvic ring are commonly due to high-energy mechanisms, such as motor vehicle and pedestrian-struck accidents. These patients tend to be polytraumatized with associated long-bone, visceral, and central nervous system injuries [5]. Due to the high rate of wound complications related to open surgery about the traumatized pelvis, less invasive techniques were developed in which percutaneous screw fixation is performed in either the prone or the supine position. This has been made possible with advances in
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intra-operative fluoroscopic imaging and pre- and postoperative CT reconstructions in both two- and three-dimensions [4]. There are several reports in the literature, primarily case series, of patients treated with percutaneous fixation of posterior ring injuries [1, 2, 6–10]. These series demonstrate that percutaneous techniques work well and that radiographic union following posterior ring injures is achievable. Many of the published series describe surgical complications and radiographic outcomes [1, 2, 6–8]. Far fewer describe both radiographic and clinically significant pelvic outcomes [9, 10]. Of those that describe pelvic functional outcomes, nearly all patients included suffered from concomitant longbone or visceral injuries, which, no doubt, affect clinical pelvic outcome measures, such as pain with ambulation, sexual dysfunction, and gait abnormalities. Consequently, our understanding of the effects that percutaneous management of posterior ring injuries have on pelvic pain and function is likely confounded by comorbid injuries. The primary goal of this analysis is to investigate functional outcomes in patients with isolated AO/OTA 61-B (partially unstable) pelvic ring injuries treated surgically with posterior only closed reduction and percutaneous fixation techniques in the supine position, as described by Routt et al. [1]. We attempted to study a cohort of subjects without confounding injuries, such as long-bone fractures, spinal cord injuries, or additional pelvic or acetabular fractures requiring surgery. Majeed first proposed his ‘‘System for functional assessment after pelvic fractures’’ in 1989 [11]. This grading system has been used numerous times in its native form as well as in modified forms [10, 12–17]. We utilized a modification of Majeed’s pelvic outcomes grading scale to assess functional outcomes related to pelvic pain with various activities, including sitting, walking, and sexual intercourse, as well as other parameters. Polytraumatized patients with confounding injuries and anterior pelvic fixation were excluded in an effort to specifically target pelvic function after posterior fixation only.
Patients and methods All subjects included in the investigation underwent surgical management between 9/6/2007 and 10/17/2011 at our institution (Urban, Level One Trauma Center). The senior author (SM) performed all procedures. Inclusion criteria for involvement in this analysis were as follows: surgical management of the pelvis using percutaneous posterior fixation techniques (Current Procedure Terminology code 27216: Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring), ability and willingness to participate in a telephone survey, preoperative and
123
postoperative CT scans of the pelvis, and preoperative and postoperative stress examination under anesthesia. Exclusion criteria were as follows: concomitant long-bone fracture(s), visceral injury requiring surgery, spinal cord injury, and death at the time of outcomes survey. Additionally, subjects were excluded if they had any internal or external anterior pelvic ring or acetabular fixation. The Institutional Review Board (IRB) at our institution approved our protocol for this analysis. Subjects were identified by searching our internal trauma database. The electronic medical record was then utilized to identify subjects that failed exclusion criteria. All subjects had postoperative plain radiographic follow-up to union. Fracture classification was based on the AO/OTA classification of acute pelvic fractures. All subjects included in this series had exam-under-anesthesia-stress-test-positive 61-B posterior ring injuries. As described by the AO/OTA classification system, 61-B injuries are partially unstable, incomplete disruptions of the posterior ring. 61-B injuries are sub-grouped into B1, B2, and B3. 61-B1 injuries are anterior–posterior compression. 61-B2 injuries are lateral compression. 61-B3 injuries are bilateral [18]. After percutaneous posterior ring fixation, all injuries were stressed in the operating room, demonstrating stable posterior ring fixation. Pre- and postoperative posterior ring displacement was measured at the point of maximal displacement of the sacroiliac joint on axial CT images. Once all appropriate subjects were identified, they were asked to participate in a telephone survey administered by the first author (MPS) based on Majeed’s pelvic outcomes grading scale. This scale was modified slightly in order to limit socioeconomic, cultural, and psychological confounders. For example, we removed all questions related to return to pre-injury occupation, as we believed return to work is likely confounded by psychological and financial factors. The functional survey consisted of six multiplechoice questions with answers graded along a continuum, Table 1. Each answer was given a point value, and points were summed to give a raw total. The raw total was then converted to a percentage, and functional outcome was based on the subject’s percentage score. We felt this was the most reliable way to standardize point values in the setting of three subjects who declined to answer questions pertaining to sexual intercourse.
Results During the study period, 470 patients were treated surgically with pelvic ring injuries. Of these subjects, 78 treated with percutaneous posterior ring fixation were initially identified from our internal trauma database as meeting the inclusion criteria for this study. Forty-six of these subjects
Eur J Orthop Surg Traumatol Table 1 Pelvic functional assessment survey modified from Majeed’s pelvic outcomes grading scale [11]
(1) In terms of your pelvic pain as it relates to activity, would you describe it as Intense and continuous at rest
5
Intense with activity
10
Tolerable but limits activity Pain with moderate activity but goes away with rest
15 20
Mild and intermittent with normal activity
25
No pain
30
(2) In terms of your pelvic pain as it relates to sitting, would you describe it as Painful with any sitting
4
Painful if prolonged
6
Uncomfortable but not painful
8
No pain
10
(3) In terms of your pelvic pain as it relates to sexual intercourse, would you describe it as Painful with any attempt
1
Painful if prolonged
2
Uncomfortable but not painful
3
No pain
4
(4) In terms of your ability to ambulate as a result of pelvic pain, do you ever use Unable to ambulate (i.e., bedridden) Wheelchair
2 4
Two crutches
6
One crutch
8
One cane
10
Nothing
12
(5) Which of the following best describes your gait, with or without assistance Cannot walk
2
Shuffle small steps
4
Major limp
6
Moderate limp
8
Slight limp
10
No limp
12
(6) In terms of the distance you are able to walk, would you describe it as Bedridden
2
Very limited in time and distance with assistance (cane, crutch)
4
Very limited in time and distance with out assistance 1 h continuous but require assistance
6 8
1 h continuous without assistance but slight pain and/or limp
10
Normal for age and general condition
12
Sum Total Grade = (sum total___/80) 9 100 Grading scale (%) Excellent: 90–100 Good: 80–89 Fair: 70–79 Poor: \70
were excluded based on exclusion criteria, leaving 32 subjects preliminarily available to participate in the questionnaire. One subject died from unrelated causes, two subjects refused to participate, and 13 subjects could not be located, leaving 16 subjects, all of whom participated in
and completed the survey. There were 13 females and three males. Mean age at the time of injury was 42.4 years (female 44.8 years and males 32 years). Injury mechanisms are as follows: road traffic accident 11 (69 %), fall 3 (19 %), and pedestrian struck 2 (13 %). Fourteen (88 %)
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subjects sustained associated traumatic injuries such as shoulder dislocation, clavicle fracture, retroperitoneal hematoma, and lung contusion. Seven (43 %) subjects required additional surgeries. No subjects had neurologic injuries. No subjects had urologic injuries. Mean time from injury to surgery was 4.2 days (range 0–12 days), and mean length of stay was 11.7 days (range 3–27 days). Mean time from injury to functional assessment was 31 months (range 14–55 months), and mean radiographic follow-up was 7.8 months (Table 2). All fractures were closed 61-B injuries (incomplete disruptions of the posterior arch that allow rotation of the hemipelvis) that were stress positive preoperatively under anesthesia with static displacement noted on CT scan ranging 0–7 mm prior to stress intra-operative stress examination. According to the Matta’s criteria for pelvic reduction, all injuries were acceptably reduced [19]. Average postoperative displacement was 0.3 mm (range 0–2 mm). All 11 unilateral injuries (61-B1 and 61-B2) were treated with single, unilateral upper sacral segment screw fixation (7.0 mm fully threaded, cannulated screws, Synthes, West Chester, PA). All five bilateral injuries (61-B3) were treated with bilateral percutaneous fixation (7.0 mm fully threaded, cannulated screws, Synthes, West Chester, PA, USA, and Zimmer, Warsaw, IN, USA). Table 2 Study cohort
Complications were limited. There were no intra-operative complications related to screw placement. One of twenty-one screws (4.8 %) breached the anterior cortex of the upper sacral segment, but did not require revision. This subject had no neurologic sequelae, and the functional score was 94 % (excellent). There were no hardware failures at follow-up or postoperative infections. There were no iatrogenic nerve root injuries. No screws loosened or had to be removed for any reason. At final radiographic follow-up, there were no findings of non-union. At final follow-up, 16 patients completed the functional assessment survey. The overall average pelvic functional assessment score for the entire cohort was 85 % (good function). A total of 37.5 % of subjects scored excellent, 25 % scored good, 18.75 % scored fair, and 18.75 % scored poor. 61-B3 injuries (bilateral) had the highest average functional score, 89.4 %. This was followed by 61-B1 injuries (Anterior–posterior compression), 87.5 %. 61-B2 injuries (Lateral compression) were the poorest, with an average functional score of 81.1 %. Overall the average score for the bilateral injuries was 89.4 % and for unilateral injuries was 83.4 %, Table 3. A breakdown of outcomes by each functional assessment question is described in Table 4. Subjects performed highest with respect to their lack of reliance of assistive devices, such
Seventy-eight met inclusion criteria ? 46 failed exclusion criteria ? 16 unavailable Sixteen subjects for analysis Mean age: 42.4 years (18–90 years) Mechanism: road traffic accident (11/16), fall (3/16), and pedestrian struck (2/16) Mean time from injury to surgery: 4.2 days Mean length of hospitalization: 11.7 days Mean follow-up: clinical 31 months; radiographic 7.8 months Preoperative displacement: 0–7 mm (prior to stress examination) Postoperative displacement: 0.3 mm (CT scan after internal fixation and stress examination) Injury pattern Unilateral: 61-B1 and 61-B2 ? 11/16 Bilateral: 61-B3 ? 5/16
Table 3 Functional outcome scores by fracture pattern
Average overall functional score—85 % 37.5 %—Excellent: 90–100 % (6/16) 25 %—Good: 80–89 % (4/16) 18.75 %—Fair: 70–79 % (3/16) 18.75 %—Poor: \70 % (3/16) 61-B1 injuries (4/16—unilateral external rotation) —mean functional score—87.5 % 61-B2 injuries (7/16—unilateral internal rotation)—mean functional score—81.1 % 61-B3 injuries (5/16—bilateral)—mean functional score—89.4 %
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Unilateral injuries (61-B1 and B2)
Bilateral injuries (61-B3)
mean functional score—83.4 %
mean functional score—89.4 %
Eur J Orthop Surg Traumatol Table 4 Functional assessment outcomes by question Question
Average score/ (total)
Interpretation
Description of pelvic pain with activity
23.8/(30) = 79 %
Between pain with moderate activity and mild pain that goes away with rest
2
Pain related to sitting
8.6/(10) = 86 %
Between uncomfortable but not painful and no pain with sitting at all
3
Pain with sexual intercourse
3.3/(4) = 83 %
Uncomfortable but not painful
1
4
Assistive devices for ambulation
11.8/(12) = 98 %
No subjects required assistive devices
5
Description of gait
11.3/(12) = 94 %
Nearly all subjects ambulating with no assistance
6
Walking distance
9.8/(12) = 82 %
1 h continuous without assistance but slight pain and/or limp
Summary of responses, average scores, and interpretation of each score of the six questions of the pelvic functional assessment survey
as cane/crutches. Two subjects (12.5 %) required a single cane for walking assistance, while all other subjects require no assistance. All subjects described gait as either with slight limp or with no limp. Sitting comfort also scored well with an average score of 86 % with just over half of all subjects describing no pain with sitting. Conversely, subjects described their comfort during sexual activity relatively poorly, with an average description of ‘‘uncomfortable but not painful’’ as well as pain or limp with walking significant distances. Comfort with daily activities scored poorest. All but three subjects reported at least some pelvic pain with daily activities and an average score of 79 % (fair).
Discussion The goal of this series was to assess pelvic-specific function in patients with isolated 61-B pelvic ring injuries treated with posterior only closed reduction and percutaneous screw fixation. To our knowledge, this is the first of its kind in which all confounding injuries were excluded in an attempt to look specifically at pelvic outcomes. Radiographic outcomes of percutaneously treated posterior pelvic ring injuries have been extensively published in the literature. Routt published the first series describing the results of patients undergoing percutaneous iliosacral screw fixation for iliosacral disruptions and sacral fractures in the supine position. Sixty-eight consecutive patients were included and 50 % required concomitant surgical fixation of anterior pelvic or acetabular fractures. There was 4 % hardware failure rate [1]. Routt later published a series of 60 consecutive sacral fractures treated with percutaneous posterior fixation. A total of 72 % had concomitant anterior pelvic or acetabular fixation. There were two non-unions and five hardware failures [7]. Radiographic outcome series has similarly been published with respect to percutaneous posterior screw fixation of U-type sacral fractures and vertically unstable sacral fractures [6, 8]. To a lesser degree, there are a number of investigations in the literature examining clinical outcomes in patients
undergoing percutaneous fixation of posterior ring injuries. Cole et al. published their extensive Pelvic Outcomes Scale based on pain, ambulation, work and activity status, clinical examination, and radiographic outcome. They examined 64 patients with C-type (unstable) posterior pelvic fractures. A total of 78 % of patients underwent percutaneous posterior ring fixation, and 58 % of patients underwent both anterior and posterior internal fixation. Nearly all patients had concomitant long-bone or neurological injury, and 22 % of patients reported significant long-term sequelae of their comorbid injuries. Overall, the average outcome score for all patients was 29 out of 40 total points [9]. Schweitzer et al. likewise described clinical outcomes in patients undergoing percutaneous fixation of posterior ring injuries. Seventy-three patients were included. A total of 81 % required provisional or definitive anterior pelvic fixation in addition to posterior percutaneous screw fixation. At final assessment, 26 % reported some degree of sacroiliac joint pain or discomfort [10]. As a consequence of comorbid injuries, varying operative techniques, and high rates of surgical complications, functional outcomes specific to pelvic ring injuries in isolation have been difficult to assess [11, 14, 20]. Concomitant injuries may negatively impact gait, contribute to chronic pin, and cause sexual dysfunction [5, 9, 10, 21–23]. In these multiply injured patients, there is often no way of assessing our ability to restore normal pelvic function in the face of simultaneous injuries. With respect to functional outcomes, our strict inclusion and exclusion criteria allowed for the controlled assessment of posterior pelvic ring injuries without additional confounding injuries. The data presented here suggest several important findings referable to radiographic and functional outcomes of percutaneously managed, isolated, partially unstable posterior pelvic ring injuries. With respect to radiographic outcomes, our average radiographic follow-up was 7.8 months. Neither radiographic non-unions nor hardware failures were identified in this series. The average length of follow-up was excellent (30.8 months). When considering all subjects, regardless of injury pattern, mean functional outcome score at final follow-up was good (85 %).
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A comparison of unilateral to bilateral injuries suggests similar long-term results between cohorts. Mean functional score for unilateral injury was 83.4 % and for bilateral injury was 89.4 %, suggesting an element of persistent disability in all fracture patterns. Intuitively, one would expect unilateral injuries to perform better than bilateral injuries. This was not seen. Reasons for this finding are unclear; however, they are perhaps related to significant pelvic floor soft tissue injury that is not addressed with bony fixation alone. This point is highlighted by the finding that all subjects in our series had stable examination before leaving the operating room, and no non-unions or malunions were found at follow-up. A breakdown of questions related to specific tasks shows interesting trends as well. Pain with sitting, reliance of assistive devices, and gait abnormality all showed excellent outcomes across fracture patterns. On the other hand, pain with sexual activity on average was reported as fair. Dyspareunia has been reported in the literature as an expected outcome of pelvic ring injuries [21–23]. This, however, is the first series to show sexual dysfunction when concomitant injuries are absent, and postoperative fracture reduction is anatomic, suggesting a persistent consequence of pelvic soft tissue trauma. The differences identified in activity-specific domains suggest the importance of different pelvic structures for specific pelvic demands. This is an area of potential future investigation. There are a number of limitations of this investigation. The most significant of which is the small study size. This is a result of both our strict inclusion/exclusion criteria and the difficulty encountered with following trauma patients post-injury. Additionally, we retrospectively examined radiographs and operative reports, which lend itself to interpretation error. In summary, our series of isolated posterior pelvic ring injuries treated with percutaneous posterior screw fixation demonstrates excellent radiographic union and good overall functional results; however, both unilateral and bilateral injuries demonstrated some element of persistent clinical pelvic dysfunction and neither laterality nor stable internal fixation predicted functional outcomes. Future considerations may be aimed at a better understanding of pelvic soft tissue injury, reconstructive options, and operative criteria. Conflict of interest
None.
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