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Introduction: Non-operative management of pelvic ring injuries in the elderly is associated with a high risk of one-year mortality. The majority of these injuries are the result of a low-energy mechanism, however, due to the multiple medical comorbidities in this patient population the injuries are associated with a high degree of morbidity. The purpose of this study was to determine the one-year mortality risk after operative treatment of pelvic ring injuries in a geriatric patient population and the effect of patient and injury characteristics on the risk of mortality.Patients and Methods: We performed a retrospective review of patients over the age of 70 who underwent operative fixation of a pelvic ring injury at two Level 1 trauma centers between January 2016 and June 2019. Medical records were reviewed for patient and injury characteristics including: Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA) physical status score or Injury Severity Score (ISS), hospital and intensive care unit (ICU) length of stay (LOS). The primary outcome of interest was the one-year mortality risk following operative treatment. Secondary outcomes included the effect of patient and injury characteristics on the one-year mortality risk and the hospital LOS.Results: Ninety patients were included with an average age of 79.8  ±  6.5 years. The overall mortality was 8.9% (n = 8) and was significantly associated with the CCI. There was no significant effect related to the ASA physical status score or ISS. The average hospital LOS was 9.2 ± 7.3 days and was associated with the CCI, ASA physical status score, and ISS.Discussion: Non-operative management of pelvic ring injuries in geriatric patients is associated with a high risk of one-year mortality. Our findings suggest operative treatment of these fractures is associated with an acceptable risk of one-year mortality that falls below the commonly reported range for non-operatively managed injuries. Furthermore, the risk of mortality was significantly associated with the patient's pre-injury state as determined by the CCI. [ABSTRACT FROM AUTHOR]

Background: Although the second (S2) and third (S3) sacral segments have been established as potential osseous fixation pathways for screw fixation, the S2 body has been demonstrated to have inferior bone density when compared to the body of the first (S1) sacral segment. Caution regarding the use of iliosacral screws at this level has been advised as a result. As transiliac-transsacral screws traverse the lateral cortices of the posterior pelvis, they may be relying on bone with superior density for purchase, which could obviate this concern. The objective of this study was to compare the bone density of the posterior ilium and sacroiliac joint to that of the sacral body at the first (S1), second (S2), and third (S3) sacral levels., Materials and Methods: A retrospective case series was performed, reviewing the CT scans of 100 patients without prior pelvic trauma. Each CT was confirmed to have available osseous fixation pathways at the first (S1), second (S2), and third (S3) sacral segments. The bone density of the posterior ilium/sacroiliac joint (PISJ) and sacral body (SB) was measured using the embedded standardized Hounsfield units (HU) tool at each sacral level., Results: The average S2 PISJ bone density (320.1) was significantly higher than the S1 (286.5) and S3 (278.9) PISJ (p < 0.0001) and S1 and S3 PISJ was not statistically different. The S1 sacral body bone density (231.1) was significantly higher than the S2 (182.1) and S3 (126.8) bone density (p < 0.0001). The PISJ bone density is greater than the sacral body at every sacral level (p < 0.0001)., Conclusion: The S2 PISJ bone density is significantly greater than S1. The S1, S2, and S3 PISJ bone density is greater than the sacral body at all sacral levels, and the S1 body has higher bone density than the S2 and S3 bodies. These differences in bone density may have implications for the stability of posterior pelvic ring fixation constructs with regard to screw purchase., Level of Evidence: Level III-Case cohort series.

Over the past 3 decades, the evolution of pelvic and acetabular surgery has been supported by the advances in intraoperative pelvic fluoroscopic imaging technology. The new Ziehm RFD 3D C-arm unit provides routine fluoroscopic pelvic imaging but also offers rapid and high-quality real-time axial, sagittal, and coronal intraoperative imaging. This technology allows the surgeon to accurately assess fracture reduction, loose body removal, and implant locations while the patient is still under anesthesia. In this way, any necessary corrections can be performed before the patient leaves the operating room. Essentially, this technology should eliminate the need for revision surgeries. In this report, we present our initial experience using this new device.

Symptomatic hypertrophic nonunions of the inferior pubic ramus are amenable to percutaneous screw fixation in patients with suitable osseous anatomy. Preoperative planning, knowledge of bony and surrounding soft-tissue anatomy, and understanding of intraoperative pelvic fluoroscopy are required for proper screw fixation in the medullary canal of the inferior pubic ramus. In this article, we report 2 cases of adults with symptomatic hypertrophic nonunions of the superior and inferior pubic ramus, treated successfully with percutaneous medullary screw fixation. Percutaneous screw fixation can be used to successfully treat symptomatic hypertrophic nonunion of the inferior ramus and avoid the potential morbidity of a more extensive open surgical procedure.

Background: Open reduction and plate fixation of the disrupted symphysis pubis is commonly performed through a horizontal Pfannenstiel incision. Certain clinical situations that complicate the soft tissue conditions of the lower abdomen may make the Pfannenstiel incision a less appealing option. We report on the use of a vertical pubic area midline skin incision in a series of patients undergoing open reduction and plate fixation of their traumatically disrupted symphysis pubis., Materials and Methods: Institutional Review Board approval was obtained for a retrospective chart review of the charts of 25 patients treated between September 2011 and October 2012. Their charts were reviewed for patient age, gender, body mass index (BMI), pelvic injury type (as classified by Young and Burgess), mechanism of injury and associated traumatic injuries. The depth of the approach was estimated using the pelvic computed tomography (CT) scan. Details from the operative procedure were recorded, as was the length of follow-up and any perioperative complications., Results: Twenty-five patients were eligible for inclusion during the defined study time period between September 2011 and October 2012. The patients' average age was 55.8 years (range 25-91). All patients were males. The average BMI was 29.3 (range 18.8-43.8). The depth measured on the axial pelvic CT scan from skin to symphysis was 57.6 mm (range 35.2-90.2 mm). Five of 25 patients had an isolated pelvic ring injury without other associated injuries. The injury pattern was APC2 in 18, APC3 in 3, LC2 in 2, LC3 in 1 and VS in 1 patient(s) [anterior posterior compression (APC), lateral compression (LC), vertical shear (VS)]. Urologic procedures were performed in the same surgical setting in four patients. The average blood loss was 244 ml (range 150-400 ml). The average follow-up was 2.5 months (range 1-12 months). Perioperative issues were noted in two patients. One patient died within a month of surgery as a result of his associated traumatic injuries. One patient developed a deep infection., Conclusion: The pubic midline skin exposure is a feasible alternative to the Pfannenstiel incision for open reduction and plate fixation of the pubic symphysis., Level of Evidence: IV, Retrospective case series.