Operative treatment of fragility fractures of the pelvis: a critical analysis of 140 patients

Abstract

Background: Fragility fractures of the pelvis (FFP) are a clinical entity with an increasing frequency. Indications for and type of surgical treatment are still a matter of debate.

Purpose: This retrospective study presents and critically analyses the results of operative treatment of 140 patients with FFP.

Setting: Level-I trauma center.

Materials and methods: Demographic data, comorbidities, FFP-classification, type of surgical stabilization (percutaneous (P-group) versus open procedure (O-group)), length of hospital stay (LoS), general in-hospital complications, surgery-related complications, living environment before admission, mobility and destination at discharge were retracted from the medical and radiographic records. Patients were asked participating in a survey by telephone call about their quality of life. SF-8 Physical Component Score (PCS) and SF-8 Mental Component Score (MCS) were calculated as well as the Parker Mobility Score (PMS) and the Numeric Rating Scale (NRS).

Results: Mean age was 77.4 years and 89.3% of patients were female. 92.1% presented with one comorbidity, 49.3% with two or more comorbidities. Median length of hospital stay was 18 days, postoperative length of hospital stay was 12 days. 99 patients (70.7%) received a percutaneous operative procedure, 41 (29.3%) an open. Patients of the O-group had a significantly longer LoS than patients of the P-group (p = 0.009). There was no in-hospital mortality. There were significantly more surgery-related complications in the O-group (43.9%) than in the P-group (19.2%) (p = 0.006). Patients of the O-group needed more often surgical revisions (29.3%) than patients of the P-group (13.1%) (p = 0.02). Whereas 85.4% of all patients lived at home before admission, only 28.6% returned home at discharge (p < 0.001). The loss of mobility at discharge was not influenced by the FFP-classes (p = 0.47) or type of treatment (p = 0.13). One-year mortality was 9.7%. Mortality was not influenced by the FFP-classes (p = 0.428) or type of treatment (p = 0.831). Median follow-up was 40 months. SF-8 PCS and SF-8 MCS were moderate (32.43 resp. 54.42). PMS was 5 and NRS 4. Follow-up scores were not influenced by FFP-classes or type of treatment.

Conclusion: Patients with FFP, who were treated operatively, suffered from a high rate of non-lethal general, in-hospital complications. Open surgical procedures induced more surgery-related complications and surgical revisions. Mental and physical follow-up scores are low to moderate. Condition at follow-up is not influenced by FFP-classes or type of treatment. Indications for operative treatment of FFP must be critically examined. Surgical fixation should obtain adequate stability, yet be as less invasive as possible. The advantages and limitations of different surgical techniques have to be critically evaluated in prospective studies.

Keywords: Complications; Fragility fracture; Mortality; Open; Operative; Outcome; Pelvis; Percutaneous.

Fig. 1

Classification of FFP in accordance with Rommens and Hofmann [6]

Fig. 2

A 92-year-old female suffered a fall at home. The pelvic a.-p. overview shows a diastasis of the pubic symphysis and a fracture line at the right ilium (arrows) (a). CT-reconstruction along the pelvic brim shows the fracture of the right ilium and the diastasis of the pubic symphysis (arrows). The patient has a FFP type IIIa (b). Postoperative a.-p. pelvic overview. The ilium fracture and the pubic diastasis have been treated with open reduction and plate and screw osteosynthesis (c). Pelvic a.-p. overview two weeks after surgery. The three right screws of the pubic plate osteosynthesis show loosening. There are signs of surgical site infection. The symphysis plate needs to be removed and serial debridement becomes necessary (d). A.-p. pelvic overview after one month. The pubic diastasis has recurred. Due to surgical site infection at the ilium, serial debridement of the wound at the ilium is also needed (e)

Fig. 3

A 79-year-old female suffered a fall at home. The pelvic a.-p. overview reveals a displaced fracture of the left upper and lower pubic ramus and a displaced fracture of the left ilium (arrows) (a). CT-reconstruction along the pelvic brim shows the fracture of the left ilium and of the superior pubic ramus near to the anterior lip of the acetabulum (arrows). The patient has a FFP type IIIa (b). Pelvic a.-p. overview 6 months after operation. The ilium fracture was stabilized with two supra-acetabular screws from the anterior inferior to the posterior superior iliac spine. The pubic ramus fracture was stabilized with a retrograde transpubic screw. The screw insertions were performed percutaneously (c). Pelvic inlet view (d). Pelvic outlet view (e). The patient is able to walk independently up to 30 minutes. PMS is 9