Minimal Invasive Surgical Treatment of Fragility Fractures of the Pelvis

Abstract

RezumatIncidenţa fracturilor de fragilitate ale pelvisului creşte rapid. Caracteristicile acestor fracturi sunt diferite de întreruperile de inel pelvin la adulţi. Fracturile de fragilitate pelviene sunt consecinţa unei traume de mică energie la pacienţi cu scădere importantă a densităţii minerale osoase. Ca urmare a unui model persistent de alterare a distribuţiei masei osoase la nivelul sacrumului, apar alte morfologii de fracturi osoase decât în cazul adulţilor tineri. Simptomul principal este durerea imobilizantă la nivel lombar, fesier, în regiunile inghinală şi/sau a simfizei pubiene. Imaginile radiologice convenţionale şi computerul tomograf vor revela prezenţa şi localizarea fracturilor la nivelul inelului pelvin anterior şi posterior. O nouă clasificare cuprinzătoare distinge 4 categorii de instabilitate. Primul criteriu este cel mai important, deoarece indică şi tipul de tratament preferenţial. Cel de-al doilea criteriu, care determină subtipurile celor patru categorii, este localizarea instabilităţii la nivelul inelului pelvin posterior. Acest criteriu indică tipul de procedură chirurgicală ce trebuie efectuată. Atunci când este ales tratamentul chirurgical, procedura aleasă ar trebui să fie cât mai puţin invazivă cu putinţă. Au fost dezvoltate diverse tehnici percutane sau de fixare mai puţin invazivă a inelului pelvin posterior. Sunt prezentate avantajele şi limitările acestora -sacroplastie, osteosinteză ileosacrată cu şurub, plasare de ciment, fixare internă transiliacă, osteosinteză transsacrată, fixare lombopelvină. Fracturile inelului pelvin anterior necesită de

Biomechanics of Osteoporotic Fracture Fixation

“…The number of low-energy, fall-related fractures outnumbers high-energy fractures by 9 to 1 [6] and is expected to substantially increase [79]. Pelvis fractures constitute a significant clinical problem [6] [80] as they cause intense pain and immobility, impair the quality of life, and lead to loss of patients' independence [81]. In the elderly population, pelvis fractures are associated with a high morbidity and mortality with up to 27% of patients dying within 1 year of surgery [82,83].…”

“…"Type B" fractures may require surgical treatment, in particular if immobilizing pain persists, fractures dislocate, or do not heal [85]. In order to address the specific situation of fractures in elderly, a dedicated classification system for fragility fractures of the pelvis (FFP) has been developed [81]. The FFP focuses on the degree of instability which poses the main basis for deciding whether to operate on the fracture or not.…”

“…Less invasive techniques including splinting and bridging in closed reduction are preferred over open reduction and internal fixation if sufficient mechanical stability can be achieved. Several biomechanical studies investigated construct stiffness and fracture displacement as measures of mechanical stability [81]. A widely accepted surgical technique is the use of percutaneous trans-sacroiliac screws inserted into the first and/or second sacral vertebral bodies [86].…”

“…Placement of two iliosacral screws achieves higher biomechanical stability than just one, and, similarly, longer screws achieve a higher stability than shorter ones [86,87]. Clinically, screws often fail by loosening or unscrewing [85] due to reduced bone quality [81] which can be effectively addressed by using cannulated screws and bone cement to augment the fixation site [88,89]. Bone cement is also an option for isolated and incomplete compression fractures [83] in which the cement is injected via a needle accessing the sacrum via the sacrum ala.…”

Associated abdominal injuries do not influence quality of care in pelvic fractures—a multicenter cohort study from the German Pelvic Registry

“…If additional stabilization of the anterior pelvic ring is necessary, there are other available approaches like open surgical procedures with plate osteosynthesis. However, open surgery often means a "second-hit," so definitive treatment with a supraacetabular external fixator is also an option [8] Regarding acetabular fractures, like in all articular fractures, the main goal of treatment is the anatomical reconstruction of the joint line to prevent the development of posttraumatic osteoarthritis. The classification of acetabular fractures follows the classification of Letournel and Judet.…”