|Year : 2017 | Volume
| Issue : 2 | Page : 139-143
Posterior pelvic plating in the treatment of tile type C unstable pelvic injuries: a prospective study
Ahmed El-Bakoury1, Abdullah Hammad2
1 Royal National Orthopaedic Hospital, Stanmore; Department of Orthopaedics, University of Alexandria, Alexandria, UK
2 Department of Orthopaedics, University of Alexandria, Alexandria, Egypt
|Date of Submission||25-Nov-2016|
|Date of Acceptance||25-Nov-2016|
|Date of Web Publication||23-Nov-2017|
1201, Alkarnak Building No. 2, Fleming Tram Station, 37 Alfateh Street, Alexandria, 21531
Source of Support: None, Conflict of Interest: None
Introduction Unstable pelvic ring disruptions result from high-energy trauma and are often associated with multiple concomitant injuries. Internal fixation has become the preferred treatment for unstable posterior pelvic ring injuries. Several methods of fixation of posterior pelvic injuries have been described, including anterior pelvic plating, posterior sacroiliac plating, lumbopelvic fixation, and percutaneous fixation with iliosacral screws.
Aim The aim of this study was to report on the clinical and radiological results of plate osteosynthesis for fixing posterior pelvic injuries in Tile’s C completely unstable pelvic ring injuries.
Patients and methods This study involved 21 patients with Tile type C pelvic injuries who had their posterior injuries fixed by plate osteosynthesis. The mean duration of postoperative follow-up was 25.29±9.93 (13–48) months. The clinical outcome was assessed with postoperative Majeed’s score and the rate of postoperative complications. The radiological outcome was assessed through the measurement of posterior displacement as per the method of Matta and Tornetta.
Results The mean±SD postoperative Majeed score was 76.57±11.21. There was a statistically significant improvement in the postoperative vertical displacement of the posterior injury (P<0.001). The incidence of postoperative complications was 38.1%.
Conclusion Pelvic plating is an effective procedure in the management of completely unstable posterior pelvic ring injuries. The treatment of these complex injuries is associated with a relatively high incidence of postoperative complications.
Keywords: completely unstable, pelvic injury, pelvic plating, tile c
|How to cite this article:|
El-Bakoury A, Hammad A. Posterior pelvic plating in the treatment of tile type C unstable pelvic injuries: a prospective study. Egypt Orthop J 2017;52:139-43
|How to cite this URL:|
El-Bakoury A, Hammad A. Posterior pelvic plating in the treatment of tile type C unstable pelvic injuries: a prospective study. Egypt Orthop J [serial online] 2017 [cited 2018 Aug 16];52:139-43. Available from: http://www.eoj.eg.net/text.asp?2017/52/2/139/219098
| Introduction|| |
Unstable pelvic ring disruptions result from high-energy trauma and are often associated with multiple concomitant injuries ,,. Bleeding, head injury, pelvic soft-tissue trauma (open fractures), and primary system complications are responsible for the high mortality associated with unstable pelvic injuries ,,. Internal fixation has become the preferred treatment for unstable posterior pelvic ring injuries ,,,. Several methods of fixation of posterior pelvic injuries have been described, including anterior pelvic plating, posterior sacroiliac plating, lumbopelvic fixation, and percutaneous fixation with iliosacral screws ,,,,.
The aim of this study was to report the clinical and radiological results of plate osteosynthesis for fixing posterior pelvic injuries in Tile’s C completely unstable pelvic ring injuries.
| Patients and methods|| |
During the period from October 2011 to January 2014, 21 patients with completely unstable pelvic injuries have had their posterior pelvic injuries fixed with plate osteosynthesis at our institution. This study was carried out at El-Hadara University Hospital, Alexandria, Egypt. All patients fulfilled the following inclusion criteria: (a) aged 18 years or older and (b) diagnosed with completely unstable pelvic ring injuries (Tile C) in which the pelvic ring is both rotationally and vertically unstable.
The mean age of our patients was 30.71±12.23 (18–60) years. Fourteen patients were males, and seven patients were females. The mean duration of postoperative follow-up was 25.29±9.93 (13–48) months. Four (19%) patients had associated medical comorbidities in the form of type II diabetes mellitus, hypertension, and bronchial asthma.
The patients’ clinical data were collected prospectively. Pelvic injury was classified according to Tile’s classification . The preoperative vertical displacement of the posterior pelvic injury was measured according to the method of Matta and Tornetta . This was carried out by measuring the difference between the heights of the femoral heads on the anteroposterior pelvic radiographs ([Figure 1]).
|Figure 1 Preoperative anteroposterior radiographs showing a C1 pelvic injury. Line A represents a line passing through the axis of the sacrum. Lines B and C are drawn from the highest points of the femoral heads perpendicular to line A. The difference between the height of both femoral heads represents the vertical displacement of the affected hemipelvis.|
Click here to view
The supine or the prone position was used depending on the planned surgical approach and the presence of an associated injury that needed to be addressed. Either the anterior or the posterior approach to the sacroiliac region was used according to the location of the posterior pelvic ring injury. For plating of sacral fractures, the posterior approach was used, whereas for sacroiliac dislocations either the anterior or the posterior approach was used. After exposure of the site of the pelvic injury, reduction was performed by a combination of traction applied to the ipsilateral leg to correct the vertical displacement and a direct reduction of the pelvic injury using different clamps designed for pelvic fractures. After reduction was achieved, the posterior injury was then fixed with a plate. For posterior iliac fractures, fixation was performed by anterior iliac plating through the lateral window of the ilioinguinal approach, which was also used to approach the sacroiliac dislocations that were fixed using anterior sacroiliac plates. For sacral fractures, we used ilioiliac plates through the posterior pelvic approach.
All patients were prescribed low-molecular-weight heparin for 28 days if they showed no contraindications (e.g. high bleeding risk). Patients were mobilized from bed as early as possible. All patients, if their general condition allowed, were advised to start toe-touch weight bearing for 6 weeks and then partial weight bearing for another 6 weeks. Patients started complete weight bearing at 12 weeks postoperatively.
All patients have been followed-up for at least 1 year postoperatively. The clinical outcome was assessed with the Majeed pelvic outcome score . Clinical grade was based on a score out of 100 points for working and out of 80 points for nonworking patients ([Table 1]).
Postoperative anteroposterior radiographs were assessed for fracture healing, residual vertical displacement (as per preoperative radiographic assessment), and the quality of reduction. The posterior reduction was graded according to Matta and Tornetta  ([Table 2]).
|Table 2 Radiological grading of the posterior reduction according to Matta and Tornetta |
Click here to view
Data were analyzed using IBM Corp., Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Qualitative data were described using numbers and percentages. Quantitative data were described using ranges (minimum and maximum), means, SDs, and medians. Significance of the obtained results was judged at the 5% level.
| Results|| |
According to Tile’s classification, 16 (76%) pelvic injuries were classified as C1 injuries, five (24%) were classified as C2 injuries, and none of the patients had C3 injuries. All patients had either APC3, vertical shear, or a combined mechanism of injury as per Young and Burgess classification. On assessing the anterior pelvic injury, seven (33.3%) patients had symphyseal diastasis, whereas 14 (66.7%) patients had pubic rami fractures with no diastasis through the symphysis pubis. In terms of posterior pelvic injury, eight (38%) patients had posterior iliac fractures, which were fixed with anterior iliac plates, eight (38%) patients had sacroiliac joint injury (dislocation or fracture dislocation), which were stabilized by anterior sacroiliac plating, and five (24%) patients had sacral fractures, which were fixed with ilioiliac plates through the posterior approach
The duration between injury and definitive fixation ranged from 2 to 11 days with a median of 6 days. Eight (38.1%) patients were managed with anterior symphyseal plating for symphyseal diastasis. Only one patient with disruption of the symphysis pubis did not have anterior fixation. The rest of our cohort (52.4%) had anterior pelvic ring injury in the form of pubic rami fractures, which were not addressed surgically.
The mean±SD preoperative vertical displacement was 16.95±2.75 mm. This showed improvement postoperatively to 4.43±1.69 mm, and the difference was statistically significant (P<0.001). All fractures were fully united at 6 months postoperatively. One (5%) patient was lost to follow-up at 4 months, with her 3-month postoperative radiographs showing callus formation at the pubic rami fracture. According to the Matta and Tornetta  method of assessment of the quality of reduction of posterior pelvic injury, eight (38.1%) patients had good radiological outcome, and 13 (61.9%) patients had excellent outcome. There were no patients with poor or fair radiological outcome.
The mean±SD postoperative Majeed score was 76.57±11.21. The overall grading of the clinical outcome showed that seven (33.3%) patients had excellent, 12 (57.1%) patients had good, and two (9.5%) patients had fair clinical outcome. The mean±SD postoperative pain score was 22.86±2.54. The mean±SD score for sitting ability was 8.48±1.08. The mean±SD postoperative standing score was 29.05±3.83. Fourteen (66.7%) patients continued with their previous jobs, while four (19%) patients had to change their jobs postoperatively. Three (14.3%) of our patients were not working before the injury.
The incidence of postoperative complications was 38.1%. We had two (4%) patients with symptomatic DVT, which was discovered 7 to 10 days after injury (3 and 4 days postoperatively).
Three (3/21, 14%) patients had superficial wound infection. Two of them had pelvic fixation through the posterior approach and one through the anterior approach. The infection was successfully treated by oral antibiotics in all of them. Two (2/21, 9.5%) patients had postoperative deep infection and were treated with surgical debridement and intravenous antibiotics.
One (4.7%) patient had redisplacement of posterior pelvic injury after the initial surgical fixation. This patient had two posterior sacroiliac plates for fixing C2–3 posterior pelvic injury and an anterior symphyseal plate. No revision surgery was performed for this patient, and she had a good clinical outcome at the end of follow-up.
One (4.7%) patient with a sacroiliac joint injury had symptomatic sacroiliac osteoarthritis that responded well to repeated computed tomography (CT)-guided steroid injection of the sacroiliac joint and had a good clinical outcome.
| Discussion|| |
Historically, nonoperative treatment was considered the treatment of choice for many pelvic ring injuries. It is now established that patients with unstable pelvic ring injuries benefit from surgical stabilization due to less residual pain and decreased incidence of malunion and nonunion ,,,. There are several methods of fixation described in the orthopedic literature to manage unstable pelvic injuries ,,,,. Among these methods, pelvic plating is used for the stabilization of posterior pelvic ring injuries.
In this study, the overall Majeed score was 76.57±11.21. We achieved satisfactory clinical (excellent or good) outcome in 90.4% of our cohort. This was similar to the results reported by Lindahl and Hirvensalo  who published 101 consecutive Tile classification type C pelvic fractures. All their patients were treated surgically, with 78 patients receiving both anterior and posterior ring fixations. Their Majeed functional score results were excellent in 68 (67.3%) patients, good in 16 (15.8%), fair in 16 (15.8%), and poor in one (0.99%), with 84 (83.2%) patients obtaining satisfactory results.
Persistent pain is one of the main contributors to long-term disability and poor functional outcome . About one-third of our patients had a degree of persistent postoperative pain. Out of these, only four (8.3%) patients had severe pain that limited their activity. This was similar to the study by Putnis et al. , who reported that among 49 patients with pelvis fractures 15 (37%) patients were pain free, 12 (29%) had either mild or very mild pain, 11 (27%) had moderate pain, and three (7%) had severe pain after 1-year of follow-up. In their series, Lindahl and Hirvensalo  also obtained similar results, with 34 (34%) patients reporting persistent pain after an average final follow-up of 23 months (range: 1–84 months). Of these 34 patients, 33 described the pain location as ‘posterior’. Similarly, in Kabak et al.’s  series of 36 type C fractures, 25% experienced pain of pelvic origin beyond 1 year. Although relatively high, these numbers are an improvement over previously published data , where 70 and 85% of patients, respectively, with type C pelvic fractures complained about long-term pelvic pain. This difference may be related to the improved surgical and rehabilitation protocols over the past few decades.
The importance of obtaining good reduction of posterior pelvic injury has been stated in different studies. Tornetta and Matta  concluded that ‘reduction to within 10 mm seems to be adequate for functional results’. In addition, Pohlemann et al.  noted that there is a correlation between good reduction and good clinical outcome. In this study, we achieved a satisfactory reduction (<10 mm) in all patients, which has been reflected on our patients’ clinical outcome.
In terms of postoperative complications, our cohort showed a relatively high rate of postoperative complications. This increased rate of complications was mainly due to a higher postoperative wound infection associated with pelvic plating. Pelvic plating, which required either an anterior or a posterior pelvic approach, is known to be associated with postoperative wound complications ,,.
The incidence of post-traumatic sacroiliac arthritis is common after pelvic injuries extending to this joint. In their series, Gänsslen et al.  have assessed the radiographic long-term results of 16 patients with type C1–2 injury. Their patients had anterior pelvic plating with a mean of 63.2 months (range: 1–14 years). Although they achieved an anatomical reduction in 81% of their patients, follow-up CT scans showed a normal sacroiliac joint in only one patient. All other patients had sacroiliac joint changes (e.g. periarticular osteophytes, degenerative changes, and ankylosis). In this study, we report a lower incidence of sacroiliac arthritis (1/8 patients, 12.5%), possibly because of our shorter follow-up and the low sensitivity of the plain radiographs compared with CT scan in detecting early degenerative changes.
| Conclusion|| |
Pelvic plating is considered an effective procedure in the management of completely unstable posterior pelvic ring injuries by which satisfactory reduction could be achieved and maintained. There was a trend for higher incidence of postoperative complications associated with pelvic plating; however, it was not statistically significant.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Rothenberger DA, Fischer RP, Strate RG, Velasco R, Perry JF Jr. The mortality associated with pelvic fractures. Surgery 1978; 84:356–361.
Gilliland MD, Ward RE, Barton RM, Miller PW, Duke JH. Factors affecting mortality in pelvic fractures. J Trauma 1982; 22:691–693.
Pohlemann T, Tscherne H, Baumgartel F, Egbers HJ, Euler E, Maurer F et al.
Pelvic fractures: epidemiology, therapy and long-term outcome. Overview of the multicenter study of the Pelvis Study Group. Unfallchirurg 1996; 99:160–167.
Mucha PJr, Welch TJ. Hemorrhage in major pelvic fractures. Surg Clin North Am 1988; 68:757–773.
Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PSJr, Poka A et al.
Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 1990; 30:848–856.
Tscherne H, Regel G. Care of the polytraumatised patient. J Bone Joint Surg Br 1996; 78:840–852.
Kellam JF, McMurtry RY, Paley D, Tile M. The unstable pelvic fracture. Operative treatment. Orthop Clin North Am 1987; 18:25–41.
Matta JM, Tornetta PIII. Internal fixation of unstable pelvic ring injuries. Clin Orthop Relat Res 1996; 329:129–140.
Matta JM, Saucedo T. Internal fixation of pelvic ring fractures. Clin Orthop Relat Res 1989; 242:83–97.
Moed BR, O’Boynick CP, Bledsoe JG. Locked versus standard unlocked plating of the symphysis pubis in a type-C pelvic injury: a cadaver biomechanical study. Injury 2014; 45:748–751.
Keel MJ, Benneker LM, Siebenrock KA, Bastian JD. Less invasive lumbopelvic stabilization of posterior pelvic ring instability: technique and preliminary results. J Trauma 2011; 71:E62–E70.
Simonian PT, Routt ML Jr, Harrington RM, Tencer AF. Internal fixation of the unstable anterior pelvic ring: a biomechanical comparison of standard plating techniques and the retrograde medullary superior pubic ramus screw. J Orthop Trauma 1994; 8:476–482.
Simonian PT, Routt ML Jr, Harrington RM, Tencer AF. Anterior versus posterior provisional fixation in the unstable pelvis. A biomechanical comparison. Clin Orthop Relat Res 1995; 310:245–251.
Routt MLJr, Kregor PJ, Simonian PT, Mayo KA. Early results of percutaneous iliosacral screws placed with the patient in the supine position. J Orthop Trauma 1995; 9:207–214.
Tile M. Acetabulum. In: Helfet D, Kellam J, editors. Fractures of the pelvis and acetabulum. 3rd ed. Philadelphia; London: Lippincott Williams & Wilkins; 2003.
Majeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg Br 1989; 71:304–306.
Borg T, Berg P, Fugl-Meyer K, Larsson S. Health-related quality of life and life satisfaction in patients following surgically treated pelvic ring fractures. A prospective observational study with two years follow-up. Injury 2010; 41:400–404.
Guthrie HC, Owens RW, Bircher MD. Fractures of the pelvis. J Bone Joint Surg Br 2010; 92:1481–1488.
Tornetta P3 rd, Dickson K, Matta JM. Outcome of rotationally unstable pelvic ring injuries treated operatively. Clin Orthop Relat Res 1996; 329:147–151.
Simonian PT, Routt MLJr, Harrington RM, Mayo KA, Tencer AF. Biomechanical simulation of the anteroposterior compression injury of the pelvis. An understanding of instability and fixation. Clin Orthop Relat Res 1994; 309:245–256.
Lindahl J, Hirvensalo E. Outcome of operatively treated type-C injuries of the pelvic ring. Acta Orthop 2005; 76:667–678.
Tile M, Helfet D, Kellam J, Varhas M. Fractures of pelvis and acetabulum. New York: Thieme 2015.
Putnis SE, Pearce R, Wali UJ, Bircher MD, Rickman MS. Open reduction and internal fixation of a traumatic diastasis of the pubic symphysis: one-year radiological and functional outcomes. J Bone Joint Surg Br 2011; 93:78–84.
Kabak S, Halici M, Tuncel M, Avsarogullari L, Baktir A, Basturk M. Functional outcome of open reduction and internal fixation for completely unstable pelvic ring fractures (type C): a report of 40 cases. J Orthop Trauma 2003; 17:555–562.
Keating JF, Werier J, Blachut P, Broekhuyse H, Meek RN, O’Brien PJ. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma 1999; 13:107–113.
Tornetta P3rd, Matta JM. Outcome of operatively treated unstable posterior pelvic ring disruptions. Clin Orthop Relat Res 1996; 329:186–193.
Goldstein A, Phillips T, Sclafani SJ, Scalea T, Duncan A, Goldstein J et al.
Early open reduction and internal fixation of the disrupted pelvic ring. J Trauma 1986; 26:325–333.
Suzuki T, Hak DJ, Ziran BH, Adams SA, Stahel PF, Morgan SJ et al.
Outcome and complications of posterior transiliac plating for vertically unstable sacral fractures. Injury 2009; 40:405–409.
Gänsslen A, Pohlemann T, Krettek C. Internal fixation of sacroiliac joint disruption. Oper Orthop Traumatol 2005; 17:281–295.
[Table 1], [Table 2]