Pelvic ring fractures usually result from significant trauma, frequently requiring operative stabilisation. The use of an anterior internal fixator (INFIX) is a new technique. This temporary construct is quick and easy to apply using pre-existing spinal implants. No reports of functional outcomes or compartive studies with existing surgical techniques exist in indexed literature. We present a prospective comparative case matched series of 21 patients treated with pelvic INFIX. 1:1 matching was achieved to a cohort of patients treated with open reduction and internal fixation (ORIF) based on fracture pattern. All patients with rotationally and/or vertically unstable pelvic ring fractures treated within our level 1 trauma centre were considered for inclusion. Patients were prospectively followed up with health outcome measures (SF-36, EQ-5D) and joint specific outcome scores (Oxford and Harris hip scores). Results. No statistically significant differences in age (mean 42v38 p=0.3143), length of stay, or operative time were seen. The ISS was significantly higher in the INFIX group (32v22 p=0.0019). Mean INFIX removal was at 14 weeks. Baseline responses were obtained on admission where feasible. Although there was no significant difference between the treatment groups, the ORIF group showed a significantly greater deterioration from the baseline than the INFIX group, suggesting INFIX better maintains pre-injury function. 29% of patients experienced LCNT palsy whilst the INFIX was in situ. 6 patients in the INFIX group experienced some form of metal work failure (3 required surgical removal), compared with 7 ORIF patients (4 required removal). Conclusions. Pelvic INFIX achieves bony stabilisation of unstable pelvic fractures, and should be considered for rotational or vertically unstable fractures requiring operative intervention. Despite higher ISS scores, INFIX patients performance in joint specific and global health functioning scores was not significantly different from ORIF patients. We do not use INFIX for pelvic fractures with symphyseal disruption

Traumatic disruption of the pelvic ring has a high risk of mortality. These injuries are predominantly due to high-energy, blunt trauma and severe associated injuries are prevalent, increasing management complexity. This population-based study investigated predictors of mortality following severe pelvic ring fractures managed in an organised trauma system. Cases aged greater than 15 years from 1st July 2001 to 30th June 2008 were extracted from the population-based state-wide Victorian State Trauma Registry for analysis. Patient demographic, pre-hospital and admission characteristics were considered as potential predictors of mortality. Multivariate logistic regression was used to identify predictors of mortality with adjusted odds ratios (AOR) and 95% confidence intervals (CI) calculated. There were 348 cases over the 8-year period. The mortality rate was 19%. Patients aged greater than 65 years were at higher odds of mortality (AOR 7.6, 95% CI: 2.8, 20.4) than patients aged 15–34 years. Patients hypotensive at the scene (AOR 5.5, 95% CI: 2.3, 13.2), and on arrival at the definitive hospital of care (AOR 3.7, 955 CI: 1.7, 8.0), were more likely to die than patients without hypotension. The presence of a severe chest injury was associated with an increased odds of mortality (AOR 2.8, 95% CI: 1.3, 6.1), while patients injured in intentional events were also more likely to die than patients involved in unintentional events (AOR 4.9, 95% CI: 1.6, 15.6). There was no association between the hospital of definitive management and mortality after adjustment for other variables, despite differences in the protocols for managing these patients at the major trauma services (Level 1 trauma centres). The findings highlight the importance of the need for effective control of haemodynamic instability for reducing the risk of mortality. As most patients survive these injuries, further research should focus on long term morbidity and the impact of different treatment approaches

The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta. There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication. The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation. This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study. The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection. Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003). This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection

Introduction. Pelvic and acetabular injuries are relatively rare and surgical reconstruction usually occurs only in specialist centres. As part of their work up there is a local protocol for radiological investigations including Judet oblique views for acetabular fractures, pelvic inlet and outlet for pelvic ring fractures and urethrograms for sustaining anterior pelvic injury. The aim of this service evaluation was to assess whether patients had these radiological investigations prior to transfer. Methods. The last 50 patients transferred for surgery were evaluated (41 male, 9 female), average age 48 (range 17–86). Four were excluded as original radiology not available and one due to non-acute presentation. Regional PACS systems were accessed and radiological investigations recorded. Results. Transfers were from 17 different hospitals including 27 acetabular fractures, 17 pelvic ring fractures and one patient with both. 22 patients sustained isolated injuries. 16 patients were investigated radiologically asstipulated in the protocol. No inlet/outlet views were performed for 10 of the ring fractures, and no Judet views for eight of the acetabular fractures. An antero-posterior pelvic radiograph was not performed on one patient. No urethro/cystogram was performed for 10 pelvic ring fractures. Average time to transfer 5.4 days (range 0–22). Discussion. A significant proportion of patients are not assessed as per protocol prior to transfer. This can lead to undetected injuries, delays to diagnosis or definitive management and increased morbidity/mortality. The reasons for not being able to perform these investigations need to be understood

High energy pelvic injury poses a challenging setting for the treating surgeon. Often multiple injuries are associated, which makes the measurement of short- and long-term functional outcomes a difficult task. The purpose of this study was to determine the incidence of pelvic dysfunction and late impacts of high energy pelvic ring fractures on pelvic floor function in women, with respect to urinary, sexual and musculoskeletal function. This was compared to a similar cohort of women with lower limb fractures without pelvis involvement. The data in our study was prospectively gathered between 2010 and 2013 on 229 adult females who sustained injury between 1998 and 2012. Besides demographic and operative variables, the scores of three validated health assessment tools were tabulated: King's Health Questionnaire (KHQ), Female Sexual Function Index (FSFI) and the Short Musculoskeletal Functional Assessment (SMFA). A multivariate regression analysis was done to compare groups. The incidence of sexual dysfunction was 80.8% in the pelvis and 59.4% in the lower extremity group. A Wilcoxon rank sum test showed a significant difference in KHQ-score (p<0.01) with the pelvis group being worse. When adjusting for age, follow-up and Injury Severity Score this difference was not significant (p=0.28), as was for FSFI and SMFA score. The mean FSFI scores of both groups met the criteria for female sexual dysfunction (<26). Patients with a Tile C fracture have better FSFI scores (16.98) compared to Tile B fractures (10.12; p=0.02). Logistic regression predicting FSFI larger than 26.5 showed that older age and pelvic fractures have a higher likelihood having a form of sexual dysfunction. Sexual dysfunction after lower extremity trauma is found in patients regardless of pelvic ring involvement. Urinary function is more impaired after pelvic injuries, but more data is needed to confirm this. Older age and pelvic fracture are predictors for sexual dysfunction in women. This study is important as it could help counsel patients on the likelihood of sexual dysfunction, something that is probably under-reported and recognized during our patient follow up

High-energy pelvic ring fractures are associated with polytrauma where staged surgery is recommended. While temporary skeletal stabilisation is part of the acute management, definitive care is done in a later phase. The purpose of this study was to evaluate the safety and efficacy of acute pelvic ORIF by comparing its short term outcome with those who were stabilised late. A 45-month retrospective review of the prospective pelvic fracture database of a level one trauma centre was performed. All high-energy trauma patients who were potential candidates for minimally invasive internal fixation of the pelvic ring were included. Patients were categorised as acute ORIF (<24 hrs) or late ORIF (>24 hrs). Demographics, ISS, pelvic AIS, 24 hour pack cell transfusions, physiological parameters, time to operating theatre, angiography requirement, LOS and mortality were recorded. Data was presented as mean+/−SD or percentages. Statistical significance was determined at ∗p<0.05 based on univariate analysis. Forty-three patients met inclusion criteria, seventeen patients had acute definitive ORIF (5.5 hrs to OT) and twenty-six late definitive ORIF (5 days to OT). Acute and late ORIF patients had statistically not different demographics (age: 48+/−22 years vs 40+/− 14, gender: 82% vs 79% males), injury severity (ISS: 30+/−18 vs 24.5+/−13, pelvic AIS: 3.7+/− 1 vs 3.4+/− 1.1) and 24 hour transfusion (4.7+/−5 U vs 6.6+/−4 U). Initial shock parameters were significantly worse in the acute ORIF group (∗SBP 69.7+/−17 vs 108+/−21 mmHg, ∗BD -7.35+/−4 vs -4.9+/−1.5 mEq/L, ∗Lactate 6.67+/−7 vs 2.51+/−1.3 mmol/L). Angiography was used 18% (3/17) vs 21% (6/29) of the cases. All early ORIF patients survived and one (3%) of the late ORIF patients died. The trend in shorter hospital LOS was not significant in the early ORIF group (25+/− 24 vs 37+/− 32 days) while the ICU LOS was comparable (12/17 patients with 2.9+/−2.5 days vs 15/26 patients with 3.7+/−3.6 days). Minimally invasive acute ORIF of unstable pelvic ring fractures could be performed even in severely shocked polytrauma patients. The procedure did not lead to increased rates of transfusion, mortality, ICU LOS or overall LOS. Furthermore, all these parameters showed a trend towards benefit compared to a staged approach

To evaluate efficacy and outcome of embolisation following pelvic ring injuries in patients presented with ongoing hypovolaemic shock. Between 2000 and 2003, 200 poly-trauma patients presented in our institutions following pelvic ring injuries. Those with ongoing hypovolaemic shock who were treated within 24h of admission with embolisation were included in this study. Demographics, mechanism of injury, ISS, type of pelvic ring fracture, arterial source of bleeding, hours from injury to embolisation, and outcome were all recorded prospectively. Out of the 200 treated in our institutions 17 (8.5%) underwent angio-embolisation. The mean age of the patients was 37 (14-70) and the mean ISS was 29. Distribution of pelvic ring injuries included: 3LC, 7APC, 7VS. The mean time from injury to embolisation was 15 hours. 8/17 patients were initially treated with an external fixator. The distribution of arterial injuries was: 7 superior gluteal arteries, 8 internal iliac arteries, 1 obturator artery and 1 internal pudental artery. The mean number of units transfused prior to embolisation was 22 (range 6-50). Mortality rate was 4 (23%) out of 17 embolised patients. Angio-embolisation for pelvic ring injuries occurred in 8.5% of our study population. This study indicates that only a small proportion of patients required embolisation secondary to arterial bleeding. The overall survival rate was in accordance to published international experience. Embolisation should be considered as a valid adjunct in some selected group of patients with pelvic fractures where ongoing bleeding refractory to other treatment modalities is present

Purpose of study. Unstable pelvic ring injuries usually occur in polytrauma patients and are associated with high mortality and morbidity. Percutaneous screw fixation of sacro-iliac joint dislocations, fracture-dislocations and sacral fractures is a well-recognised technique first described by Routt and is increasingly gaining popularity. This method is biomechanically comparable to open reduction and internal fixation with plates and screws but offers the advantages of minimally invasive surgical techniques. It is however a technically demanding procedure with reported complications including hardware failure, misplacement of screws, nerve injury and poor posterior reduction. The purpose of the study is to report clinical results of patients treated with closed reduction and percutaneous ilio-sacral screw fixation for unstable pelvic ring fractures by a single surgeon. Methods. A review of prospectively collected data was performed on all patients who had percutaneous sacro-iliac fixation between 2009 and 2012. Thirty five percutaneus sacro-iliac screws were inserted in 30 patients with a mean age of 25.6 years (range 17–62). Fracture types included 10 AO type B, and 20 AO type C. The mean follow-up period was 11.6 months (range 3–38). The complications assessed were screw misplacement, neurovascular complications, hardware breakage and loss of reduction. Results. All patients had a satisfactory initial reduction. One patient (2.8%) had misplacement of a screw with resultant temporary neurological fallout. One patient (2.8%) had screw misplacement without neurological fallout. Both of these patients initially had two screws inserted and the misplaced screws were removed and not reinserted. One patient (2.8%) had screw cut-out with loss of reduction. This screw was removed, open reduction peformed and the screw was re-inserted. Conclusion. The use of percutaneous sacro-iliac screws provides a safe and effective technique for the management of unstable posterior pelvic ring injuries. Our combined complication rate is comparable to published literature. NO DISCLOSURES

INTRODUCTION. Isolated injuries of the sacral bone are rare. The pathomechanism of these injuries are usually high velocity accidents or falls from large heights. The computer-assisted implantation of iliosacral screws (SI-screw) becomes more important in the treatment of dorsal pelvic ring fractures. The advantage of the minimal-invasive screw placement is the reduction of the non-union and deep wound infection rate. Another advantage of computer-navigated SI-screw placement is the reduction of intraoperative radiation for the patient and the surgical staff. The purpose of this study was to analyse the position of navigated iliosacral screws. METHODS. In the study group 74 screws (49 patients) were included and radiologically analysed. All screws were implanted using 3D-navigation (BrainLAB Vector Vision, Brainlab, Germany). Navigation was always executed with the same 3D c-arm (ARCADIS Orbic 3D, Siemens, Germany) and navigation system. We determined the grade of perforation and angular deviation in the postoperative CT-scans in all screws. The classification was performed according to Smith et al in 4 grades. Grade 0 implies no perforation and grade 1 a perforation less than 2 mm. Grade 2 correlates a perforation of 2–4 mm and grade 3 a perforation of more than 4 mm. Furthermore the intra- and postoperative complications as well as the body-mass-index, the co-morbidities and the duration of radiation were documented. The statistical analysis was executed using Microsoft Excel 2003. RESULTS. The mean age of the 49 patients was 42.2 years ± 18 (16–79 years). 28 male and 21 female patients were included. 25 patients received a single iliosacral screw in S1. In 19 cases a screw in S1 and S2 was placed on the same side. Four patients got bilateral SI-screws in S1 and another patient received bilateral screw placement in S1 as well as an additional screw in S2. The mean operation time was 100 min ±103 (20–540 min). The isolated time for SI-placement was 50 min ± 20 (20–93 min). The mean radiation time was 3 min ± 1.7 (0.9–7.4 min) (n = 28). Altogether 84% of the screws showed an intraosseous position (grade 0). In the axial plane 7 screws perforated ventrally, 5 screws penetrated the adjacent neural foramen. In the frontal plane the screws showed greater variations, 61% deviated less than 5° (grade 0). In the study group 5 screws needed surgical revision because of either malplacement or postoperative pain. There were no infections or neurological complications. There was no statistical correlation between screw perforation and the body-mass-index. CONCLUSION. The computer-assisted implantation of iliosacral screws is a safe method in relation to screw perforation. It shows a high security and accuracy concerning the ventral and dorsal cortical perforation. There is a frequent angular deviation in the frontal view without appearance of screw perforation or mechanic, neurologic and angiologic complications. The minimal-invasive procedure shows a low postoperative revision rate

Minimally invasive placement of iliosacral screws (SI-screw) is becoming the standard surgical procedure for sacrum fractures. Computer navigation seems to increase screw accuracy and reduce intraoperative radiation compared to conventional radiographic placement. In 2012 an interdisciplinary hybrid operating theatre was installed at the University of Ulm. A floor-based robotic flat panel 3D c-arm (Artis zeego, Siemens, Germany) is linked to a navigation system (BrainLab Curve, BrainLab, Germany). With a single intraoperative 3D scan the whole pelvis can be visualised in CT-like quality. The aim of this study was to analyse the accuracy of SI-screws using this hybrid operating theater. 32 SI-screws (30 patients) were included in this study. Indications ranged from bone tumour resection with consecutive stabilisation to pelvic ring fractures. All screws were implanted using the hybrid operating theatre at the University of Ulm. We analysed the intraoperative 3D scan or postoperative computed tomography and classified the grade of perforation of the screws in the neural foramina and the grade of deviation of the screws to the cranial S1 endplate according to Smith et al. Grade 0 stands for no perforation and a deviation of less than 5 °. Grade 1 implies a perforation of less than 2 mm and a deviation of 5–10°, grade 2 a perforation of 2–4 mm and a deviation of 10–15° and grade 3 a perforation of more than 4 mm and a deviation of more than 15°. All patients were tested for intra- and postoperative neurologic complications and infections. The statistical analysis was executed using Microsoft Excel 2010. 32 SI-screws were implanted in the first 20 months after the hybrid operating theatre had been established in 2012. All 30 patients were included in this study (15 men, 15 women). The mean age was 59 years ±23 (13–95 years). 20 patients received a single screw in S1 (66.7%), 1 patient 2 unilateral screws in S1 and S2 (3.3%), one patient 2 bilateral screws in S1 (3.3%) and 8 patients a single screw stabilising both SI-joints (26.7%). 27 screws showed no perforation (84.4%), 1 screw a grade 1 perforation (3.1%) and 4 screws a grade 2 perforation (12.5%). There was no grade 3 perforation. Furthermore there was no perforation of the neural foramina or the ventral cortex in the axial plane of the SI-screws stabilising one SI-joint (24 screws). Only single SI-screws bridging both SI joints showed a perforation of the neural foramina (37% grade 0, 12.5% grade 1, 50% grade 2, 0% grade 3). In the frontal plane 23 screws (71.9%) showed a deviation of less than 5°. In 5 screws a grade 1 deviation (15.6%) and in 4 screws a grade 2 deviation (12.5%) could be found. There was no grade 3 deviation. There were no infections or neurological complications. The high image quality and large field of view in combination with an advanced navigation system is a great benefit for the surgeon. All SI-screws stabilising only one joint showed completely intraosseous placement. Single SI-screws bridging 2 SI-joints intentionally perforated the neural foramina ventrally in 5 cases because of dysmorphic sacral anatomy. This makes image-guided implantation of SI-screws in a hybrid operating theatre a very safe procedure