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Fragility Fractures of the Pelvis: a Systematic Review

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Fragility Fractures of the Pelvis: a Systematic Review Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-024737 on 19 May 2019. Downloaded from Effectiveness of surgical fixation for lateral compression type one (LC-1) fragility fractures of the pelvis: a systematic review Alison Booth, 1 Helen Margaret Ann Ingoe, 1,2 Matthew Northgraves,1 Elizabeth Coleman,1 Melissa Harden,3 Jamila Kassam,4 Iris Kwok,4 Catherine Hilton,4 Peter Bates,4 Catriona McDaid 1 To cite: Booth A, Ingoe HMA, ABSTRACT Strengths and limitations of this study Northgraves M, et al. Objectives To undertake a systematic review of the Effectiveness of surgical evidence base for the effectiveness of surgical fixation of ► This review systematically examines the available fixation for lateral compression lateral compression (LC-1) fragility fractures of the pelvis type one (LC-1) fragility evidence, searching multiple databases, assessing compared with non-surgical approaches. fractures of the pelvis: a the risk of bias in included studies and using meth- Searches MEDLINE, EMBASE, the Cochrane Central systematic review. BMJ Open ods to reduce error and bias in study selection, data Register of Controlled Trials and two international trials 2019;9:e024737. doi:10.1136/ extraction and assessment of risk of bias. bmjopen-2018-024737 registers were searched up to January 2017 (MEDLINE to ► This is a rapidly evolving area for surgery, with ever February 2019) for studies of internal or external fixation of increasing incidence, so the searches of electronic ► Prepublication history and fragility fractures of the pelvis. additional material for this databases were supplemented by searches for on- Participants Patients with lateral compression pelvic paper are available online. To going trials. fractures, sustained as the result of a low-energy view these files, please visit ► Key health databases were searched and efforts mechanism, defined as a fall from standing height or less. the journal online (http:// dx. doi. were made to find unpublished studies via trial reg- Interventions Surgery using either external or internal org/ 10. 1136/ bmjopen- 2018- isters, however we did not have the resources to fixation devices. Conservative non-surgical treatment was 024737). search more widely and retrieval was restricted to the defined comparator. studies published in English. Received 11 June 2018 Outcome measures Outcomes of interest were patient http://bmjopen.bmj.com/ ► The review found many narratives on surgery for Revised 1 March 2019 mobility and function, pain, quality of life, fracture union, fragility fractures of the pelvis, but no randomised Accepted 5 April 2019 mortality, hospital length of stay and complications controlled trials, and only four retrospective case (additional operative procedures, number and type of series that met all the inclusion criteria. adverse events and serious adverse events). Quality assessment and synthesis The Joanna Briggs Institute Checklist for Case Series was used to assess the a significant impact on patients and put a included studies. Results were presented in a narrative strain on healthcare provision. A common synthesis. Results Of 3421 records identified, four retrospective fragility fracture pattern in older adults is on September 25, 2021 by guest. Protected copyright. case series met the inclusion criteria. Fixation types were the lateral compression type-1 (LC-1) pelvic © Author(s) (or their not consistent between studies or within studies and most fracture. This typically results from a low-en- employer(s)) 2019. Re-use patients had more than one type of pelvic fixation. Where ergy fall from standing height and increases 2–4 permitted under CC BY-NC. No reported, mobility and function improved post-surgery, in likelihood with age. LC-1 fractures commercial re-use. See rights and a reduction in pain was recorded. Length of hospital and permissions. Published by are projected to have the largest incidence BMJ. stay ranged from 4 days to 54 days for surgical fixation of increase (by 56% over 20 years) of all osteopo- any type. Reported complications and adverse outcomes 1Department of Health Sciences, rotic fractures and the associated treatment University of York, York, UK included: infections, implant loosening, pneumonia and costs are predicted to rise by 60% between 2Trauma and Orthopaedics, The thrombosis. Use of analgesia was not reported. 2005 and 2025.5 6 Conclusions There is insufficient evidence to support James Cook University Hospital, The effects of LC-1 fractures can be devas- Middlesbrough, UK guidance on the most effective treatment for patients who 3 tating for patients. The pain and associated Centre for Reviews and fail to mobilise after sustaining an LC-1 fragility fracture. Dissemination, University of Trial registration number CRD42017055872. immobility leads to secondary complications, York, York, UK including respiratory and urinary tract infec- 4Barts Health NHS Trust, London, tions, pressure sores and venous thromboem- UK bolic events.7 8 Correspondence to INTRODUCTION Many patients with LC-1 fractures report Alison Booth; Fragility fractures of the pelvis (FFP) can that they do not return to their pre-injury func- alison. booth@ york. ac. uk result in significant long-term disability,1 have tion and they have reduced independence Booth A, et al. BMJ Open 2019;9:e024737. doi:10.1136/bmjopen-2018-024737 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-024737 on 19 May 2019. Downloaded from with activities of daily living.2 4 This can result in the need What works in younger patients with good bone quality for intermediate care or residential facilities in addition is less effective in older patients.25 In 2010 a new tech- to anxiety, emotional stress and reduced confidence.9 10 nique of anterior subcutaneous internal fixation (INFIX) Mortality for FFP at 1 year is 27%,11 which is comparable was developed, combining the principles of internal and to hip fractures at 33%.12 Furthermore, hospital stay external fixation. It involves placing screws in the supra-ac- for FFP has been shown to be similar to hip fractures in etabular corridors and developing a subcutaneous tunnel the elderly.9 13 The standard treatment for hip fractures in which a rod is connected to the screws to stabilise the (so-called fractured neck of femur) is rapid surgical pelvis. fixation or joint replacement, within 36 hours of injury, The use of the INFIX device has been described across aimed at early weight-bearing and minimising immobil- younger age groups and pelvic fracture types; alone or ity-related complications.14 Paradoxically, despite the in combination with external surgical fixation tech- similarities in patient cohorts and their vulnerability to niques.26–29 However, the use of INFIX for the manage- pain-induced immobility, the standard of care for elderly ment of the FFP population who sustain an LC-1 fracture LC-1 fragility fractures of the pelvis (LC-1 FFP) is non-op- remains unclear as there has been no systematic review of erative treatment and to ‘mobilise as pain allows’.15–17 the evidence. Many patients with stable fractures are able to mobilise Given the uncertainty around the management of within a few days of injury, typically with a walking aid. LC-1 fractures in the elderly and the potential of INFIX However, patients with unstable fractures (those that are to change the management of these injuries, we sought unable to withstand physiological loads without displace- to identify and synthesise the evidence on the effective- ment18) typically have disabling pain with almost all move- ness of surgical fixation in fragility fractures of the pelvis. ments, even moving around the bed. This unstable group We included both internal and external surgical fixation, are at greater risk of the immobility-related complications in order to provide a broad overview of the evidence on discussed above.9 11–13 15 surgical fixation. There are various classifications of pelvic ring frac- tures based on the mechanism of injury, ligamentous involvement and anatomical location. For the purpose OBJECTIVE of this review, LC-1 FFPs were defined by respective To undertake a systematic review of the evidence base for anatomical classifications in patients with a low-energy the effectiveness of surgical fixation of LC-1 fragility frac- mechanism. tures when compared with non-surgical approaches. 1. Young and Burgess: an oblique or transverse ramus fracture with or without ipsilateral anterior sacral alar 19 20 compression fracture (LC-1). MATERIALS AND METHODS http://bmjopen.bmj.com/ 2. Tile classification: rotationally unstable, vertically sta- The protocol was prospectively registered in PROS- ble. Ipsilateral, the rami commonly fractured anterior- PERO: CRD42017055872. The Centre for Reviews and 21 ly and the posterior complex is crushed (Tile B2). Dissemination (CRD) guidance for undertaking reviews 3. AO classification: unilateral, partial disruption of pos- in healthcare was followed and reporting is in line with 22 terior arch, internal rotation (AO 61 - B2.1). Preferred Reporting Items for Systematic Reviews and 4. The Rommens classification is designed specifically Meta-Analyses guidelines.30 31 to encompass the different fracture patterns seen in fragility fractures of the pelvis. The LC-1 FFP injury Patient and public involvement on September 25, 2021 by guest. Protected copyright. corresponds with Rommens type IIb and IIc injuries There was no patient involvement in this systematic review allowing further stratification of the severity of this in- of existing literature. jury. This describes an ipsilateral anterior disruption with either a sacral crush fracture (type IIb) or undis- Data sources placed sacral alar fracture (type IIc).18 An experienced information specialist undertook searches Until recently, surgical fixation options for these frac- of MEDLINE (including Epub Ahead of Print, In-Pro- tures were limited. External fixators, a combination of cess & Other Non-Indexed Citations, Ovid MEDLINE pins, bars and clamps outside of the skin, are cumber- Daily and Ovid MEDLINE), EMBASE and the Cochrane some, poorly tolerated and carry a high risk of pin-site Central Register of Controlled Trials.
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