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Should We Take a Broader View When Treating Fragility Fractures of the Posterior Pelvis? a Retrospective Cohort Study

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Should We Take a Broader View When Treating Fragility Fractures of the Posterior Pelvis? a Retrospective Cohort Study Orthopedics and Rheumatology Open Access Journal ISSN: 2471-6804 Clinical Case Ortho & Rheum Open Access J Volume 18 issue 3 - June 2021 Copyright © All rights are reserved by Laurenz Jaberg DOI: 10.19080/OROAJ.2021.18.555988 Should we take a Broader view when treating Fragility Fractures of the Posterior Pelvis? A Retrospective Cohort Study Manuela Notzli1, Laurenz Jaberg2*, Ralph Zettl2, Daniel Smolen3, JoEllen Welter2, Alexander Dullenkopf2 and Florian Hess2 1Department of Orthopedic Surgery, Schulthess Clinic, Zurich, Switzerland 2Department of Orthopedic Surgery and Traumatology, Cantonal Hospital Frauenfeld, Switzerland 3Alphaklinik, Zurich, Switzerland Submission: May 28, 2021; Published: June 10, 2021 *Corresponding author: Laurenz Jaberg, Department of Orthopedic Surgery and Traumatology, Cantonal Hospital, Frauenfeld Pfaffenholzstrasse 4 8501 Frauenfeld, Switzerland Abstract Background: however, treatment can differ from recommendations. Our aims were to describe patient outcomes based on the approach used to treat FFP, to A classification system to treat fragility fractures of the pelvis (FFP) based on fracture type has been proposed. In practice, assess the consistency of our treatment with recommendations proposed by the classification system, and to identify risk factors potentially influencingMaterials treatment and Methods: allocation. was necessary, either unilateralBetween or bilateral January lumbopelvic 2014 and stabilizationJune 2018, a wastotal performed of 145 patients with witha minimally an FFP I-IVinvasive were approach. were treated. Treatment Seventy-seven course, patients (median age of 82 years; IQR, 73-87; range, 56-95) with posterior pelvic ring fractures (FFP II-IV) were included in our study. If surgery patient demographics, and factors potentially influencing outcomes (e.g., diabetes, chronic renal insufficiency, chronic steroid use, neurological 6-monthdisease) werefollow-up. analyzed. We measured the consistency rate between our treatment of Type III and IV fractures with the recommendations. We defined ‘successful outcome’ using three parameters (return to original residence, pain level, and fracture consolidation using CT scan) at the Results: Twenty-six patients underwent immediate posterior stabilization using minimally invasive lumbopelvic fixation, 18 had delayed surgical stabilization, and 33 were treated conservatively. The success rate for the cohort was 86%. Eight of the 11 failures (73%) were in the immediate surgery group. Conservative treatment succeeded in 62% (16/26) Type II, 29% (7/24) Type III, and 33% (9/27) Type VI fractures. Success by fracture type was: 88% in Type II, 75% in Type III, and 93% in Type IV. Success by treatment group was 69% (immediate surgery), 89% (delayed surgery), 97% (conservative); and the complication rate within the first six months was 34.6%, 27.8%, and 12.1%, respectively. AmongConclusion: those with Type III and IV fractures, 33% of patients were successfully treated conservatively. No risk factors were significantly different. While the proposed classification system is useful for treating FFP, 33% of our patients with more complex and unstable fracturesLevel (Type of Evidence: III and 3IV) were treated conservatively, which differed from the recommended treatment courses. Keywords: Fragility fracture of the pelvis; Sacrum fracture; Osteoporosis; Geriatric patient Abbreviations: ASA: American Society of Anesthesiologists; BMI: Body Mass Index; FFP: Fragility Fracture of the Pelvis; VAS: Visual Analog Scale Introduction Especially problematic are severe secondary complications Fragility fractures of the pelvis (FFP) are caused by mild stemming from long-term immobilization, such as urinary tract infections, pneumonia, loss of muscle mass, and side effects of bones [1-5]. The incidence of fragility fractures is on the rise, trauma that would not usually be sufficient to fracture healthy chronic use of pain medication [13]. and an increase in life expectancy is one contributing factor [6- 10]. Higher healthcare costs associated with sacral fractures, The decision to treat a fracture surgically or conservatively is particularly in older patients [6,9], are primarily due to prolonged and intense pain, immobility, and loss of independence [11,12]. FFP is conservative treatment with mobilization and analgesics difficult. The most common approach to managing non-displaced Ortho & Rheum Open Access J 18(3): OROAJ.MS.ID.555988 (2021) 001 Orthopedics and Rheumatology Open Access Journal (OROAJ) based on pain levels [4,5]. Problems can arise when conservative (i) all adult patients aged 18 years and older who had a FFP of and patients who underwent conservative or surgical treatment therapy fails, mainly due to the risk of complications associated the posterior ring; (ii) a Type II, Type III, or Type IV fracture; (iii) method should be used, when feasible, to treat this vulnerable (immediate or delayed) of the FFP. Seventy-seven patients with with prolonged immobility. If surgery is needed, the least invasive population [2]. fracture due to a low energy trauma were included. We excluded Although the incidence of sacrum fractures is increasing, a median age of 82 years (IQR 73-87, range 56-95) who had a all patients who (i) were previously diagnosed with osteoporosis reports on management strategies are limited, and evidence- and had undergone antiresorptive therapy, (ii) had sacrum fractures caused by a malignant tumor with bone metastases, (iii) based treatment guidelines reached by consensus are lacking. were undergoing revision surgery, or (iv) had a pelvic fracture due In 2013, Rommens & Hofmann [6] described a separate to a high energy trauma. from fractures in healthy bones caused by high energy trauma classification system for FFP since its fracture morphology differs Fragility Fractures of the Pelvic Ring) includes a broad spectrum [1-3]. This classification system (Comprehensive Classification of To assign the fracture type, we used the FFP classification of fracture morphologies caused by low energy trauma and [2]. In addition to baseline characteristics (e.g., gender, age, and permits international comparisons of such fractures. According BMI), the overall well-being of patients was scored using the ASA Physical Status Classification System. Likewise, we documented to this classification system, Type II fractures ought to be treated concomitant injuries and risk factors with the potential to influence should be stabilized surgically. conservatively, whereas Types III and IV with signs of instability bone healing, such as diabetes mellitus, chronic renal insufficiency Despite the advances made with the establishment of these [15], chronic steroid use [16,17], neurological disease, and pain quality and to estimate the extent of osteoporosis, the cortical levels (measured with visual analog scale (VAS)). To quantify bone recommendations by Rommens & Hofmann, this system centers of hospitalization and operative time were also included in the thickness index was measured using x-ray images [18]. The length on the fracture type. Questions such as ‘what degree of dislocation analyses. This retrospective study was approved by the local is relevant for treatment’ and ‘which types of fractures are truly considered when treating a mostly geriatric population, such as unstable’ remain unanswered. A multitude of factors could be consent was obtained from the participants. the array of comorbidities, degree of immobility, and pain level. ethics committee (01.5301(2013/2006/kap)012), and written General patient management However, including all potential risk factors into a treatment Patients admitted to the emergency department or seen algorithm would not only be challenging, but it might also make for orthopedic consultation initially received a conventional definingAt ourstandard institution, procedures we too attempted complicated. to carry out the recommendations of Rommens et al. [14] when treating FFP cases. by x-ray or the patient complained of posterior compression pain, radiograph. If the injury to the posterior pelvic ring was confirmed We found, however, that the everyday challenges in clinical practice a CT scan was done to assess the fracture more precisely. Since did not always permit adherence to these recommendations. For most elderly patients are unable to mobilize adequately enough to return to their residence, all patients were admitted to the signs of instability refused surgery and were subsequently treated hospital. example, some patients with Types III and IV fractures showing During this initial hospitalization, our intention was to failed conservative treatment and eventually underwent surgery. conservatively. Likewise, several patients with Type II fractures provide conservative treatment with pain medication and daily system needs to be expanded slightly to include factors beyond These cases prompted us to question if the proposed classification just fracture type. The primary aim of our study was physiotherapy for five days, regardless of the patient’s fracture movement with an adequate degree of mobilization was possible, type. If the pain level was under control and independent i. the patient was discharged from the hospital to either their used to treat FFP. We also assessed residence or a rehabilitation clinic to improve mobility [5]. This To describe patient’s outcomes based on the approach ii. The consistency of our treatment with recommendations was made directly by the patient or, in cases of dementia, by the decision
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