Causes And Treatment Options Of Old Pelvic Fracture

BackroundFrom damage control surgery(DCS)to damage control orthopedics(DCO),it embodies the progress of the theory.The specific application of the advanced life support,external fixation,pelvic volume control,liquid recovery,limited internal fixation,gauze packing and vascular embolization,reduce the early mortality rate of pelvic fractures.From suppressing systemic inflammatory response syndrome(SIRS)to reducing the occurrence of multi-organ dysfunction(MOSF),the later death rate of pelvic fractures is reduced.So pelvic fracture as a kind of multiple and severe trauma,was treated effectively by orthopaedic surgeons.The improvement of pre-hospital first-aid level and the standardized application of rescue procedures resulted in a significant reduction in the mortality of patients with pelvic fractures.On the other hand,due to the increased number of patients and inappropriate treatments,nonunion and malunion of pelvic fractures occur more.There are morphological diversity and operative complexity.So the orthopedic surgeons face a great challenge.Therefore,the treatment of old pelvic fractures,especially the nonunion and malunion,has become a hot issue and difficult problem.At the same time,there are few related literatures,and there is no clear clinical path for the treatment of old pelvic fractures.So it is necessary to carry out systematic research and summarize the effective treatment methods to form a relatively perfect treatment concept and operation standard.Meanwhile,We find that the understanding deviation of the theory of damage control theory also lead to more cases of old pelvic fracture.Old pelvic fracture refers to the fracture over 3 weeks.If the fracture exists more than 6 weeks,nonunion and malunion occurs for the large amount of cancellous bone in the pelvic area.The underlying cause is the instability of the pelvic.The treatment of severe and prolonged pelvic fracture is mainly manifested in the treatment of nonunion and malunion.The nonunion operation of old pelvic fracture is mainly based on open reduction,and the treatment of malunion is mainly fixed with osteotomy.The aim is to improve the quality of life by relieving the pain and correcting gait.Although the ideal treatment of deformity is to replicate the initial fracture condition and then reposition and fix it,it is often not possible for pelvic fractures.The fracture of posterior pelvic ring,especially the vertical unstable fracture with sacrum fracture and sacroiliac joint injury,forms complex deformity healing.The loss of bony traces and the dislocation of the neurovascular structure make the in situ osteotomy difficult and dangerous.Iliac osteotomy is an effective surgical treatment for certain types of pelvic fractures.Although the iliac osteotomy is not usually the first choice for orthopedic surgeons to deal with the malformation of the pelvic fractures,it effectively addresses the problem of lower limb length in selected cases.In the first part of this study,a retrospective study was made to analyze the real causes of the old pelvic fractures.In the second part,retrospective study was performed to evaluate the application of iliac osteotomy for the treatment of old pelvic fractures.The two parts of the study is more detailed as follows:The first part:Study on the causes of old pelvic fracturesObjectiveThrough a retrospective study of 42 patients with old pelvic fractures,the true causes were found,so as to reduce the formation of old pelvic fractures and reduce the disability rate.Methods42cases(26males,16 females)old pelvic fractures were selected from the department of orthopedic of the Shandong Provincial Hospital and jinan city people's hospital.The average age was 42.14 years old(18-53 years).The Injury Severity score(ISS)was 30-68 points,averaging 46 points.Retrospective study was conducted to analyze the cause of injury,fracture classification,whether the initial treatment was appropriate,the time from the injury to the final operation of the fracture,and the surgical method of the old pelvic fracture.ResultsThe time from injury to final surgery was 22-365 days,with an average of 138 days.The causes of injuries included fall injuries in 13 cases,traffic accident injuries in 26 cases,and falling injuries in 3 cases.There were 20 cases with craniocerebral trauma,23 cases with multiple rib fractures,pulmonary contusion and hemopneumothorax,14 cases with abdominal injury,8 cases with urethral injury and 4 cases with vaginal injury.There were 10 cases of open pelvic fractures,32 cases of closed pelvic fractures.According to Tile classification,there are 10 C1.1,14 C1.2,10 C2 and 8 C3 cases.Initial treatment:20 cases were treatmented with anterior ring external fixator.Due to inadequate understanding of the treatment measures,7 cases were treated with non-surgical treatmen.At the time of injury,no final operation was allowed,and 10 cases were treated with non-surgical treatment.According to the injury time,the treatment of combined injury,fracture type,the pelvic fracture union situation,the patient subjective request and so on comprehensive judgment,to the formation old pelvic fracture to take the different surgical treatment way.The operation method includs the open reduction internal fixation,the external fixator or the femoral supracondylar traction cooperation under the open reduction internal fixation,Iliac bone osteotomy and internal fixation.Conclusion1.For the unstable fracture patients,non-surgical treatment should not be recommended.The pelvic external fixator as the ultimate treatment should not recommend to whom accompanied by vertical instability pelvic fractures.2.Damage control theory is not equal to no treatment,is not equal to negative treatment.The essence of the damage control theory is to require the surgeon to have global concept,want to have a dynamic concept,at the same time to prospectively predicting patient outcome,with the best method of minimally invasive,processing compound injury patients complicated pathophysiologic problem.In this way,the systemic inflammatory response syndrome(SIRS)is inhibited,and the occurrence of MODS of multiple organ dysfunction syndrome is reduced,and the mortality and disability rate of pelvic fractures are reduced.3.Old pelvic fractures are formed because patients with multiple injury and open pelvic fractures can't be treated in a short time(3 weeks)for effective fixation surgery.Old pelvic fractures occur because the treatment of other parts of the body deviates from the treatment of pelvic fractures.Old pelvic fractures Can be avoided by forbidding the inappropriate conservative treatment and external fixator application.If the orthopedic surgeon inaccurate understand the damage control theory,old pelvic fracture occurs.4.For the old pelvic fracture patients,final operation should be taken early.Then the operation is relatively simple with low risk and good prognosis.The second part:Treatment of old pelvic fractures with transiliac osteotomyObjectiveEvaluation of the indications and clinical efficacy of iliac osteotomy for the treatment of old pelvic fracturesMethodsA retrospective study was conducted in this study.From January 2006 to January 2014,a total of 13 cases of old pelvic fractures were eligible for inclusion exclusion criteria in this study,of which men were 9 cases,female 4 cases,the average age was 40.22 years(22-55 years).According to the presence or absence of 3D printing before surgery and the corresponding finite element analysis,the patients were divided into the conventional group and the 3D printing group,including 8 cases in the conventional group and 5 cases in the 3D printing group.The cause of injury included high fall injury in 3 cases and traffic accident injury in 10 cases.According to Tile classification there are 3 C1.1,4 C1.2,4 C2 and 2 C3.There were traumatic brain injury in 7 cases,multiple rib fractures,pulmonary contusion and hemopneumothorax in 5 cases,abdominal injury in 2 cases,urethral injury in 2 cases.In 13 patients,there were different degrees of limb shortening and the length of 3.9 cm(2-5.2cm)from navel measurements to internal malleolus.There exist Abnormal gait,limp and seat imbalance.The pain of 3 cases in the back of the pelvic region should be treated with daily analgesic medication.The ultimate operation was taken after 9.75 months(3.5-12 months).In the preoperative 3D printing group,in addition to routine X-ray CT and 3D reconstruction CTA examination,3D printing models of the same size and volume were obtained for osteotomy program design and simulated surgery.SP approach was used in the conventional group.The ilioinguinal approach was adopted in the 3D printing group,and k-L approach was combined in 2 cases of acetabular fractures.Surgical procedures include iliac osteotomy,bone grafting,and internal fixation with a double plate or screws.The operative time,intraoperative blood loss,intraoperative fluoroscopy,and length of hospital stay were observed and recorded in the conventional group and the 3D printing group,respectively.Statistical analysis was performed,and follow-up and postoperative complications were recordedResultsThe average operative time of the conventional group was 262.5±65.41 hours,the average intraoperative blood loss was 2225±1003.92 ml,the average intraoperative fluoroscopy was 13.5±4.0 times,the average limb length was 2.87±0.26 cm,and the average hospital stay was 23.12±7.41 days.In the 3D printing group,the average operation time was 189.2±29.76 minutes,the average intraoperative blood loss was 1200±254.95 ml,the average intraoperative fluoroscopy times were 9.2±1.92,the average limb length was 3.02±0.25 cm,and the average hospital stay was 14.4±3.5 days.There were significant differences between the two groups in average operation time,average intraoperative blood loss,average intraoperative fluoroscopy frequency and average hospital stay.The average operative time of the 3D printing group was less than that of the conventional group.There was no significant difference in the average length of limb extension between the two groups.Compared with the conventional group,the 3D printing group had no significant advantage in extending limb length.After 23.25 months of follow-up,the results showed that all iliac bone grafts were healed,no osteotomy clearance and internal fixation were found.Pain in the posterior pelvic region improved in 2 of 3 patients before surgery.8 patients with lower lumbar pain relief.Eight patients had normal gait and three had mild claudication and did not need crutches.Two patients need to support crutches when standing and walking for a long time.Five patients returned to work,six patients changed their jobs and engaged in light physical labor,and two patients were competent for daily life but unable to engage in work and physical activities.4 patients were very satisfied with the results of treatment,8 patients were satisfied and only one patient was not satisfied.According to Majeed score,there are 2 excellent cases,10 good cases,1 middle case.Postoperative complications included:No infection occurred after operation,2 patients had delayed soft tissue healing for 3-4 weeks,2 patients complained of numbness and sensory hypersensitivity in the anterior and lateral thigh.One patient developed deep vein thrombosis in the left thigh.Filter was placed to prevent thrombosis and pulmonary embolism.No sciatic nerve injury and vascular injury was occurred.ConclusionThe iliac osteotomy surgery,which take the safe area of the pelvic for osteotomy and avoid in situ osteotomy,can correct as a result of pelvic fracture malunion caused by foot length and sitting imbalance,can partially correct the pelvic vertical deformity.The operation has the advantages of low risk and high safety.The posterior rotatory deformity cannot be corrected because the operation does not involve the posterior ring.This method should not be used when the patient has persistent back pain or posterior ring instability.This is the limitation of this operation.For the treatment of old pelvic fractures,the operative methods are various,the indications should be carefully mastered before the operation,and the selection of surgical treatment should be personalized.Due to the high difficulty and high risk of the operation,the preoperative planning should be carried out in detail.3D printing computer-assisted surgery should be carried out when necessary.At the same time,there is an obvious learning curve in the operation,which needs the cooperation of the standard training team.We successfully corrected the complication of pelvic fracture deformity healing with iliac osteotomy and provided a therapeutic option for patients with old pelvic fractures.