Conservative versus operative treatment of FFP II fractures in a geriatric cohort: a prospective randomized pilot trial.

A clear recommendation regarding treatment strategy of fragility fractures of the pelvic ring is missing. The most typical fracture pattern is a lateral compression type injury with non-displaced fractures of the anterior pubic rami and a unilateral os sacrum fracture (FFP II). We hypothesized that operative treatment would be superior to conservative treatment. From October 2017 to April 2020, a randomized prospective non-blinded trial with n = 39 patients was carried out. Two arms with 17 operative versus 22 conservative cases were created. Inclusion criteria were a posterior pelvic ring fracture FFP type II, age over 60 years and acute fracture (< 3 weeks). Barthel index, pain level (VAS), quality of life (EQ-5D-3L), and Tinetti-Gait Test were determined on admission, at discharge, and after 3, 6, 12 and 24 months. Median follow-up was 12.9 months. The Barthel index (= 0.325), VAS (p = 0.711), quality of life (p = 0.824), and Tinetti-Gait Test (p = 0.913) showed no significant differences between the two groups after 12 months. Two patients switched from the conservative to the operative arm due to persistent immobilization and pain. The one-year mortality rate showed no significant difference (p = 0.175). Our hypothesis that surgical treatment is superior was refuted. No significant benefit was shown in terms of quality of life, mortality and pain levels. The results suggest a more differentiated treatment approach in the future, with initial conservative treatment preferred. A larger multi-center trial is required to confirm these findings.Trial registration: The study was retrospectively registered with the German Clinical Trials Registry (DRKS00013703) on 10/12/2018.

Full endoscopic anterior intrapelvic plate osteosynthesis: a cadaveric feasibility study.

In this investigation, it was assumed that it must be possible to visualize the intrapelvic aspect as accustomed by pelvic surgeons using the anterior intrapelvic (modified Stoppa) approach. Moreover, it was hypothesized, that plate mountings will not only be possible for the symphysis but also at the supra- and infrapectineal aspect as well as to the posterior column. Ten anonymized cadaveric specimens were included in this study. A standard laparoscopic totally extraperitoneal (TEP) approach was used. A total of 10 landmarks were defined that are usually within reach in the open anterior intrapelvic (AIP) approach. Moreover, five different plate mountings were tested. The locations were chosen in accordance with the indication spectrum suitable for open surgery through the traditional AIP approach. It was possible to gain intrapelvic visibility in seven of ten cases. In all of those seven cases, it was technically possible to place plates to the symphysis, superior pubic ramus, as well as longer anterior column plates up to the aspect posterior of the acetabulum. In the last four of the seven cases, it was possible to mount plates to the infrapectineal aspect as well as the posterior column, too. The team, previously trained in arthroscopic surgical techniques as well as pelvic trauma surgery, observed a steep learning curve. This investigation demonstrated, that endoscopic anterior intrapelvic plate osteosynthesis was feasible in the majority of the cases in a series of ten cadaveric models. New instruments will be needed such as extra-long rasp elevators, ball-spikes as well as devices to hold and position plates and extra-long self-holding screwdrivers. With these, endoscopic pelvic surgery will likely be a realistic option for selected pelvic trauma cases in the future.