Pararectus Approach in Acetabular Fractures in Patients Older Than 65 years. Is it Possible to Improve the Technique?

OBJECTIVES: Review clinical results of the treatment for acetabular fractures using the pararectus approach and analyze surgical variations of the traditional approach. DESIGN: Retrospective. SETTING: Tertiary referral hospital. PATIENTS: 46 patients over 65 years of age who sustained an acetabular fracture and underwent surgery using the pararectus approach. INTERVENTION: Fractures were treated using a pararectus approach. Three variations of the original technique were performed: (1) Ligature of the deep iliac circumflex artery and vein, (2) separation of the psoas and iliacus muscles, and (3) isolation of the spermatic cord in men and round ligament in women together with the iliac and epigastric vessels. MAIN OUTCOME MEASUREMENTS: Outcomes measures included surgical, demographic, and clinical data, and information related to follow-up. RESULTS: Duration of surgery, 125 minutes (95-210). Quality of reduction on postoperative computed tomography (CT) scan; anatomic in 22 patients (47.8%), incomplete in 16 (34.8%), and poor in 8 (17.4%). In patients in whom the hip was preserved (n = 41), functional status was excellent in 15 patients (36.5%), good in 17 (41.4%), fair in 6 (14.7%), and poor in 3 (7.4%), with mean functional score of 16 points (7-18). Seven patients (15.2%) developed posttraumatic osteoarthritis and 4 of these patients underwent total hip replacement. CONCLUSIONS: This study reports positive outcomes in fracture reduction and clinical outcomes with low complications in older patients who suffered acetabular fractures and were treated using a pararectus approach. Small variations in the technique, such as those proposed in this study, may help to widen access to the surgical site and simplify the technique. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pelvic post-traumatic asymmetry: Assessment and sequenced treatment.

The most common cause of post-traumatic pelvic asymmetry is, by far, initial nonoperative treatment.Open reduction and internal fixation of unstable pelvic fractures are recommended to avoid pelvic nonunion or subsequent structural deformities.The most common symptom is pelvic pain. Pelvic instability is another symptom, as well as persistent urogenital problems and neurological sequelae.Preoperative evaluation of these patients requires careful clinical and functional assessment, in addition to a complete radiological study.Surgical treatment of pelvic fracture nonunions is technically demanding and has potentially serious complications.We have developed a new classification that modifies and completes Mears and Velyvis's classification in which we highlight two types of post-traumatic sequelae with different clinical conditions and whose basic differentiating element is whether pelvic deformity is present or not. Based on this classification, we have established our strategy of surgical treatment. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170069.

Is cannulated-screw fixation an alternative to plate osteosynthesis in open book fractures? A biomechanical analysis.

OBJECTIVES: The current biomechanical work compares the symphyseal and sacroiliac stability obtained with two systems of bone osteosynthesis. The two methods of fixation compared were the 6-hole suprapubic non-locked plate and pubic fixation with two cannulated screws, a novel technique that can be applied percutaneously in the clinical practice. The aim of this study was to examine the validity of the use of two-cannulated-screws osteosynthesis in order to minimize the secondary effects of open fixation, especially in patients in whom an open reduction is contraindicated. MATERIALS AND METHODS: A biomechanical study was designed in 9 fresh, human pelvis specimens, simulating an AO B1.1 type injury, using both fixation systems sequentially in each specimen. In both parts of the test, the specimens were subjected to an axial load of 300N. Displacements and rotations between the different pelvic elements were studied by means of a discrete set of points. The absence of differences between the two systems has been set as the null hypothesis. RESULTS: There were significant differences in favor of the cross-cannulated screws in most of the displacements measured at the pubic symphysis and sacroiliac joint. CONCLUSIONS: Fixation of the AO B1.1 type fractures with cross cannulated screws restores the biomechanical behavior of the pubic symphysis, obtaining better stability than fixation with the 6-hole non-locked plate. To date, no comparative, biomechanical studies have been conducted with these two systems of osteosynthesis. This study demonstrates that cross-cannulated screws fixation of the pubic symphysis in AO B1.1 pelvic fractures should be considered as an alternative to the conventional plating system.

Percutaneous iliosacral fixation in external rotational pelvic fractures. A biomechanical analysis.

INTRODUCTION: Although the gold standard in open book pelvic fractures remains the pubic symphysis (PS) plate fixation, the clinical outcomes are not satisfactory, despite the excellent anatomical reduction assessed radiologically. Some authors suggest that residual instability of the posterior pelvic elements may be responsible for the chronic pain and the early osteoarthritic changes in the sacroiliac joint (SIJ). OBJECTIVE: To evaluate whether the isolated posterior fixation with one or two iliosacral screws (ISSs) is sufficient to provide adequate stability for the treatment of Burgess Young APC-II (YB APC-II) type of pelvic ring injuries. METHODS: Biomechanical experimental study using 7 fresh human pelvises, where an YB APC-II pelvic injury was previously implemented. The isolated posterior fixation of the pelvic ring with 1 or 2 ISSs directed in the S1 vertebra body was analysed in each specimen following an axial load of 300N. The different displacement of the SIJ and of the PS were analysed in all three spatial axes, using the validated optical measurement system 3D PONTOS 5M. A multivariate version of Friedman test (non-parametric ANOVA for repeated measures) was performed. RESULTS: The isolated fixation of the SIJ with 1 ISS did not show any differences with respect to the intact pelvis (p=0.851). Regarding the PS, both type of fixations (with 1 or 2 ISSs) confirmed an acceptable correction and adequate control of the PS even though with some differences compared to the intact pelvis (p=0.01). The presence of the second ISS found not to offer any significant additional benefit. The three-dimensional analysis of the behaviour of the pelvic elements, in these two different types of fixation, did not show any statistical significant differences (p=0.645). CONCLUSION: The posterior fixation with ISS can represent an alternative option for treatment of pelvic injuries associated with rotational instability. Further prospective clinical studies are necessary to determine, the influence of the residual pubic symphysis mobility in the every day life, when the above-mentioned technique is applied.

Bone health, daily physical activity, and exercise tolerance in patients with cystic fibrosis.

BACKGROUND: Daily physical activity (PA) may be an excellent tool for the maintenance of bone health in patients with cystic fibrosis (CF). The aim of this study was to analyze the possible association between physical capacity and activity and bone mineral density (BMD) in young adults with CF. A secondary goal was to evaluate vertebral fractures in this population. METHODS: A cross-sectional study was conducted in 50 patients with CF who were clinically stable and aged > 16 years but not lung transplant recipients. PA was quantified with a portable motion monitor (BodyMedia Fit Armband). Cardiopulmonary exercise and 6-min walk tests were used to assess exercise capacity. BMD was obtained from dual-energy x-ray absorptiometry of the lumbar column, hip, and whole body. To analyze vertebral fractures and deformity, we performed the Genant and Cobb methods. RESULTS: Daily PA time at low (3-4.8 metabolic equivalent tasks [METs]) and moderate (4.8-7.2 METs) intensity, respectively, was correlated with Z score (BMD) of the lumbar column (r = 0.36, P < .01 and r = 0.59, P < .001), the neck of femur (r = 0.51, P < .001 and r = 0.72, P < .001), and the total hip (r = 0.54, P < .001 and r = 0.74, P < .001). PA, BMI, age, and sex were predictors of BMD. Vertebral fractures correlated with kyphosis (r = 0.42, P = .02), but not with BMD. Patients who were mildly and severely affected differed in vertebral fracture rate and kyphosis prevalence (P = .002 and P = .013, respectively). CONCLUSIONS: The most active patients with better exercise capacity had higher BMD. Those with more affected pulmonary function had a greater prevalence of vertebral fractures and dorsal kyphosis.