Part 1: Outcome of Posterior Pelvic Ring Injuries and Associated Prognostic Factors - A Five-Year Retrospective Study of One Hundred and Sixty Five Operated Cases with Closed Reduction and Percutaneous Fixation.

PURPOSES: The aim of this study was to evaluate: 1. the outcome of pelvic ring fractures treated by closed reduction and percutaneous fixation, 2. the prognostic factors associated with a poor quality reduction, 3. the prognostic factors associated with ilio-sacral screws misplacement and 4. the prognostic factors associated with nonunion. METHODS: Data from medical charts for all patients admitted with unstable posterior pelvic ring injuries from 2009 to 2013 were extracted. A total of 165 patients with a mean age of 40 years were included. One hundred and five patients were reviewed at a mean of 32 months of follow-up. The prognostic factors analyzed were clinical and radiological factors. Tile B and Tile C pelvic ring fractures were compared and analyzed separately. Then specific statistical analysis was performed using a logistic regression model to eliminate confusion factors. RESULTS: An excellent or good clinical result was achieved for 94 patients (90%). An excellent or good reduction was achieved for 141 patients (85%). Nonunion rate, smoking patients, bad reductions, age of patients and ISS score were significantly higher in Tile C group. To eliminate confusion factors we used a multivariate analysis logistic regression model. Only unstable vertical bilateral posterior injuries (Tile C2 and C3) were independent prognostic factors for unsatisfactory reduction (p = 0.001; OR = 4.72; CI 95% [2.08-16.72]). Screw misplacement was recorded for 30 patients (16%) and sacral dysmorphia was an associated prognostic factor (p = 0.0001; OR = 15.6; CI95% [3.41-98.11]). Nonunion was recorded for ten patients (6%) and smoking was an associated prognostic factor (p = 0.01, OR = 5.12; CI95% [1.1-24.1]). CONCLUSIONS: Posterior pelvic ring fractures treated by closed reduction and percutaneous fixation are associated with excellent/good clinical results if excellent/good reduction and bone healing are achieved without screw misplacement. Bilateral unstable vertical posterior pelvic ring injuries, and sacral dysmorphia are risk factors for bad quality reduction and screw misplacement respectively.

Epidemiology and treatment of acetabular fractures in a level-1 trauma centre: Retrospective study of 414 patients over 10 years.

BACKGROUND: Epidemiological studies of acetabular fractures (AFs) are scarce and, to our knowledge, the most recent one from France, by Letournel and Judet, dates back to 1993. Studies have suggested a decrease in high-energy AFs contrasting with an increase in low-energy AFs due to the longer life expectancy. However, a French case-series study failed to confirm these data. We therefore conducted a 10-year retrospective study in a level-1 trauma centre to: (1) characterise the epidemiological profile of AF; (2) and to describe the treatment strategy. HYPOTHESIS: The epidemiological profile of AF in France is consonant with data from European case-series studies. METHOD: All patients managed for AF between 2005 and 2014 were included in this single-centre retrospective study. All patients were re-evaluated at our centre or another facility 6 months after the fracture. The epidemiological data were compared in the three treatment groups: non-operative, open reduction and internal fixation (ORIF), and total hip arthroplasty (THA). RESULTS: Between 2005 and 2014, 414 patients were admitted for AF. Mean age was 49.4 years (range: 15-101 years). Treatment was non-operative in 231 (56%) older patients, most of whom had low-energy fractures involving the anterior wall. THA with or without acetabular reinforcement and screw-plate fixation was performed in 27 (7%) older patients, most of whom had posterior-wall fractures and experienced postoperative complications (26/27 patients, 96%). ORIF was used in 156 (38%) younger patients, most of whom had high-energy fractures of greater complexity. CONCLUSION: Our results reflect the current indications in AF management. The epidemiological characteristics in our population are comparable to those reported in the few recent European epidemiological studies. To our knowledge, this is the largest French epidemiological study since the landmark work by Letournel and Judet. LEVEL OF EVIDENCE: Level IV, retrospective study.

Interest of intra-operative 3D imaging in spine surgery: a prospective randomized study.

PURPOSE: We report a single-center, prospective, randomized study for pedicle screw insertion in opened and percutaneous spine surgeries, using a computer-assisted surgery (CAS) technique with three-dimensional (3D) intra-operative images intensifier (without planification on pre-operative CT scan) vs conventional surgical procedure. MATERIAL AND METHOD: We included 143 patients: Group C (conventional, 72 patients) and Group N (3D Fluoronavigation, 71 patients). We measured the pedicle screw running time, and surgeon's radiation exposure. All pedicle runs were assessed according to Heary by two independent radiologists on a post-operative CT scan. RESULTS: 3D Fluoronavigation appeared less accurate in percutaneous procedures (24 % of misplaced pedicle screws vs 5 % in Group C) (p = 0.007), but more accurate in opened surgeries (5 % of misplaced pedicle screws vs 17 % in Group C) (p = 0.025). For one vertebra, the average surgical running time reached 8 min in Group C vs 21 min in Group N for percutaneous surgeries (p = 3.42 × 10(-9)), 7.33 min in Group C vs 16.33 min in Group N (p = 2.88 × 10(-7)) for opened surgeries. The 3D navigation device delivered less radiation in percutaneous procedures [0.6 vs 1.62 mSv in Group C (p = 2.45 × 10(-9))]. For opened surgeries, it was twice higher in Group N with 0.21 vs 0.1 mSv in Group C (p = 0.022). CONCLUSION: The rate of misplaced pedicle screws with conventional techniques was nearly the same as most papers and a little bit higher with CAS. Surgical running time and radiation exposure were consistent with many studies. Our work hypothesis is partially confirmed, depending on the type of surgery (opened or closed procedure).

Technique for reduction and percutaneous fixation of U- and H-shaped sacral fractures.

We describe an early reduction and percutaneous fixation technique for isolated sacral fractures. Strong manual traction combined with manual counter-traction on the torso is used to disimpact the fracture. Transcondylar traction is then applied bilaterally and two ilio-sacral screws are inserted percutaneously on each side. Open reduction and fixation, with sacral laminectomy in patients with neurological abnormalities, remains the reference standard. Early reduction and percutaneous fixation ensures restoration of the pelvic parameters while minimising soft-tissue damage and the risk of infection. Decompression procedures can be performed either during the same surgical procedure after changing the installation or after a few days. These complex fractures warrant patient referral to specialised reference centres.

Traumatic atlantooccipital dislocation with survival: case report and review of the literature.

We present the case of a patient with traumatic atlantooccipital dislocation. The initial neurological examination showed no abnormalities. Dislocation was the result of rapid deceleration in a motor vehicle accident. The mechanism of injury was hyperextension/rotation, probably combined with a distraction force. Only a few cases of atlantooccipital dislocation without neurological involvement have been reported. Every report pointed out difficulties of initial diagnosis. Special attention should be directed toward the atlanto-odontoid-basion relationships as seen on lateral radiographs. Prompt recognition and surgical stabilization are essential to avoid further neurological injury.

[Cotrel-Dubousset instrumentation in the treatment of thoracolumbar and lumbar spine fractures]. / L'instrumentation de Cotrel-Dubousset dans le traitement des fractures de la charnière dorso-lombaire et du rachis lombaire.

Thirty-three thoracolumbar and lumbar spine fractures have been operated on using Cotrel-Dubousset instrumentation. Most were thoracolumbar burst fractures. Regional kyphosis at follow-up was 4 degrees, vertebral kyphosis was 8 degrees. Secondary loss of regional kyphosis was 1 degree, and 10 degrees of vertebral kyphosis. This construct with screws varies according to the level (thoraco-lumbar or lumbar); it seems reliable, as compared with other kinds of internal fixation. Restoring the height of the vertebral body is essential and is the key to a good final result. Addition of a postero-lateral fusion and or a brace did not improve the results.