Early Operative Versus Nonoperative Treatment of Fragility Fractures of the Pelvis: A Propensity-Matched Multicenter Study.

OBJECTIVE: To compare early operative treatment with nonoperative treatment of fragility fractures of the pelvis regarding mortality and functional outcome. DESIGN: Retrospective. SETTING: Two trauma centers. PATIENTS AND METHODS: Two hundred thirty consecutive patients 60 years of age or older with an isolated low-energy fracture of the pelvis and with a follow-up of at least 24 months. In center 1, treatment consisted of a nonoperative attempt and early operative fixation if mobilization was not possible. In center 2, all patients were treated nonoperatively. MAIN OUTCOME MEASUREMENTS: Primary outcome was mortality. Secondary outcomes were in-hospital complications. Patients who survived were contacted by phone, and a modified Majeed score was obtained to assess functional outcome at the final follow-up. RESULTS: At the final follow-up (mean 61 months, SD 24), 105/230 (45.7%) patients had died. One year after the initial hospitalization, 34/148 patients [23%, 95% confidence interval (CI): 17%-31%] of the early operative group and 14/82 patients (17%, 95% CI: 10%-27%) of the nonoperative group had died (P = 0.294). Nonoperative treatment had a protective effect on survival during the first 2 years (hazard ratio of the nonlinear effect: 2.86, 95% CI: 1.38-5.94, P < 0.001). Patients in the early operative treatment group who survived the first 2 years had a better long-term survival. The functional outcome at the end of follow-up as measured by a modified Majeed score was not different between the 2 groups (early operative: 66.1, SD 12.6 vs. nonoperative: 65.7, SD 12.5, P = 0.910). CONCLUSION: Early operative fixation of patients who cannot be mobilized within 3-5 days was associated with a higher mortality rate and complication rate at 1 year but with a better long-term survival after more than 2 years. Hence, patients with a life expectancy of less than 2 years may not benefit from surgery with regard to survival. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rate of intraoperative problems during sacroiliac screw removal: expect the unexpected.

BACKGROUND: The indications for sacroiliac screw (SI) removal have been under debate. Data on complication rates of SI screw removal is missing in the current literature. The objective of this study was to compare the rate of intra- and perioperative problems and complications during SI screw removal to those with SI screw fixation. METHODS: A retrospective observational study with two interventions in the same cohort was performed. Consecutive patients who underwent both sacroiliac screw fixation for an isolated fracture of the pelvic ring and removal of the same implants between November 2008 and September 2015 (n = 19; age 57.3, SD 16.1 years) were included. Intraoperative technical problems, postoperative complications, duration of surgery, and radiation dose were analysed. RESULTS: Intraoperative technical problems occurred in 1/19 patients (5%) during SI screw fixation and in 7/19 cases (37%) during SI screw removal (p = .021). Postoperative complications were seen in 3/19 patients after SI screw fixation and in 1/19 patients after SI screw removal (p = 0.128). The surgical time needed per screw was longer for screw removal than for implantation (p = .005). The amount of radiation used for the whole intervention (p = .845) and per screw (p = .845) did not differ among the two interventions. CONCLUSIONS: Intraoperative technical problems were more frequent with SI screw removal than with SI screw fixation. Most of the intraoperative technical problems in this study were implant-related. They resulted in more surgical time needed per screw removed but similar radiation time.

Mid-term follow-up after surgical treatment of fragility fractures of the pelvis.

INTRODUCTION: Early operative treatment of fragility fractures of the pelvis (FFP) has been suggested to reduce pain and allow for earlier mobilization. The aim of this study was to determine mortality and functional outcome after operative treatment. PATIENTS AND METHODS: Patients aged ≥60 years (n = 60; mean age 79 years, 53 female) who had operative treatment of a FFP and a follow-up of at least 2 years were identified and mortality was assessed using a national social insurance database. Those who had survived were contacted by phone and a modified Majeed Score was obtained. RESULTS: At final follow up (62 months, range, 29-117), 32 patients (53.3%) had deceased. One-year-mortality rate was 28.3% and 2-year mortality was 36.7%. Mortality was not linked to fracture type (p > .05). Complications during hospitalization occurred in 26/60 patients (43.3%). Patients with a bilateral FFP had a longer hospitalization (18 vs. 11 days; p = .021). The mean modified Majeed score of surviving patients was 65 points (85.5% of achievable maximum). CONCLUSION: Mortality and in-hospital complications remain high among patients with FFP even when treated operatively. A longer hospitalization can be expected in patients with posterior bilateral fractures.