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.

Radius' Giant Cell Tumor: Allograft with Conservation of Distal Radioulnar Joint.

Purpose Giant cell tumor of the distal radius are frequent lesions, and different types of surgeries have been described. Functional results, after conservative treatment or arthrodesis, often find a decreased strength and range of motion. The sacrifice of the distal radioulnar joint could be one of the causes. We report the case of a 26-year-old patient who presented with a Campanacci Grade III giant cell tumor of the distal radius. We managed his case by the association of en bloc resection and allograft reconstruction with the preservation of distal radioulnar joint. Hypothesis This procedure could improve functional results, without increasing the risk of recurrence at 2 years follow-up. Case Report The originality of our technique was the possibility of distal radioulnar joint conservation. We preserved a long portion of cortex bone all through the ulnar side of the distal radius. We then used an allograft of distal radius, fixed by a reconstruction anatomical plate. Results At 2 years follow-up, the range of motion was 100° with 60° of palmar flexion, 40° of extension, 75° of pronation, and 70° of supination. Radial and ulnar inclination were 10 and 15°, respectively. MTS (Musculoskeletal Tumor Society Score) 1993 was 88% and DASH score was 6. Concerning grip strength, it was measured at 85% in comparison with the other side. Pronation and supination strengths were 80 and 73%, respectively, in comparison with the other side. At follow-up, standard X-rays showed no recurrence. The allograft was well integrated. Conclusion Conservative treatment of the distal radioulnar joint allowed an almost ad integrum recovery, concerning strengths and range of motion. It allows a better functional recovery, without increasing the risk of recurrence.

Chronic low back pain after lumbosacral fracture due to sagittal and frontal vertebral imbalance.

PROBLEM AND HYPOTHESIS: Over time, some patients with unilateral or bilateral lumbosacral injuries experience chronic low back pain. We studied the sagittal and frontal balance in a population with these injuries to determine whether mismatch in the pelvic and lumbar angles are associated with chronic low back pain. PATIENTS AND METHODS: Patients with posterior pelvic ring fractures (Tile C1, C2, C3 and A3.3) that had healed were included. Foreign patients and those with an associated spinal or acetabular fracture or nonunion were excluded. The review consisted of subjective questionnaires, a clinical examination, and standing A/P and lateral stereoradiographic views. The pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), measured lumbar lordosis (LLm), T9 sagittal offset, leg discrepancy (LD) and lateral curvature (LC). The expected lumbar lordosis (LLe) was calculated using the formula LLe=PI+9°. We defined lumbopelvic mismatch (LPM) as the difference between LLm and LLe being equal or greater than 25% of LLe. RESULTS: Fifteen patients were reviewed after an average follow-up of 8.8 years [5.4-15]. There were four Tile C1, five Tile C2, five Tile C3 and one Tile A3.3 fracture. Ten of the 15 patients had low back pain. The mean angles were: LLm 49.6° and LLe 71.9° (P=0.002), PT 21.3°, SS 44.1°, PI 62.9° in patients with low back pain and LLm 57.4° and LLe 63.2° (P=0.55), PT 13°, SS 43.1°, PI 54.2° in those without. LPM was present in 9 patients, 8 of who had low back pain (P=0.02). Six patients, all of whom had low back pain, had a mean LC of 7.5° [4.5-23] (P=0.02). The mean LD was 0.77cm. DISCUSSION: The findings of this small study suggest that patients who experience low back pain after their posterior arch of the pelvic ring fracture has healed, have a lumbopelvic mismatch. Early treatment of these patients should aim to reestablish the anatomy of the pelvic base relative to the frontal and sagittal balance. LEVEL OF EVIDENCE: IV.

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.

Which pelvic ring fractures are potentially lethal?

PURPOSE: Global mortality of polytraumatised patients presenting pelvic ring fractures remains high (330%), despite improvements in treatment algorithms in Level I Trauma Centers. Many classifications have been developed in order to identify and analyse these pelvic ring lesions. However, it remains difficult to predict intra-pelvic haemorrhage. The aim of this study was to identify pelvic ring anatomical lesions associated with significant blood loss, susceptible to lead to life-threatening haemorrhage. MATERIAL AND METHOD: This study focused on a retrospective analysis of patients' medical files, all of whom were admitted to one of the shock rooms of Grenoble University Hospital, France, between January 2004 and December 2008. Treatment was given according to the institutional algorithm of the Alps Trauma Center and Emergency North Alpine Network Trauma System (TRENAU). Different hemodynamical parameters at arrival were measured, and the fractures were classified according to Young and Burgess, Tile, Letournel and Denis. One hundred and ninety seven patients were analysed. They were subdivided into two groups, embolised (Group E) and non-embolised (Group NE). RESULTS: Group NE included 171 patients with a mean age of 40.2 ± 8.7 years (15-90). Group E included 26 patients with a mean age of 41.6 ± 5.3 years (18-67). Twenty-six patients died during the initial treatment phase. Eleven belonged to Group E and 15 to Group NE. Mortality was significantly higher in Group E (42.3% vs 8.8% in Group NE) (p < 0.05). There were significantly many more Tile C unstable fractures in Group E (p = 0.0014), and anterior lesions, according to Letournel, with pubic symphysis disruption were significantly more likely to lead to active bleeding treated by selective embolisation (p = 0.0014). Posterior pelvic ring lesions with iliac wing fracture and transforaminal sacral fractures (Denis 2) were also more frequently associated with bleeding treated by embolisation (p = 0.0088 and p = 0.0369 respectively). DISCUSSION/CONCLUSION: It appears that in our series the primary identification and classification of osteo-ligamentous lesions (according to Letournel and Denis' classifications) allows to anticipate the importance of bleeding and to adapt the management of patients accordingly, in order to quickly organise angiography with embolisation.

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.

Bilateral testicular dislocation with pelvic ring fracture: a case report and literature review.

We report a case of a bilateral testicular dislocation with B1-1 pelvic-ring fracture according to the modified Tile AO classification, in a patient of 62 years. The mechanism of injury was impaction on the tank of a motorcycle. Symphyseal plate fixation using a Pfannenstiel approach was associated to bilateral orchidopexy through scrotal approach. The posterior pelvic ring was stabilized by iliosacral screwing because the left sacroiliac joint was open. The outcome was favorable without disorders of gonadal function. Systematic testicular palpation and careful CT analysis of the genital organs enabled identification and effective management of these rare urinary tract lesions.

Relevance of a press-fit dual mobility cup to deal with recurrent dislocation of conventional total hip arthroplasty: a 29-case series.

UNLABELLED: The aim of this paper was to assess the impact on stability of revision of 29 standard acetabular cups to press-fit uncemented dual mobility (DM) cups in THAs with recurrent dislocation. This series was composed of 17 women and 12 men aged on average 75.6 ± 8.1 years (55-88), operated on between November 2000 and July 2010. The average number of dislocations before revision surgery was 3.87 ± 1.79 (2-10), and the average time from primary procedure to revision was 6.6 ± 4.3 years (45-15 years). 9 patients (31.03 %) had already undergone one or more procedures for instability prior to revision to DM cup. All patients were reviewed at an average time of 46 ± 28 months (range: 17 months-11 years). Only one patient had redislocated in this time (3.4 %). This patient underwent a simple closed reduction and did not dislocate again. LEVEL OF EVIDENCE: IV retrospective cohort study.

Section of the sciatic nerve by a metal acetabulum reinforcement ring: a literature review through one case.

We report the case of a sciatic nerve section in a patient operated for a multi-acetabular loosening. Clinical symptoms were a progressive sensitive and motor deficit in the sciatic nerve territory. At the last loosening, the Burch-Schneider metal frame, which builds on the ischium, tipped on its axis causing the large section of the sciatic nerve. A literature review will discuss this rare case and give some recommendations.

Dorsally displaced distal radius fractures treated by fixed-angle volar plating: Grip and pronosupination strength recovery. A prospective study.

INTRODUCTION: Malunion following open reduction and internal fixation of distal radius fracture threatens wrist function. Fixed-angle palmar plates provide rigid fixation that is stable over time; however, the pronator quadratus sectioning required by the anterior approach entails a risk of pronation strength loss and of distal radioulnar joint destabilization. The present study assessed recovery of grip, pronation and supination strength following such internal fixation. PATIENTS AND METHOD: A prospective study included 26 distal radial fractures with dorsal displacement, osteosynthesized using a fixed-angle palmar plate, in 25 patients (mean age: 47.5 years; range: 17-72 years). Assessment concerned the classical parameters, plus grip and pronosupination strength recovery. RESULTS: At a mean 14 months follow-up (range: 6-30 months), patients had recovered 91% grip strength, 88% pronation strength and 85% supination strength with respect to the healthy side. Complications comprised three cases of malunion, two of reflex sympathetic dystrophy syndrome, and four of post-traumatic carpal tunnel syndrome. DISCUSSION: A study of the literature found 75-95% grip strength recovery following osteosynthesis using fixed-angle plates. Few studies, however, have focused on pronosupination strength, and none reported its evolution following osteosynthesis. CONCLUSION: The present study found no drawbacks associated with a technique which usually involves sectioning the pronator quadratus. Except in case of malunion or joint stiffness, fixed-angle palmar plate osteosynthesis was followed by recovery of grip and pronosupination strength. LEVEL OF EVIDENCE: Level IV: prospective non-randomized, non-comparative observational study.

Is femoral head fracture-dislocation management improvable: A retrospective study in 110 cases.

INTRODUCTION: There is no established consensus on the diagnosis and treatment of traumatic fracture-dislocation of the femoral head --largely due to the rarity of this injury. HYPOTHESIS: Analysis of a large series of fracture-dislocations of the femoral head using a single coherent classification should enable the means of diagnosis and treatment of fracture-dislocations of the femoral head to be specified. OBJECTIVES: The hypothesis was tested by analyzing a retrospective series of 110 patients charts admitted between 1972 and 2008, using Pipkin's classification and an alternative new one, Chiron's classification. MATERIAL AND METHODS: The series comprised 21 women and 89 men; mean age: 37.1 years. Dislocation was posterior in 102 cases and anterior in eight. Associated lesions comprised 46 fractures of the acetabulum and four of the femoral neck. Classification following Pipkin and Chiron was based on double reading of radiology documents from 102 patients. Treatment was exclusively conservative in 32 cases, and surgical in 78, with 51 posterior, 19 anterior and four medial approaches and four arthroscopic procedures. Surgery comprised osteosynthesis of the femoral head in 30 cases and of the acetabulum in 16, removal of fragments in 40 cases and total hip replacement (THR) in five cases as a primary treatment. RESULTS: Mean follow-up was 37 months. THR was performed in 25 cases: five as a primary treatment and 20 secondarily, 15 of which were performed within the first 6 months. Significant predictive factors for THR were: old age, Chiron grade 3, and femoral neck fracture. The THR and non-THR groups differed on the Chiron but not on the Pipkin classification at the time of the injury. Specific treatments were not predictive of evolution. Fragment removal was more often by a posterior than an anterior or medial approach. CONCLUSION: The Chiron classification showed prognostic value for evolution to THR; to be reproducible, it needs to be based on CT data. No particular mode of treatment emerged as preferable. Better initial lesion analysis should enable prognosis and target indications. LEVEL OF EVIDENCE: Level IV Retrospective study.