Additional clinical value of routine CT imaging in fragility fractures of the pelvis: a prospective cohort study (ARTIFACT).

PURPOSE: Additional CT imaging for fragility fractures of the pelvis (FFP) has a high detection rate for concomitant posterior ring fractures (cPRFs). However, the clinical value of routine additional CT imaging is unknown. This study aimed to determine the additional clinical value of routine CT imaging by changes in treatment policy and to establish the predictive value of pain localized around the sacroiliac joint (SIJ) for cPRFs. METHODS: A prospective cohort study was conducted in a single teaching hospital in the Netherlands between November 2019 and November 2020. Patients were included if they were ≥ 65 years and had a (suspected) FFP on the pelvic radiograph. All patients underwent additional CT imaging. Changes in treatment policies ((possible) surgery, restrictive weight-bearing, hospital admission and outpatient follow-up) after CT imaging were registered. RESULTS: Fifty-one patients (44 female) were included with a mean age of 80.6 years. Routine CT imaging revealed an additional cPRF in 27 patients (53%). A change in treatment occurred in 29 patients (57%), of which 7 (12%) were managed either surgical or with restrictive weight-bearing. The presence of pain around the SIJ had a sensitivity of 89% and specificity of 61% for detecting a cPRF. CONCLUSION: Routine additional CT imaging has few direct therapeutic consequences with regards to surgical management or restrictive weight-bearing. These findings may be altered when considering a lower threshold for surgical intervention. The presence of pain around the SIJ was highly predictive for a clinically relevant cPRF. TRIAL REGISTRATION: NL8011 on 02-09-2019.

Outcome of pubic rami fractures with or without concomitant involvement of the posterior ring in elderly patients.

INTRODUCTION: Pubic rami fractures are common fractures in a growing osteoporotic geriatric population. Concomitant posterior ring fractures (cPRF) are often found when properly looked for. The pain and consequent immobilization leaves this vulnerable patient group at risk for complications. Conservative therapy is usually sufficient, but with cPRF's surgery can be indicated. Although previous studies have pointed out that mortality rates are high, longer term morbidity outcomes are lacking. This study aims to further establish the longer term consequences of these fractures. Risk factors will be identified for complications, also addressing the possible differences between patients with or without a cPRF. METHOD: Retrospective analysis of patients aged over 65 years sustaining a pubic rami fracture in the North-West Hospital Group Alkmaar combined with a survey to establish risk factors for morbidity and mortality after 6 months' post trauma. Multiple logistic regression analysis was used to identify risk factors. RESULTS: 117 patients matched inclusion criteria with a median age of 83 and of which 86% was female. 23 cPRF's were identified. Significant deterioration in ambulation and independency was found. 34% was institutionalized at discharge. 49% lost their independent mobility status and 40% of the patients did not experience a full recovery. One-year mortality rate was 23%. Patients with a cPRF had a significant higher complication rate (44 vs 18% p = 0.02), but mortality and other morbidity outcomes did not statistically differ. The strongest predictor for 1-year mortality was complications during admission and a dependent ambulatory status (OR 5.2 and 4.1 respectively). CONCLUSION: Pubic fractures with or without involvement of the posterior pelvic ring in patients aged over 65 have a significant impact on mobility and independency. Mortality rates are similar to hip fracture patients. Careful evaluation of every patient's mobility status is necessary to identify patients at risk for complications and determine their future health care needs. Future studies are needed to achieve consensus on diagnostic and treatment protocols and identify ways to decrease the significant impact of this injury.