Prospective assessment of key factors influencing treatment strategy and outcome of fragility fractures of the pelvis (FFP)

Abstract

Background Fragility fractures of the pelvis (FFP) are a clinical entity with an increasing significance in clinical practice. Little is known about the conditions, which influence decision making and outcome. Setting Level I trauma center. Material and methods Prospective assessment of selected parameters of patients, who were admitted with a FFP in a 2-year period. Fractures were classified in accordance with the Rommens and Hofmann classification. Living environment, level of autonomy (independent walking), type of treatment (conservative versus operative), type of surgical technique, European Quality of Life-5 Dimensions-5 Levels (EQ-5D-5L), Short Form-8 Physical Component Score (SF-8 PCS) and Short Form-8 Mental Component Score (SF-8 MCS), Barthel Index, Parker Mobility Score (PMS) and Numeric Rating Scale (NRS) were collected at primary presentation (t1), at discharge (t2) and after 3 (t3) and 12 months (t4). Length of hospital stay, in-hospital complications, surgery-related complications, new osteoporotic fractures and mortality rate within the first year were also registered. The key factors influencing the choice of therapy and outcome were looked for. Results 110 patients, 99 women (90%) and 11 men (10%), were included in the study. Their mean age was 79.2 years (SD 10 years). Fourteen patients had FFP type I (12.7%), 59 FFP type II (53.6%), 11 FFP type III (10%) and 26 FFP type IV fractures (23.6%). All patients with FFP type I were treated conservatively. 48 patients with FFP types II-IV were treated conservatively and 48 operatively. Patients, who got a conservative outpatient treatment first and were hospitalized later, had higher FFP fracture types at admission. Operatively treated patients were hospitalized at a median of 33.5 days after the beginning of complaints, whereas the median day of admission of the conservative group was the day of trauma (p < 0.001). The operatively treated patients were hospitalized in a worse clinical condition (SF-8 PCS, EQ-5D-5L, autonomy). Length of stay (LoS) of operatively treated patients was significantly longer than of conservatively treated (p < 0.001). There was a tendency to more in-hospital complications in the operative group (p = 0.059). The rate of surgery-related complications (8.3%) was low with only one revision needed. Selected outcome parameters improved during the observation period nearly reaching the level before FFP after 1 year. SF-8 PCS, Barthel index and rate of patients living home were higher in the operative group at t4. The improvement of autonomy (independent walking) between t1 and t4 was significant in the operated group (p = 0.04) but not in the conservative group (p = 0.96). One-year mortality rate was 11.7% with no difference between the fracture types. One-year mortality rate of conservatively treated patients with FFP type II-IV was 13.5% versus 6.9% in the operative group (p = 0.38). Conclusion Conservative treatment is appropriate in patients with FFP type I as well as in patients with FFP type II, provided that the last ones are hospitalized immediately after the traumatic event. Surgical treatment is recommended in patients with higher fracture types, with delayed presentation or after unsuccessful conservative treatment. In the conservative and operative group, all selected parameters considerably improved between t1 and t4 with a steeper increase in the operative group. The rate of postoperative complications is low. The 1-year mortality rate is the lowest in the operative group. Surgical stabilization of FFP is safe and reliable provided it is performed with care and in the appropriate target group.

Fragility fractures of the pelvis: An update

“…[68] In their prospective study on 110 patients, Rommens et al worked out that the degree of pelvic instability, late presentation, and failure of conservative treatment were key factors for the indication of operative treatment. [66] The last studies endorse the original recommendations for surgical treatment published by Rommens and Hofmann in 2013. [21,69]…”

“…Nevertheless, there is no difference found in mobility and independence between operatively and conservatively treated patients in several studies. [65,66] In the series of Schmitz et al, quality of life and mobility were even higher in the conservative group. [67] On the contrary, large case series indicate that mortality is lower in operatively treated patients.…”

Comparative outcome of different treatment options for fragility fractures of the sacrum

“…With a comparable distribution of FFP types, Rommens et al [ 75 ] also found a lower mortality in surgically treated patients. The one-year mortality rate of surgically treated patients with FFP types II-IV was halved in comparison with conservatively treated patients [ 76 ]. As in our case, surgically treated patients benefit from minimally invasive percutaneous procedures in terms of complication rate and mortality [ 77 ].…”

Curvafix: A novel implant for pelvic fragility fractures

“…While all fragility fractures carry associated complications, FFP carry a significant one year mortality risk of 16.7–19 % from different sources, rising to 22 %–27 % with increasing age or residence in a nursing home [6] . Reduction in mortality rate is centralized upon early mobilization, decreasing the multifold complications associated with prolonged bed rest in the elderly population [4] . Many of these pelvic fractures are treated conservatively with nonoperative management, pain control, and weight bearing as tolerated.…”