Surgical management of osteoporotic pelvic fractures: a new challenge

Abstract

The number and variety of osteoporotic fractures of the pelvis are rapidly growing around the world. Such fractures are the result of low-impact trauma. The patients have no signs of hemodynamic instability and do not require urgent stabilization. The clinical picture is dominated by immobilizing pain in the pelvic region. Fractures may be located in both the ventral and the dorsal pelvic ring. The current well-established classification of pelvic ring lesions in younger adults does not fully reflect the criteria for osteoporotic and insufficiency fractures of the pelvic ring. Most osteoporotic fractures are minimally displaced and do not require surgical therapy. However, in some patients, an insidious progress of bone damage leads to complex displacement and instability. Therefore, vertical sacral ala fractures, fracture dislocations of the sacroiliac joint, and spinopelvic dissociations are best treated with operative stabilization. Angular stable bridge plating, the insertion of a transsacral positioning bar, and iliolumbar fixation are operative techniques that have been adapted to the low bone mineral density of the pelvic ring and the high forces acting on it.

Assessment of the Breakaway Torque at the Posterior Pelvic Ring in Human Cadavers

“…Besides the risk for complications secondary to immobilization, immobilizing pain was considered to be the most significant symptom experienced by this patient group leading to its previous name "the fracture disease" [22]. As a treatment option, percutaneous screw fixation was feasible, allowed for early mobilization with less pain and was recommended in selected cases [1,22,23].…”

“…Besides the risk for complications secondary to immobilization, immobilizing pain was considered to be the most significant symptom experienced by this patient group leading to its previous name "the fracture disease" [22]. As a treatment option, percutaneous screw fixation was feasible, allowed for early mobilization with less pain and was recommended in selected cases [1,22,23]. However, the loss of fixation at the posterior pelvic ring and the subsequent need for revision surgery resulting in recurrent surgical morbidity and/or residual instability at the fracture site leading to chronic pelvic pain may be the most significant failure in the management of geriatric pelvic trauma.…”

Implementation of a standardized protocol to manage elderly patients with low energy pelvic fractures: can service improvement be expected?

“…This approach is due to the following: (a) a significant proportion of these fractures are thought to be mechanically stable; (b) limitations of current pelvic fixation techniques in the presence of severe osteoporosis; (c) the high perioperative morbidity of open pelvic surgery in this frail cohort of patients; and finally, (d) the relatively scarce availability of trained pelvic trauma surgeons. Nevertheless, there are specific indications for surgical treatment of FPFs, especially of the posterior elements, usually with minimal invasive or percutaneous techniques [16][17][18].…”

“…It is of interest that inadequate initial management in combination with the poor bone quality and the slow progress of fracture healing [19] could lead to further displacement of bony fragments, development of additional fracture lines, secondary loss of reduction, implant failure, non-union and poor clinical outcome [18]. Initial imaging in these patients with a suspected low energy pelvic ring injury is usually limited to plain X-rays.…”

Pelvic and acetabular fractures

“…Keel et al [1] provide an overview of some important developments in pelvic surgery. Rommens et al [2] discuss specific aspects that arise in fractures of the pelvis in the older patient. In addition to this work, the article by Rickman et al [3] deals with the management of complex acetabular fractures in the elderly.…”