1.15.2 Insufficiency fractures of the pelvis: operative management

10.1055/b-0035-121640

1.15.2 Insufficiency fractures of the pelvis: operative management

Karen Hand, James F Kellam

1 Patient selection and indications

Traditionally, insufficiency fractures of the pelvis have been treated with limited bed rest, partial-weight bearing, early mobilization, and analgesic medications. Although early mobilization is encouraged, pain may produce a prolonged period of inactivity in many cases. The complications are well known, including deep vein thrombosis, pulmonary embolism, weakness, respiratory insufficiency, decubitus ulcers, and constipation. The 1-year mortality rate associated with pelvic insufficiency fractures is 14.3%; 50% of patients will not return to their prior level of function [1].

Indications for surgical intervention were defined in the previous edition [2] to include patients with severe deformities, symptomatic nonunion, pseudarthrosis, or chronic debilitating pain not responsive to nonoperative measures. Over the past decade, several alternative treatments have been explored, with some surgeons advocating earlier and more aggressive intervention to decrease pain and allow earlier return to function. When evaluating the patient with a pelvic insufficiency fracture, it is important to assess the risks of both nonoperative and operative treatment. The surgeon must consider the patient′s overall activity and level of health, and how it will affect the ability to tolerate either method of treatment. As our population ages and insufficiency fractures become increasingly common [3], new treatments will abound, making these decisions progressively more complex.

2 Preoperative planning

The appropriate imaging of pelvic insufficiency fractures is critical both for diagnosis and determination of treatment, including preoperative planning. Insufficiency fractures of the pubic rami, parasymphyseal regions, and iliac wing are often evident on plain x-rays. These should include the AP, inlet, and outlet views. Sacral insufficiency fractures, however, are frequently missed on plain x-rays [4]. Bone scintigraphy may be useful for demonstrating increased tracer activity in the area of an occult fractures, but can be confusing due to bowel and bladder activity or degenerative changes in the sacroiliac joint. Computed tomography offers greater sensitivity and fracture detail, and may provide opportunities for navigated percutaneous fixation [5]. Magnetic resonance imaging has emerged as the most sensitive and specific method in demonstrating sacral insufficiency fractures [6, 7]. T1-weighted images show decreased signal indicating marrow edema, and T2-weighted short tau inversion recovery or fat saturated T2-weighted images show increased signal indicating the same marrow edema.

Other preoperative planning should include special consideration for poor bone quality. Traditional internal fixation devices may not hold in the severely osteoporotic bone, requiring special techniques including extensive use of adjuvant fixation and bone grafting [8, 9]. In addition, the surgeon must consider preoperative patient optimization and appropriate anesthesia. This is specific to the planned method of fixation. For example, a patient undergoing percutaneous sacroplasty may need only intravenous sedation for the procedure. The same patient may be discharged home the same day, negating the need for extended hospitalization or prolonged bed rest. In contrast, a patient undergoing spinopelvic fixation will need to be optimized for general anesthesia and may need to be discharged to an inpatient rehabilitation facility several days after the procedure. These are important points to consider, and it is important that the patient understands the risks and postoperative implications of the planned procedure.

3 Surgical techniques

3.1 Percutaneous techniques

Sacroplasty for sacral insufficiency fractures was first described by Garant [10], evolving from the success of vertebroplasty and kyphoplasty for treatment of thoracic and lumbar insufficiency fractures. Sacroplasty involves the injection of polymethylmethacrylate (PMMA) into the fracture zone with the goal of relieving pain through restoration of mechanical integrity [4, 11–13]. This procedure is typically performed by a physiatrist, pain specialist, or interventional radiologist with the use of intravenous sedation or general anesthesia. Computed tomography, image intensification, or both are used for guidance and multiple needle insertion techniques have been described [11]. Patients are discharged home the same day and report rapid relief of symptoms.

Frey et al [13] reported on 37 patients treated with percutaneous sacroplasty and found significant pain relief 30 minutes after the procedure, with improvement sustained through 1 year. Whitlow et al [14] compared clinical outcomes of patients undergoing sacroplasty and vertebroplasty, and found the ability to ambulate and perform activities of daily living improved in both groups, with a statistically significant improvement in pain scores as well. Cement injection techniques have also been attempted at other sites of pelvic insufficiency fractures with successful outcomes. Beall et al [15] reported on percutaneous augmentation of the superior pubic ramus in two patients, both of whom experienced immediate pain relief and sustained results at 6 and 9 months. Injection of PMMA into insufficiency fractures of the ilium and acetabulum also provided pain relief [12, 16].

Despite the enthusiasm and apparent short-term successes of cement injection techniques, the long-term outcomes remain unknown [11, 12]. Extravasation of cement remains a concern, but the implications are uncertain [11–13]. Furthermore, some orthopedic surgeons have argued against the widespread use of sacroplasty due to concerns of fracture healing and risk of neurological or vascular injury to the sacral foramens [17].

Only gold members can continue reading. Log In or Register to continue