1.16.2 Outcomes after pelvic ring injuries: critical review of the world experience
1 Introduction
The literature on pelvic ring injuries tends to focus on emergency management and initial treatment, describing several techniques to treat these injuries.
In contrast, adequate follow-up studies on pelvic ring fractures are lacking. No clear data are available regarding outcome parameters and instruments in relation to specific fracture types, stabilization procedures, or treatment concepts. Recently, more interest has been expressed in the literature regarding outcome evaluation of vertically unstable Tile classification type C injuries of the pelvic ring. This chapter describes possible outcome measurements for pelvic ring injuries by reviewing current data on functional and radiographic outcomes following pelvic ring injuries, including pain, return to work, urogenital and neurological symptoms, and prognostic factors indicative of inadequate long-term results. An attempt has also been made to analyze the outcomes of specific fracture types and stabilization concepts.
2 Health outcomes and management
The overall goals of treatment are to prevent injury, disease, and death, minimize disagreeable symptoms, maximize function, and improve overall well-being. Health outcomes must be defined and measured in a consistent manner to compare the degree to which competing treatment strategies succeed in achieving these goals. Traditionally, evaluation of the end result of treatment focused on radiographic results or crude nonvalidated measures of pain and function, neither of which facilitate comparison of results across studies [1]. With the advent of validated measurement instruments, deficits in physical, social, and emotional functioning subsequent to injury and disease can now be consistently quantified [2].
Several nonvalidated and validated outcome measures have been used to describe long-term results after pelvic ring fractures. Most authors use the validated Short-Form 36 Health Survey (SF-36) [3] or the Musculoskeletal Function Assessment (MFA) [4, 5]. Although they capture relevant impairment of the overall quality of life, the individual importance of these limitations localized to the pelvis is not sufficiently analyzed [6]. Therefore, other rating scales, especially those that describe problems after pelvic ring injuries, are still widely used, including Majeed Score [7], the outcome instrument of the German Pelvic Multicenter Study Groups (GMS1 Scale) [8, 9], and the Oswestry Disability Index (ODI) to analyze posterior pelvic complaints [10].
2.1 Validated scores
The SF-36, which is the most commonly used outcome instrument, is a self-assessment of mental health, physical health, and social aspects [3]. The SF-36 is a meaningful measurement instrument for evaluating the overall quality of life. A potential disadvantage of the SF-36 is that it captures relevant impairments to quality of life, but the relative individual importance of these limitations is not sufficiently analyzed.
Scores on the SF-36 range from 0–100, with higher scores indicating a better state of health. Eight different scales are analyzed: physical functioning (PF), role limitations due to physical health (RP), bodily pain (BP), general health perceptions (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (RE), and general mental health (MH). Of these PF, RP, BP and GH are summarized to measure physical health (Physical Component Summary) and VT, SF, RE, and MH to mental health (Mental Component Summary).
The MFA is a validated 101-item, self-reported health status questionnaire designed to detect functional differences in patients who have a broad range of musculoskeletal disorders [4, 5]. Its short version is a two-part, 46-item, self-reported health status questionnaire that also can be used for clinical evaluation of the impact of treatment after an injury in individual patients or patient groups [11]. The main items are analysis of daily activities, general injury-related daily impairments, and injury-related impairments in daily activities, including working abilities and social status. As with the SF-36, individual analysis of pelvic ring impairments cannot be made; therefore, only general functional impairments can be clearly characterized.
Additionally, region-specific scores can help in the analysis of long-term sequelae in regions of specific injury. An example is the Oswestry Low Back Pain Disability Questionnaire, which measures the patient′s permanent functional disability in the lumbosacral region [10]. The score consists of ten items with score values from 0–10%. The analyzed items are: pain intensity, personal care (eg, washing, dressing), weight lifting, walking ability, impairments while sitting, standing, or sleeping, sexual impairments, social life, and traveling. The score rates disability into five categories: minimal (0–20%), moderate (21–40%), severe (41–60%), crippled (61–80%), and bed bound or symptom exaggeration (more than 80%).
2.2 Nonvalidated scores
There are a variety of self-assessment scores. In the literature, the most popular scores are currently the Majeed score and the GMS1 scale. The Majeed score focuses on purely functional results, whereas the GMS1 scale distinguishes between clinical and radiographic results after pelvic ring injuries and combines both results to establish a Pelvic Outcome Score.
The Majeed score is a nonvalidated pelvic fracture-specific functional assessment instrument with a maximum of 100 points for patients working before injury, or 80 points for patients not working before injury ( Table 1.16.2-1 ) [7]. The scored items are walking ability (36%), pain (30%), return to work (20%), sitting disturbances (10%), and sexual impairments (4%). Walking ability is subdivided into use of walking aids (12%), analysis of unaided gait (12%), and walking distance (12%). A score of either 80 or 100 points is defined as the best result. Patients who worked before injury are graded as excellent with a score of at least 85, good with a score of 70–84, fair with a score of 55–69, and poor with a score of less than 55. Patients who did not work before injury are graded as excellent, good, fair, and poor with scores of at least 70, 55–69, 45–54, and less than 45, respectively. The disadvantage of the Majeed score is that neurological impairments, which have relevant prognostic influence, are not integrated into the score.
2.2.1 GMS1-Outcome Scale
The GMS1 Scale is a nonvalidated scale consisting of three items: clinical, radiographic, and social integration criteria ( Table 1.16.2-2 ) [8, 9]. Clinical criteria include pain, functional impairments (ie, limping, walking assistance), and persistent neurological and urogenital impairments. Radiographic criteria focus on the reconstruction of the posterior pelvic ring and to a lesser degree on the integrity of the anterior pelvic ring. Social reintegration criteria are working ability, free-time activities, sport activities, social activities, and need for external assistance. The total result of the pelvic injury is estimated using a 7-point scale, using radiographic (3 points) and clinical (4 points) results. The total result is summarized as follows: excellent (7 points), good (6 points), adequate (4–5 points), and poor (2–3 points).
3 Level of evidence and evidence-based practice
Scientific evidence to support medical and surgical intervention lies at the core of modern medicine. The strength or level of evidence, graded as A (randomized trials) to D (empirical observation), is a term meant to quantify the level of confidence that an observed result is correct [12]. Treatment recommendations can be graded by considering the strength of evidence in support of a particular management strategy. More recently, the concept of study quality has been extended to allow grading of studies concerning diagnosis, prognosis, and economic analysis [12]. Evidence-based practice involves awareness by the practicing clinician of the strength of evidence in support of recommended treatment in the clinical setting [13]. Grades C to D are recommended with regard to treatment options or the effect of outcome and potential prognostic factors with respect to pelvic ring injuries. No prospective randomized study is yet available to describe outcomes of pelvic ring injuries.
4 Basis of outcomes evaluation of pelvic ring injuries
When describing the prognosis of pelvic injuries or comparing treatment options, the main question is: when should a long-term result be stated? Majeed et al [14] noted that patient function improved over the first 18 months and then stabilized, whereas Kreder [1] previously identified a functional plateau between 6 months and 1 year postinjury.
Therefore, it is imperative that follow-up studies for pelvic ring injuries have at least a minimum follow-up evaluation of 1 year.
Comparable analyses of types B (Young-Burgess APC I–II, LC I–III) and C (Young-Burgess APC III, VS, combined) injuries offer confusing results. Several reports [15–17] showed that overall type C injuries have the worst overall results, whereas others [18] stated that no difference exists between these fracture groups or that type B1 (Young-Burgess APC I–II) fractures are associated with the highest degree of disability, followed by type C (Young-Burgess APC III, VS, combined) fractures. Types B2 (Young-Burgess LC I–II) and B3 (Young-Burgess LC III) fractures demonstrate the lowest degree of disability [1]. In the outcome analyses presented in this chapter, the focus is on results within the fracture types (A, B, and C), the injury region, and on types of osteosynthesis in these different regions.
A recent multicenter analysis reported excellent or good clinical results according to the Majeed score in 85% of patients. A decrease in these results was observed with increasing pelvic ring instability from type A to type C (Young-Burgess APC III, VS, combined) injuries. Neurological long-term sequelae depended on the type of pelvic ring injury, occurring in 4% of patients after type A fractures, 11% after type B (Young Burgess APC I–II, LC I–II) fractures, and 17% after type C (Young-Burgess APC III, VS, combined) injuries. Urological and sexual disturbances were both present in 8% of patients, with highest rates (each at 14%) after type C (Young-Burgess APC III, VS, combined) injuries. Additionally, patients with less than 5 mm residual displacement had the best functional outcomes, with the Majeed score higher than 90, whereas significantly lower scores were observed with increasing displacement [19]. Pavelka et al [20] reported comparable results in a single hospital analysis. Excellent and good clinical outcomes according to the Majeed score were seen in 83% of patients after type B (Young Burgess APC I–II, LC I–II) fractures and in 70% of patients after type C (Young-Burgess APC III, VS, combined) fractures. Radiographic results were excellent (< 5 mm residual displacement in 83% and 61% of patients, respectively).
5 Outcomes after type A injuries
Type A (no equivalent injury according to the Young-Burgess classification) fractures are commonly referred to as benign injuries; most are treated nonoperatively. These injuries normally require only short-term rehabilitation [21]. Consequently, no significant effort has been made to analyze long-term outcomes. The main problem in analyzing isolated type A injuries is that with adequate diagnostic studies many of these injuries have an additional posterior pelvic ring lesion that is not detected when using only conventional x-rays. Gertzbein and Chenoweth [22] used bone scans or scintigraphy to identify a posterior injury in most patients in the older age group who appeared to have an isolated anterior pelvic ring fracture, as shown on conventional x-rays. These data are confirmed in the present analyses. Schädel-Höpfner et al [23] analyzed 70 consecutive patients with anterior pelvic ring lesions only. In 53% of patients, computed tomographic (CT) scans of the pelvis identified posterior pelvic ring lesions. This changed their injury classification from type A to type B. However, the revised classification did not change the original treatment strategy (ie, from nonoperative to operative) in any patient treatment but the knowledge of the posterior injury lead to a more targeted rehabilitation. In their literature overview, even in early reports from the 1980s, Schädel-Höpfner et al [23] reported posterior injury rates of 46–100% using scintigraphy or CT scans [22–25]. This problem of overlooking posterior ring injuries was called “A-B” problem and was recently analyzed by Tosounidis et al [26], who reported a significantly lower incidence of classification changes. Our own data revealed this change, with a more or less complete incidence change between types A and B injuries in all patients with pelvic ring fractures. The use of CT scans has increased from 37% in the 1990s to more than 95% today ( Fig 1.16.2-1 ).
Therefore, CT scans are indicated for all patients with pelvic ring injuries to distinguish among various fractures types in an effort to better evaluate outcome based on the fracture classification subgroup.
The clinical relevance of type A injuries also has been described. In 1997, Koval et al [27] reported that patients, especially the elderly, with single anterior pelvic ring injuries are hospitalized for a mean of 14 days and have a 10% mortality rate after the first year. Of these patients, 16% reported moderate or severe pain after 1 year, and 26% exhibited trauma-related limping on the affected side at follow-up.
The first GMS1 Scale reported long-term results in 90 adult patients with type A injuries [8]. Most patients (86.7%) had no pain or only slight pain, but 13.3% reported moderate to severe pain. A good correlation was observed between pain assessment by the physician and the patients via the Visual Analog Scale (VAS). A significant number of patients (20–25%) reported some pain in the posterior pelvic region. Neurological sequelae, specifically slight or moderate sensory or motor impairment, were reported by 4.4% of patients. Using the Merle d′Aubigné score, the average value was 16.7 points, and in 95.6% of the patients bilateral equal point values differed only by a maximum of 1 point. Follow-up AP x-rays of the pelvis were available in 57 patients. Transpubic fractures achieved anatomical healing in 91.2% of patients, with no sign of significant malposition of the pubic symphysis, resulting in a rate of 14.0% residual displacement in the anterior pelvic ring with complete anatomical healing of the posterior pelvis.
When asked to assess their overall condition, 59% of patients reported being very satisfied or satisfied; an additional 23% offered a neutral response, leaving 17% claiming to be dissatisfied or very dissatisfied. Overall, 96% of the patients with isolated type A injuries were able to return to their previous professions. Severe limitations to sports activities were reported by 8% of these patients.
According to the GMS1 outcome evaluation, 81% of patients achieved a good or excellent clinical result; all patients who were subjected to radiographic follow-up showed an excellent total result, with restoration of the normal anatomy of the pelvic girdle [8, 9]. Overall outcomes of pelvic injury following isolated type A injuries were good or excellent in 82% of patients.
Miranda et al [28] reported that after type A injuries 77% of patients returned to their preinjury occupation level, 72% resumed their previous level of sexual activity, and 56% could perform heavy recreational activities. Pain was reported in 16% of patients, and of these 53% had no functional impairments.
Recently, Steinitz et al [29] retrospectively analyzed the long-term result (at least 1 year postinjury) in 33 patients (mean age, 46 years) with medial and high superior pubic ramus fractures using the Harris Hip Score and the MFA. Patients with high superior ramus fractures near the acetabulum reported significant hip pain on the affected side as a limiting factor in their mobility. Additionally, the Harris Hip Score and the functional assessment were worse compared with patients who had more medial ramus fractures.
Overall, despite the heterogenic characteristics (ie, no clear treatment regimen, different fracture types) of patients with type A injuries of the pelvic ring, between 10% and 20% had long-term problems in these so-called uncomplicated fractures.
6 Outcomes after type B injuries
As described earlier, type B (Young-Burgess APC I–II, LC I–III) injuries normally result in better long-term results than type C injuries. However, few studies present long-term results after isolated type B injuries. For this subgroup of patients, Kreder [1] noted that functional results associated with type B1 (Young-Burgess APC I–II) fractures are more similar to those of type C (Young-Burgess APC III, VS, combined) fractures. Therefore, we concluded that inclusion of types B2 (Young-Burgess LC I–II) and B3 (Young-Burgess LC III) groups makes it difficult to differentiate between types B and C injuries when comparing both groups of patients. Analyses of type B injuries must distinguish between external rotationally unstable fracture subgroup (B1 and B3.1) and the internal rotationally unstable subgroup (B2 and B3.2).
Some studies provide an overview of outcomes in patients with type B injuries of the pelvic ring. The SF-36 was first used by Oliver et al [18] to describe outcomes of 35 patients with types B and C injuries at a mean follow-up of 2 years (range, 16–28 months). They reported a Physical Component Summary of 67.1, which represents approximately 14% impairment compared to the common US population.
The GMS1 Scale was used to analyze the outcome of 87 patients with isolated type B injuries without additional acetabular fractures. No consistent treatment strategy was used. A total of 79.3% of patients reported either no pain or slight pain in the pelvic region. A comparison of patients with types B1 and B2 injuries showed that after lateral compression (type B2) fractures, fewer patients reported pain and their pain was less severe than that in patients with an external rotational (type B1) injury [8]. Pain localization was solely anterior in 4.6% (symphyseal/pubic region); whereas 34.5% reported single posterior pain and 16.1% suffered from both ventral and dorsal pain. Thus, half of patients reported disturbing posterior pelvic pain.
Functional limitations, analyzed with the Merle d′Aubigné score, showed a mean value of 17 points, and 83% of patients had identical scores or differences of 1 point bilaterally. Leg-length discrepancies were exclusively the result of accompanying lower extremity injuries. Complete radiographic follow-up was available in 78 patients. Of these, 90% showed anatomical healing of the posterior pelvic ring. In 28% of patients, some malunion occurred at the anterior ring. A total of 88.5% of patients offered a positive or neutral assessment of their condition. A total of 74% continued in their previous profession or remained in the same training program, 14% were at least partly able to work, and 13% were unable to work as a result of the injury. Overall, 87% of patients were still able to work, 69% reported that their sporting activities had not been altered by the injury, a further 11% reported only slight limitations, and 90% reported no or only slight limitations regarding hobbies. The total clinical result was assessed as excellent or good in 83.9% of patients. A poor total clinical result was due to permanent urological and neurological disturbances or significant pelvic pain. The overall pelvic outcome assessment led to 77.5% of patients achieving a good or very good result after a type B injury.
Miranda et al [28] analyzed outcomes after pelvic ring fractures using the SF-36 and the Iowa Pelvic Score (IPS) in patients treated with external fixation (60%) and nonoperatively (40%). The IPS is a nonvalidated 100-point score that also assesses the specific pelvic outcome. Six areas are analyzed: pain (25%), activities of daily life (20%), return to work (20%), limping (20%), pain by VAS (10%), and cosmesis (5%). Pain is integrated as subjective (VAS) and evaluated by the examiner. The IPS neurological and sexual dysfunction is not integrated. Patients with type B injuries had the lowest percentage of returning to previous occupation but had the highest percentage returning to preinjury levels of recreation. Additionally, 27% of patients suffered from sexual dysfunction and 35% reported significant persistent pelvic pain. Overall, only 32% reported no functional impairments.
Tornetta et al [30] analyzed patients with types B1 and B2 injuries after open reduction and internal fixation (ORIF) of the anterior ring at least 1 year after injury (range, 12–84 months). Full ambulation at follow-up was possible in 96% of patients but only 69% of them were pain free. A total of 27% reported pain with strenuous activity. Overall, 83% of patients returned to work within 1 year after injury and 75% returned to their original jobs.
Cano-Luis et al [31] analyzed long-term results using the SF-36 in 32 patients with type B injuries that were treated by different methods including nonoperative treatment and several types of stabilization techniques. The mean physical functional value was 75.8 and the pain value was 69.8.
Mardanpour and Rahbar [32] analyzed 27 patients with type B injuries; all were treated with ORIF. Functional results were graded with Majeed score and showed 81% good and excellent results. Only 48% of these patients reported being completely pain free at follow-up.
In unselected patient groups with type B (Young-Burgess APC I–II, LC I–II) rotationally unstable injuries, approximately 30% of patients suffer from long-term problems (ie, pain or functional limitations), with an overall rate of acceptable results in 75–80% of patients.
6.1 Type B1 (open book) injuries
Type B1 (Young-Burgess APC I–II) injuries are considered the most severe type B injuries, with a potential risk for permanent disability. Gruen et al [33] analyzed nine patients with type B1 injuries using the Sickness Impact Profile (SIP) at a minimum of 1 year following injury. A SIP score of less than 10 is interpreted as mild disability; 10–30, moderate disability; and a score higher than 30, severe disability. All patients underwent ORIF. Type B1 injuries were associated with the greatest degree of disability compared with types B2 (lateral compression injuries) and C (Young-Burgess APC III, VS, combined) injuries. The total mean SIP score was 12.4, indicating moderate disability. The total physical score was 11.1, with the worst value for ambulation (20.2 points). The mean psychosocial score was 10.9, with emotional disability scoring 17 points. The scores for working (25.7 points), recreation (24 points), home management (17.2 points), and sleep (16.6 points) indicated moderate impairment. In a further analysis, the ODI also was used for the same study group [16]. The overall ODI for all patients showed only minimal disability related to low back pain. The specific subgroup of seven patients with type B1 injuries had a mean score of 20.07, just at the level of moderate disability.
Weber et al [34] analyzed 22 patients with type B1 open book injuries treated with symphyseal plating. The GMS1 Scale was used to evaluate long-term outcomes at least 1 year after injury (range, 1–9 years). A total of 41% of patients reported pelvic pain, with eight patients who underwent anatomical reconstruction of the pelvic ring reporting persistent pain.
Pohlemann et al [35] presented 15 patients who underwent plate osteosynthesis after open book injury without additional complex pelvic trauma. These patients were reevaluated 14–49 months postoperatively. Using GMS1 Scale, 93.3% of these patients had an excellent or good functional result, and all patients had anatomically bony pelves. Of these, 73% were completely pain free.
Lindahl et al [17] used the Majeed score to analyze eight patients with type B1 open book injuries after a mean of 4.1 years (range, 1–11 years). All patients were treated with an anterior external fixator alone. Six of eight patients had a fair or poor radiographic result at follow-up, with > 11 mm displacement at the injury site. Three of these patients also had significant pelvic pain, and 50% of the patients had fair or poor functional results. The authors concluded that external fixation alone is of limited value treating open book injuries.
Rommens et al [36, 37] devised their own grading system to analyze long-term results in 31 type B1 injuries treated by a variety of stabilization techniques, including external fixation and ORIF. Some patients were treated with combined anterior and posterior techniques. Good or excellent functional results were observed in 74% of patients. Significant permanent pain was reported in 29% of patients, and 36% had moderate to severe pelvic pain. In contrast, radiographic results showed anatomical healing in 93% of patients.
After open book injuries, including unilateral and bilateral open book lesions (types B1 and B3.1), Cano-Luis et al [31] reported mean SF-36 physical functioning values of 72.8 and pain values of 73.3.
Van Loon et al [38] recently used both SF-36 and the Majeed score to analyze functional outcomes of 32 patients with open book injuries after median follow-up of 84 months. All patients underwent initial anterior ring stabilization, and approximately 25% required an additional iliosacral screw. The average Majeed score was 95.7 points. All values of the different SF-36 categories were lower compared with uninjured German and American patients who sustained type B1.1 injuries. The median level of physical functioning was 95%, no patient reported role limitations and the median pain level using VAS was 10%. Patients who required additional posterior iliosacral screw fixation tended to have worse results than patients who underwent symphyseal stabilization alone.
After type B1 (Young-Burgess APC I–II) injuries, moderate disability and 30–40% relevant persistent pain can be expected, despite a high rate of anatomical healing. The overall functional result is excellent to good in 70–90% of patients when symphyseal plating is performed. Single external fixation seems to lead to worse results.
Related posts:
1.16.1 Outcomes after pelvic ring injuries: general concept and conclusion
1.17 Venous thromboembolism in pelvic trauma
1.19 Malunion and nonunion of the pelvis: posttraumatic deformity
1.18 Complications of pelvic trauma
1.8.4 The management of the injured pelvic ring: internal fixation of the anterior pelvic injuries—open book (type B1)
2.23 Results of treatment for fractures of the acetabulum
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