Unstable pelvic fractures are mostly caused by high energy, and in the past, conservative treatment was used, which mostly had sequelae such as poor pelvic repositioning and unequal length of both lower limbs, and now surgical treatment is advocated. From January 2005 to June 2009, 27 cases of TileC-type pelvic fractures were treated by incisional internal fixation, including 12 cases treated by simple posterior approach and 15 cases treated by expanded iliac inguinal approach.
1. Data and methods
1.1 Case data
There were 17 male and 10 female patients in this group; age ranged from 25 to 58 years old, with an average of 39.5 years old. Cause of injury: 17 cases of traffic accident, 9 cases of fall injury, and 1 case of smash and crush injury. According to the Tile typing criteria, there were 12 cases of C1 type, 4 cases of C2 type, 9 cases of C1+C2 type, and 2 cases of C3 type. There were 5 cases of combined vertebral fractures, 7 cases of extremity fractures, 1 case of posterior urethral injury, and 4 cases of rib fractures and hemothorax. Preoperative routine anteroposterior, entrance and exit pelvic radiographs were taken, and CT three-dimensional imaging was performed in all patients to get a detailed understanding of the fracture site, displacement, and the situation. All cases in this group were sacral and iliac fractures of the posterior ring or sacroiliac joint separation with displacement in the vertical direction, i.e. TileC type.
1.2 Preoperative management
Active treatment of life-threatening complications, rehydration and blood transfusion, emergency treatment of combined injuries, and continuous skin traction or bone traction of unilateral or bilateral lower limbs until the patient’s condition is stable. Psychological care was given before surgery, and antibiotics were routinely applied to prevent infection.
1.3 Surgical methods
1.3.1 Simple posterior approach group
Continuous epidural anesthesia or general anesthesia with tracheal intubation was used, the patient was placed in prone position, the abdomen was hollowed, an arc-shaped incision was made from the posterior superior iliac crest along the iliac crest outward and downward, the gluteus maximus muscle was peeled off subperiostally at the posterior end of the iliac crest, the gluteus medius muscle was distracted, the fracture end and sacroiliac joint were exposed, the fracture end and sacroiliac joint were repositioned under C-arm surveillance, and the anterior aspect of the sacroiliac joint was touched through the large sciatic incision to judge the repositioning situation, temporary fixation was performed with a Kirschner pin, and the pelvis was orthogonalized and After the pelvis is satisfactorily repositioned by pelvic entry position examination, it is fixed with 2~3 reconstructed titanium splints.
If needed, 1 hollow tension screw was added; for sacroiliac joint dislocation and sacral fracture, 1~2 sacral screws were used for fixation. Anterior pelvic ring fractures can generally be achieved with acceptable intraoperative traction, but significant displacement can affect the volume of the true pelvic ring and may interfere with the woman’s future reproductive process; therefore, they should be anatomically repositioned as much as possible in young women. Finally, repositioning and internal fixation are checked by fluoroscopy again, and the layers are repaired in turn, drained by placement of a tube and dressed with sterile dressings under pressure. Intraoperative blood transfusion was performed depending on the amount of bleeding.
1.3.2 Expanded iliac inguinal approach group
The patient was placed in the supine position, and the incision started about 3 CM above the pubic symphysis, extended laterally to the anterior superior iliac spine, and extended along the iliac crest to the junction of the middle and posterior 1/3, sharply peeling the abductor muscle and the iliac muscle at the end of the iliac crest, and subperiosteal peeling of the iliac muscle from the internal plate of the iliac bone, which could be peeled all the way to the sacroiliac joint as needed. The external oblique and rectus abdominis tendon membranes are incised inward along the skin incision and turned distally to open the inguinal canal, and the spermatic cord or round ligament is retracted to protect the lateral femoral cutaneous nerve, which is carefully identified and protected.
The inguinal ligament is carefully dissected in the direction of the inguinal ligament to avoid damaging the neurovascular underneath, and the internal oblique muscle, transversus abdominis muscle and fascia attached to the inguinal ligament are retracted upward to reveal the muscle cavity and vascular cavity underneath, bluntly separating the lateral iliopsoas muscle, the femoral nerve and the iliopubic fascia of the medial iliac artery and vein vessels, free dissecting the iliopubic fascia, and dissecting laterally under the iliopsoas muscle to reveal the quadrilateral area and the true pelvis The iliopubic fascia was dissected freely, and the quadrilateral area and true pelvis were exposed by lateral dissection under the external iliac vessels to the posterior pubic space.
The pelvic plate of appropriate length was selected, shaped and placed above the true pelvic rim and screwed in place. Finally, fluoroscopy was performed to check the reset and internal fixation, and each layer was repaired in turn, with tube drainage and sterile dressing with pressure. Intraoperative blood transfusion was performed depending on the amount of bleeding.
1.4 Postoperative treatment
Anti-inflammatory, anti-swelling, blood transfusion, depending on the wound drainage 2~3 days later, the drainage tube was discharged, during which light bed activities were feasible, and the anterior-posterior, entrance and exit X-ray of the pelvis were reviewed in the first and third weeks after surgery, respectively.
2. Results
All patients were followed up from 6 months to 24 months, with an average of 12.6 months. During the follow-up period, all patients had satisfactory results and resumed their daily work ability without any complications such as secondary displacement, plate fracture, shortening of the affected limb, pelvic tilt, or lower back pain. When comparing the two approaches (see the table), there were significant differences in the operative time, intraoperative bleeding and incision length between the two groups (P<0.05), and the simple posterior approach was superior to the expanded iliac groin approach, while the time to the ground and hip function were not statistically significant between the two groups (P>0.05).
4. Discussion
Pelvic fractures are often caused by the direct action of tremendous violence, compression or impact on the pelvis, and their treatment has been a clinical challenge due to the severity of most injuries, high morbidity and mortality rates, and frequent complications. In the past, pelvic fractures were treated conservatively, such as bone traction, pelvic suspension, and plaster fixation, with a high disability rate [1]. The development of internal fixation technique for pelvic fractures was slow, and it was only gradually and widely used in foreign countries in the 1980s and rapidly developed in China in the late 1990s, and now there is a consensus on the treatment of unstable pelvic fractures with incision and internal fixation [2].
The correct pelvic fracture typing is the key to determine the treatment plan, and the Tile classification is most commonly used at present. tile classifies pelvic injuries into 3 types of stable, rotationally unstable and vertically unstable injuries according to the stability of the pelvis and the injury site, and further divides them into subtypes. Among them, Tile type C, the vertically unstable pelvic fracture, is the most serious type of pelvic fracture in which the anterior ring pubic symphysis is separated or the upper and lower pubic and sciatic branches are fractured and the posterior ring sacrum and iliac bone is fractured or the sacroiliac joint is separated and displaced in the vertical direction.
Tile [3] proposed vertical unstable pelvic fractures as an absolute indication for incisional internal fixation; recently, with the study of the anatomy and biomechanics of pelvic fractures and the mechanism of injury, more and more scholars are taking a more aggressive treatment. The aim of surgical treatment of vertically unstable pelvic fractures is to correct deformity, early activity, prevent late pelvic instability and bone nonunion, and strive for pain-free and functionally satisfactory treatment. matta et al [4] found in a group of comparative efficacy studies that for posterior pelvic arch injuries, the satisfaction rate of surgical treatment was 96%, which was significantly better than other treatments, and therefore advocated the use of incisional internal fixation for displaced and unstable pelvic fractures. Korovessis et al [5] treated 74 cases of unstable pelvic injuries with incisional internal fixation and obtained satisfactory radiological results in 90% of the patients.
In the present study, 12 cases were treated with a simple posterior approach and achieved good clinical results, with no significant difference in efficacy compared to the group with an expanded iliac groin approach. However, the simple posterior approach group was better than the expanded iliac inguinal approach group in terms of surgical incision, operative time, and intraoperative bleeding.
Therefore, in clinical practice, for TileC-type pelvic fractures, the application of simple posterior approach with incision and internal fixation posterior ring treatment can achieve the expected surgical results with less trauma and relative safety, which is a reference method for internal fixation. However, due to the small amount of case data and too short follow-up time in this group, the indications and long-term efficacy of using a simple posterior approach to fix the posterior ring for TileC-type pelvic fractures still need to be further explored.