Discussion
death, pelvic fractures, pain, Tile B1, fractures, trauma
RECRUITMENT, APC, MEDICAL COMPLICATION
The aim of this study was to compare clinical outcomes as well as the one-year mortality of comprehensive conservative versus surgical treatment of low-energy posterior pelvic ring fractures that are typically found in older populations. We found no significant difference between the surgically and conservatively treated groups in need of care (Barthel Index), level of pain (VAS), quality of life (EQ5D), gait performance (Tinetti) and in terms of mortality.Our data showed that non- to minimally displaced fractures of the posterior pelvic ring have a major impact on the patient’s well-being, which is reflected in all measured scores. However, pain improvement occurred quickly, usually within the first 6 weeks. It was achieved slightly faster in the surgical group and remained generally low after one year. The restoration of mechanical stability of the posterior pelvic ring using surgical stabilization is a well-established treatment for unstable pelvic fractures caused by high-velocity traumaRommens et al.Successful surgical fixation via a transiliosacral bar, sacroiliac screw, or a triangular osteosynthesis of the posterior pelvic ring has already been described and validated in this particular cohort by the literature in recent yearsThe utilization of external fixation for stabilizing the anterior pelvic ring has become an established practice in the management of high-velocity trauma, particularly in cases involving open book fractures (Tile B1 or APC I) in young adults, as part of damage control surgeryOur primary objective was to pursue a minimally invasive approach, but it is essential to acknowledge that alternative techniques for stabilizing the anterior pelvic ring exist. These include open reduction and internal fixation using contoured plates or minimally invasive retrograde transpubic screw fixation that show adequate pain reliefThe Barthel index was lower in the surgical patients in the first 6 weeks, which may be explained by the external fixator interfering with upright sitting and the daily pin care. However, the patient quality of life with an external fixation device was not found to be worse when compared to the conservative group.The primary endpoint of our study was patient mortality during the 12-month follow-up period. An overall mortality of 4 out of 39 patients (10%) was measured, with three patients dying in the ST group, and one in the CCT group. It is known that immobilization, even for only 24 to 48 h, is one of the main risk factors for death in frail patients due to medical complications after a proximal femur fractureThere are retrospective studies from the early 2000s without adequate diagnostics that investigated unilateral pubic ramus fractures in patients immobilized and hospitalized due to painThere are several limitations to our study. First, the number of patients included is not as high as was deemed necessary in our a priori analysis (n = 130), mainly due to the study participants not willing or able to be randomized and the COVID-19 pandemic, which forced us to discontinue recruitment and follow-up. This must be considered when interpreting the results of this randomized controlled trial, as its design is underpowered. However, this study represents the first attempt to prospectively investigate FFP II fractures. As usual when studying frail patient groups recruitment is difficult. Therefore, the information provided in this paper may likely add scientific information to the field of pelvic surgery, although it is underpowered. Secondly, we had a 25% loss of follow-up, which is not unusual in geriatric cohorts. Nevertheless, the achieved follow-up rate is still representative, especially in this older population. Thirdly, we conducted a non-blinded follow-up and evaluation because the nature of the surgery did not allow for blinded follow-up. Understandably, sham surgeries would have been unethical in a cohort of elderly with a number of pre-existing conditions. There are also some noteworthy strengths of our study. Most prominently, this is the first study to examine this emerging injury in a prospective manner without the surgical selection bias often seen in previous publications.