الفهرس 
Sequential examination under anesthesia as a method to determine management plan for lateral compression pelvic ring injuries
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Abstract
Background: Pelvic ring fractures comprises about 3% of adult fractures. Lateral compression (LC) pelvic fractures are the most common pelvic fractures, particularly lateral compression type 1 (LC 1) which represents two-thirds of all pelvic ring injuries. There is no wide accepted fixation strategy for LC pelvic ring injuries, with growing interest in examination under anesthesia (EUA) owing to its effectiveness. Sequential EUA can be reliable in detecting pelvic instability and determining method of fixation for LC cases.
Objective: To evaluate reliability of sequential pelvic examination under anesthesia to determine intra-operative pelvic instability and management plan and evaluating radiological and functional outcome in cases of isolated lateral compression pelvic fractures.
Methodology: A prospective case series/ single-arm clinical study was conducted from June 2020 to July 2021 at Cairo university hospital to evaluate reliability of sequential pelvic examination under anesthesia to determine intraoperative pelvic instability and management plan of lateral compression pelvic fractures. In this study, 40 cases with lateral compression pelvic fractures (inclusion criteria: LC 1 with complete fracture sacrum, LC 2 or LC 3) were examined to evaluate the radiological and functional outcome of these patients. Each patient was followed up for a minimum of one year.
Results: Patients were categorized in either 2 groups; group A (posterior only fixation) contained 26 cases (12 cases of LC 1 and 14 cases of LC 2) and group B (combined posterior and anterior fixation) contained 14 cases (10 cases of LC 1 and 4 cases of LC 2).Posterior fixation was done using trans-ilial internal fixator (TIFI), iliosacral screw or double sacroiliac plates, while anterior fixation was done using anterior infix or external fixator. Five cases
(19 %) of posterior only fixation group have shown secondary displacement of mean 5.88mm ± 0.70 mm (range from 5 – 6.9 mm) while none of cases has shown secondary displacement in combined posterior and anterior fixation group with no statistically significant difference between both groups, (P value=0.143). Four cases (out of 5 cases with secondary displacement) had tetra-ramic anterior ring injury which was a statistically significant difference. We have found that at 14.5 mm or more preoperative initial displacement at the anterior ring, there is high tendency for secondary displacement. Both study groups attained union. For posterior only fixation group, the mean time to union was 13 ± 2.14 weeks while for combined posterior and anterior fixation group; mean of 13.14 ± 2.32 weeks, with no statistically significant difference.
Patients with secondary displacement have shown comparable functional outcome scores; Majeed score at 6 months, one year and pelvic outcome score at one year, to patients with no secondary displacement with no statistically significant difference. Both study groups showed comparable results in functional outcome scores. In posterior only fixation group, Majeed score at one year had mean of 92.73 ± 3.38 while in combined posterior and anterior fixation; mean of 90.07 ± 4.38 with no statistically significant difference. The mean of pelvic outcome score at one year was 33.54 ± 2.35 in posterior only fixation group while 33.29 ± 2.09 in combined posterior and anterior fixation with no statistically significant difference.
Posterior only fixation group showed shorter operative time, lesser radiological exposure, lesser blood loss (when using TIFI or iliosacral screw for posterior fixation) and lesser iatrogenic nerve injury compared to combined posterior and anterior fixation group.
Conclusion: We recommend EUA as a reliable method to determine intraoperative pelvic instability and management plan for LC pelvic ring injuries containing unilateral anterior ring injury (whether ipsilateral or contralateral), as it results in union of fractures without major displacement and with comparable functional outcomes. We recommend combined posterior and anterior fixation if there is tetra-ramic fracture or initial preoperative anterior ring displacement of 14.5 mm or more, regardless the result of EUA, as there is a high tendency for secondary displacement in both situations. Posterior only fixation , if feasible to provide rigid fixation according to EUA, has the advantages of shorter operative time, lesser radiological exposure, lesser blood loss (when using TIFI or iliosacral screw) and lesser iatrogenic nerve injury compared to combined posterior and anterior fixation, with comparable functional outcome scores.