Hassan R. Mir, MD, MBA, FACS
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2 DISCLOSURES Hassan R. Mir, MD, MBA, FACS Paid Consultant for a Company or Supplier Smith & Nephew Zimmer Biomet Trice Medical Stock or Stock Options Core Orthopaedics OrthoGrid Systems Research Support from a Company or Supplier AO Trauma North America Smith & Nephew Medical/Orthopaedic Publications Editorial/Governing Board JOT Associate Editor JAAOS Consultant Reviewer JBJS Consultant Reviewer OsteoSynthesis, The JOT Online Discussion Forum Editor OTA International Digital Editor Board Member/Committee Appointments for a Society AAOS HealthCare Systems Committee AOA Leadership / Fellowships Committee OTA Education Committee, Board of Specialty Societies FOT Research Committee Special Thanks to Dr. Frank Avilucea for Select Slides/Images
3 3 Months
4 3 Months
5 12 Months
6 Pelvic Stability one that could withstand the physiologic forces incurred with protected weightbearing, and/or bed to chair mobilization without abnormal deformation of the pelvis, until bony union or soft tissue healing could occur. - Olson SA, Pollak AN. Assessment of pelvic ring stability after injury: indications for surgical stabilization. Clin Orthop Relat Res. 1996;329:
7 Pennal and Tile Vector APC, LC, VS Tile Stability A,B,C Young and Burgess Subgroups I, II, III Classification Schemes
8 OTA Classification APC LC
9 Classification Based on Static Radiographs and CT Binders/Sheets can Mask True Extent of Injury Pelvic Recoil is Significant 48% for APC 80% for LC
10 APC Pelvic Ring Injury Increasing Instability
11 APC Stability Historically Based on Cadaveric Video Studies APC I <2.5 cm Posterior and Floor Ligaments Intact (ST, SSp, ASI, PSI) APC II >2.5 cm Posterior and Floor Ligaments Partially Disrupted (ST, SSp, ASI) PSI Intact*
12 APC Stability
13 APC Stability
14 APC Stability Which APC-1 s are Occult APC-2 s? Which APC-2 s have Attenuated PSI Ligaments and Multiplanar Instability?
15 EUA Supine AP, Inlet, Outlet 5 views in each Plane Static IR ER Push Pull
16 EUA 7/14 APC-1 s (50%) found Unstable >2.5 cm Horizontal Rotation Anterior Fixation 9/23 APC-2 s (39%) found Unstable >1cm Vertical & >2.5cm Horizontal Rotation A/P Fixation
17
18
19 6/22 (27%) patients with APC-1 Found Unstable
20 24 yom Case
21 CT Case
22 EUA Case
23 Healed Case
24 53 yom Case
25 CT Case
26 EUA Case
27 Postop Case
28 Healed Case
29 VS
30 No Difference
31 Failure of Fixation and Subsequent Malunion Anterior Plate Only Anterior Plate + Iliosacral Screw # Patients NS Anterior Fixation Failure 17 (40.4%) 5 (5.4%) < Malunion 15 (35.7%) 1 (1.08%) < P
32 Latency of Implant Failure
33 My Current APC Treatment Stable on EUA (<2.5 cm horizontal and <1 cm vertical) Nonop WBAT Unstable on EUA (>2.5 cm horizontal or >1 cm vertical) Anterior and Posterior Fixation TDWB / Foot Flat x 12 Weeks on Posterior Injured Side
34 Lateral Compression Pelvic Ring Injury Increasing Instability
35 LC Stability LC-1 Historically Thought to be Vertically Stable Treated Nonoperatively 1.5 cm Shortening Acceptable
36 Late Displacement >5mm LC Stability
37 LC Stability Which LC Injuries are Unstable? Which Ones Need Fixation?
38 EUA Supine AP, Inlet, Outlet 5 views in each Plane Static IR ER Push Pull
39 EUA 7/20 LC-1 s (35%) found Unstable >1 cm Overlap Anterior Fixation Only (n=1) >2cm Overlap A/P Fixation (n=6) 5/8 LC-2 s (63%) found Unstable Any Displacement A/P Fixation
40 EUA Limitations Natural History after Negative EUA? Can EUA guide fixation strategy? Posterior / Anterior Fixation?
41 Investigate the utility of a negative EUA APC: <2.5 widening of symphysis LC-1: < 1cm ramus overlap LC-2: no displacement Bilateral WBAT
42
43 Negative Predictive Value 100% Static Internal Stress
44
45 Background Methods Results Discussion Research Question LC Pelvic Fractures When Should the Posterior and Anterior Pelvic Ring be Fixed in Unstable LC injuries?
46 Background Methods Results Discussion Hypothesis Sequential EUA Guides Fixation Strategy with Good Results
47 Background Methods Results Discussion Lateral Compression Pelvic Ring Injury Treatment Algorithm (Sagi) Pelvic EUA > 1cm Pelvic Displacement for LC-1 fractures, or any Pelvic Displacement for LC-2/LC-3 injuries
48 Background Methods Results Discussion Lateral Compression Pelvic Ring Injury Treatment Algorithm (Sagi) Pelvic EUA > 1cm Pelvic Displacement for LC-1 fractures, or any Pelvic Displacement for LC-2/LC-3 injuries Posterior Pelvic Fixation Treatment Algorithm (Mir) Repeat Pelvic EUA Anterior Displacement <1cm Anterior Ring Displacement >1cm No Further Fixation Anterior Pelvic Fixation (Repeat Pelvic EUA if Bilateral Injury)
49 Background Methods Results Discussion Mother (50 yof) and Son (18 yom) in MVC Each with Unilateral Complete Sacral Fx and Bilateral Anterior Fxs on CT
50 Background Methods Results Discussion Mother 12 Months No Displacement
51 Background Methods Results Discussion 6 Weeks 8mm Displacement Son 12 Months
52 Background Methods Results Discussion 74 Patients 72 LC-1/LC2 2 LC-3 36 Ant + Posterior 36 Posterior Only 1 Ant + Posterior 1 Posterior Only Unilateral Ramus Fracture No Displacement Unilateral Ramus Fracture Bilateral Ramus Fracture No Displacement No Displacement 27 No Displacement 9 Displaced
53 Background Methods Results Discussion Conclusions Pelvic Fractures are Dynamic Sequential EUA Guides Fixation Strategy Consider Fixation if Bilateral Anterior Injuries
54 My Current LC Treatment Incomplete Sacral Fracture Nonop WBAT If they can t mobilize, then EUA Complete Sacral Fracture EUA by Sequential Protocol TDWB / Foot Flat x 12 Weeks on Posterior Injured Side
55 Conclusions Pelvic Injuries are Dynamic Static Evaluation Poorly Predictive of Instability (Xray, CT, MRI) EUA can Guide Need for Fixation Op vs Nonop for APC and LC Sequential EUA can Guide Fixation Strategy Posterior vs Anterior+Posterior for LC Anterior+Posterior for All APC* Effect on Functional Outcomes? More Studies Needed
56 THANK YOU Hassan R. Mir, MD, MBA, FACS
6/5/2018. DISCLOSURES Hassan R. Mir, MD, MBA, FACS. Evolution of Distal Radius Fracture Treatment [Chung Hand Clinics 2012]
![6/5/2018. DISCLOSURES Hassan R. Mir, MD, MBA, FACS. Evolution of Distal Radius Fracture Treatment [Chung Hand Clinics 2012]](/thumbs/83/87610068.jpg "6/5/2018. DISCLOSURES Hassan R. Mir, MD, MBA, FACS. Evolution of Distal Radius Fracture Treatment [Chung Hand Clinics 2012]")
DISCLOSURES Hassan R. Mir, MD, MBA, FACS Paid Consultant for a Company or Supplier Smith & Nephew Zimmer Biomet Trice Medical Stock or Stock Options Core Orthopaedics OrthoGrid Systems Research Support
Principles Starting Point Trajectory L/A/R Stable Construct. DISCLOSURES Hassan R. Mir, MD, MBA, FACS 5/16/2017
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DISCLOSURES Hassan R. Mir, MD, MBA, FACS
DISCLOSURES Hassan R. Mir, MD, MBA, FACS Medical/Orthopaedic Publications Editorial/Governing Board OTA Newsletter Editor OsteoSynthesis, The JOT Online Discussion Forum Editor JOT Associate Editor JAAOS
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