Closed Reduction and Minimally Invasive Fixation for the Treatment of Bilateral Displaced Posterior Pelvic Ring Disruption

Abstract

Objective

Close reduction and internal fixation have gained popularity for the treatment of pelvic fractures. However, the closed reduction of bilateral displaced posterior pelvic ring disruption is a great challenge even for the most experienced surgeon. In this study, we describe in detail a novel unlocking closed reduction technique (UCRT) frame that allows strong traction for bilateral posterior pelvic ring displacement and presents preliminary clinical outcomes.

Methods

We retrospectively reviewed 32 patients with bilateral displaced posterior pelvic ring disruptions (AO/OTA 61-C2 and C3) who were initially treated with this technique between July 2017 and July 2022. According to the AO/OTA classification, there were 9 cases (28.12%) of 61-C2, and 23 cases (71.88%) of 61-C3. There were 11 males, 21 females, with an average age of 38.1 years. The interval from injury to operation was 4-27 days, with a cut-off of 12.5 days (receiver operating characteristic curve). Operative time, blood loss, and postoperative radiographic findings were recorded. The functional outcomes and complications were followed.

Results

A total of 30 (93.8%) patients achieved successful closed reduction, whereas 2 required open reduction. The successful closed reduction rate was 95.5% (21/22) in patients whose injury-to-operation time was less than 12.5 days. The vertical displacement percent correction of the obviously displaced hemipelvis was 70.20% ± 16.79% on average. The average degree of pelvic deformity correction was 64.86% ± 17.71%. Thirty patients were followed up for at least 12 months (12-36 months), and no complications of nonunion or redisplacement were observed. The Matta-Tornetta scoring standard revealed that the excellent (25/30) and good (4/30) rate was 96.7%. The Majeed clinical efficacy score revealed that the overall excellent and good rate was 100%. One patient had INFIX-related infection, and 2 reported numbness in the lateral thigh. The numbness was improved after INFIX removal.

Conclusions

This study presents an updated technique for closed reduction using a UCRT frame for bilateral posterior pelvic ring disruption, which has been shown to be effective, as indicated by excellent surgical and functional outcomes.

Keywords

Pelvic fractures / Unlocking closed reduction technique / Minimally invasive internal fixation

© The Author(s), under exclusive licence to Huazhong University of Science and Technology 2025

Acknowledgements Not applicable.

Author Contributions Zhen Wang: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Visualization, Writing - original draft, Writing - review & editing. Zhe Xu: Conceptualization, Investigation, Methodology, Resources, Writing - original draft. Peng-hui Xiang: Conceptualization, Methodology, Project administration, Resources, Validation, Writing - original draft. Mei-qi Gu: Conceptualization, Investigation, Methodology, Resources, Validation, Writing - original draft. Rui Zhang: Conceptualization, Methodology, Project administration, Resources, Supervision, Validation, Writing - original draft. Hua Chen: Conceptualization, Data curation, Investigation, Project administration, Resources, Supervision, Validation, Writing - original draft. Li He: Conceptualization, Data curation, Investigation, Methodology, Project administration, Resources, Supervision, Writing - original draft, Writing - review & editing. Cheng-la Yi: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing.

Funding This work was supported by the National Key Research and Development Program of China (2022YFC2504303); Innovation Foundation of National Clinical Research Center for Orthopaedics, Sports Medicine & Rehabilitation (2021-NCRC-CXJJ-ZH-24); Medical Innovation and Transformation Incubation Project of Tongji Hospital (2022ZHFY10). The funding organization had no role in the design and conduct of the study.

Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Conflict of Interest The authors declare that they have no competing interests.

Ethics Approval Written informed consent was obtained from all participants and was approved by the Institutional Review Board of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (TJ-IRB20231168).

Consent for Publication Not applicable.

References

[1] Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries. Injury. 2004; 35(7):671-677.

[2] Kabak S, Halici M, Tuncel M, et al. Functional outcome of open reduction and internal fixation for completely unstable pelvic ring fractures (type C): a report of 40 cases. J Orthop Trauma. 2003; 17(8):555-562.

[3] Verbeek DO, Routt ML, Jr. High-Energy Pelvic Ring Disruptions with Complete Posterior Instability: Contemporary Reduction and Fixation Strategies. J Bone Joint Surg Am. 2018; 100(19):1704-1712.

[4] Stahel PF, Hammerberg EM. History of pelvic fracture management: a review. World J Emerg Surg. 2016; 11:18.

[5] Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br. 1988; 70(1):1-12.

[6] Matta JM, Tornetta P, 3rd. Internal fixation of unstable pelvic ring injuries. Clin Orthop Relat Res. 1996; 329:129-140.

[7] Kellam JF, McMurtry RY, Paley D, et al. The unstable pelvic fracture. Operative treatment. Orthop Clin North Am. 1987; 18(1):25-41.

[8] Routt ML Jr, Simonian PT. Closed reduction and percutaneous skeletal fixation of sacral fractures. Clin Orthop Relat Res. 1996; 329:121-128.

[9] Abou-Khalil S, Steinmetz S, Mustaki L, et al. Results of open reduction internal fixation versus percutaneous iliosacral screw fixation for unstable pelvic ring injuries: retrospective study of 36 patients. Eur J Orthop Surg Traumatol. 2020; 30(5):877-884.

[10] Thaunat M, Laude F, Paillard P, et al. Transcondylar traction as a closed reduction technique in vertically unstable pelvic ring disruption. Int Orthop. 2008; 32(1):7-12.

[11] Lefaivre KA, Starr AJ, Barker BP, et al. Early experience with

[12] i.reduction of displaced disruption of the pelvic ring using a pelvic reduction frame. J Bone Joint Surg Br. 2009; 91(9):1201-1207.

[13] Boudissa M, Roudet A, Fumat V, et al. Part 1: Outcome of Posterior Pelvic Ring Injuries and Associated Prognostic Factors A Five-Year Retrospective Study of One Hundred and Sixty Five Operated Cases with Closed Reduction and Percutaneous Fixation. Int Orthop. 2020; 44(6):1209-1215.

[14] Chen H, Zhang Q, Wu Y, et al. Achieve Closed Reduction of Irreducible, Unilateral Vertically Displaced Pelvic Ring Disruption with an Unlocking Closed Reduction Technique. Orthop Surg. 2021; 13(3):942-948.

[15] Chen H, Zhang Q, Hao M, et al. A multicenter retrospective study assessing pelvic unlocking closed reduction device for reducing unstable pelvic posterior ring disruption. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi (Chinese). 2022; 36(11):1327-1334.

[16] Luo Y, Chen H, He L, et al. Displaced posterior pelvic ring fractures treated with an unlocking closed reduction technique: Prognostic factors associated with closed reduction failure, reduction quality, and fixation failure. Injury. 2023; 54(Suppl 2):S21-S27.

[17] Matta JM. Indications for anterior fixation of pelvic fractures. Clin Orthop Relat Res. 1996; 329:88-96.

[18] Dyck PJ, Hughes RAC, O'brien PC. Quantitating overall neuropathic symptoms, impairments, and outcomes. In: Dyck PJ, Thomas PK, Peripheral Neuropathy. 4th ed. Philadelphia: Elsevier Saunders; 2005.

[19] Coccolini F, Stahel PF, Montori G, et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg. 2017; 12:5.

[20] Lefaivre KA, Blachut PA, Starr AJ, et al. Radiographic displacement in pelvic ring disruption: reliability of 3 previously described measurement techniques. J Orthop Trauma. 2014; 28(3):160-166.

[21] Nystrom LM, McKinley TO, Marsh JL. Accuracy in radiographic assessment of pelvic ring fracture deformity: analysis of current methods. J Orthop Trauma. 2013; 27(12):708-715.

[22] Steelman K, Bray R, Vaidya R. Technical Note on Placement of Low-Profile Triangular Osteosynthesis for Unstable Posterior Pelvic Ring Injuries. J Orthop Trauma. 2022; 36(8):e337-e342.

[23] Vaidya R, Oliphant BW, Hudson I, et al. Sequential reduction and fixation for windswept pelvic ring injuries (LC3) corrects the deformity until healed. Int Orthop. 2013; 37(8):1555-1560.

[24] Majeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg Br. 1989; 71(2):304-306.

[25] Giannoudis PV, Tzioupis CC, Pape HC, et al. Percutaneous fixation of the pelvic ring: an update. J Bone Joint Surg Br. 2007; 89(2):145-154.

[26] Keating JF, Werier J, Blachut P, et al. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma. 1999; 13(2):107-113.

[27] Dahill M, McArthur J, Roberts GL, et al. The use of an anterior pelvic internal fixator to treat disruptions of the anterior pelvic ring: a report of technique, indications and complications. Bone Joint J. 2017; 99-b(9):1232-1236.

[28] Vaidya R, Kubiak EN, Bergin PF, et al. Complications of anterior subcutaneous internal fixation for unstable pelvis fractures: a multicenter study. Clin Orthop Relat Res. 2012; 470(8):2124-2131.