Session VIII - Pelvis
Long-term Functional Outcome following Severe Pelvic Trauma: A Comparison of Vertical Shear Fractures to APC-III, LC-III, and Complex Acetabular Fractures
Purpose: This study was conducted to analyze the long-term functional outcome of vertical shear fractures in comparison to other forms of severe pelvic injuries APC-III, LC-III, and complex acetabular fractures.
Methods: We identified 31 vertical shear fractures in 29 consecutive patients and compared them with 34 patients with APC-III, 32 patients with LC-III, and 32 patients with complex (at least bicolumnar) acetabular fractures to form the control group, who were matched for age and sex with the vertical shear fracture group. The mean follow-up was 62 months. Functional outcome was assessed in all patients using the following generic outcome measurement tools: EuroQol EQ-5D, SF36 v2 (short form), VAS, SMFA (Short Musculoskeletal Functional Assessment), and Majeed score. In addition, Merle d' Aubign and Postel scores (Matta, 1986) and radiologic degenerative hip scores (Matta, 1994) were used to assess patients with acetabular fractures.
Results: The mean age of all the patients in the study was 43.5 years (range, 16 to 71 years) and the median injury severity score was 22 (range, 12 to 32). All patients had their pelvic ring stabilized at least temporarily within 24 hours and all acetabular fractures were reduced and stabilized by 7 days. Functional outcome was assessed in all members of the control group and in 28 of 29 patients in the vertical shear fracture group. In the vertical shear fracture group, 35% of the patients have returned to their previous jobs (49% in control group), 30% have changed their professions (30% in control group), and 25% (14% in control group) have retired from regular work. In the acetabular group, 10 patients (31%) had neurologic injury (6 sciatic, 3 common peroneal, 1 femoral); of these, 4 were iatrogenic. Six patients had complete neurologic recovery. Heterotopic ossification was seen in 19 patients (59%). Three patients (9%) with acetabular fractures (all had associated posterior wall fracture) had total hip replacements at 29, 40, and 51months. The clinical outcome of patients in the acetabular fracture group was 5 excellent (3 THA), 4 good, 13 fair, and 10 poor. The radiologic score of degenerative hip disease (Matta, 1994) for the acetabular fracture group was 4 excellent, 8 good, 14 fair and 3 poor. Analysis of the functional outcome is shown in Table 1.
Table 1*Functional Outcome Analysis
| VS | LC-III | AP-III | Acetab | Vertical shear (VS) fractures vs. | ||||
| LC-III | AP-III | Acetab | Norm | |||||
| EQ-5D | ||||||||
| Description score | 0.43±0.12 | 0.63±0.18 | 0.69±0.11 | 0.49±13 | P>0.05 | P=0.03 | P>0.05 P=0.001 | |
| Valuation score | 46.1±19.4 | 62.3±21.9 | 78±11.4 | 51.4±11.2 | P>0.05 | P=0.02 | P>0.05 | P=0.002 |
| SF36 v2 | ||||||||
| Physical health | 44.4±19.3 | 62.5±11.3 | 78.3±9.6 | 54.2±16.3 | P=0.04 | P=0.02 | P>0.05 | P=0.005 |
| Mental health | 46.2±12.1 | 68±19.2 | 76.5±15.7 | 56.3±10.7 | P>0.05 | P=0.03 | P>0.05 | P=0.001 |
| SMFA | ||||||||
| Dysfunction index | 63.3±11.3 | 44.6±11.2 | 38.3±17.3 | 54.1±19.8 | P>0.05 | P=0.01 | P>0.05 | P=0.006 |
| Bother index | 60.5±13 | 49±13.2 | 34.2±11.9 | 57.2±14.3 | P>0.05 | P=0.02 | P>0.05 | P=0.002 |
Conclusion: Patients with vertical shear fractures represent the spectrum of high-energy pelvic disruption. The functional outcome is significantly better in patients with APC-III and LC-III fractures compared to vertical shear and complex acetabular fractures, reflecting the severity of the injury. Secondary osteoarthritis and neurologic injury appear to contribute to the poor outcome of acetabular fractures. Sound reconstruction of the pelvic ring is not always associated with good results, probably due to the extensive pelvic floor trauma.