OTA 2002 Posters

Combined Injuries of the Pelvis and Acetabulum: Demographics, Acute Outcome, and Functional Data of the Tile C3 Pelvis Fracture

Mark J. Leber, MD; Wade R. Smith, MD¹; Bruce H. Ziran, MD²; Daniel S. Horwitz, MD³; Steven J. Morgan, MD¹; Jennifer Kumar, MS; ¹University of Colorado Health Science Center, Denver, Colorado, USA ²University of Pittsburgh, Pittsburgh, Pennsylvania, USA ³University of Utah, Salt Lake City, Utah, USA

Purpose: Several well-accepted classification systems have been described for both pelvic and acetabular fractures. The Tile classification includes type C pelvic injuries, which are rotationally and vertically unstable. There is no report in the literature describing the Tile C3 injury and analysis of its outcome. These fractures present unique management and reconstructive issues.

Methods: Prospective pelvic registries at three level-I trauma centers were reviewed, including records of all patients admitted from 1997 to 2000 with a diagnosis of Tile C3 pelvic fracture or acetabular fracture. Thirty-six patients with an average age of 35 years had combined pelvic and acetabular fracture requiring hospital admission. Demographic data collected included age, location of injuries, mechanism of injury, associated injuries, Injury Severity Score (ISS), transfusion requirements, review of radiographic classification, type of operative procedures, timing and length of procedures, angiographic data, complications, mortality rate, and discharge disposition. Outcome data were then obtained an average of 31.4 months (range, 20 to 66) after injury from 21 of the 34 remaining patients (62%). Both the SF-36 and SMFA questionnaires were used to determine the functional status of the patients.

Results: The average ISS of the patients was 24 (range, 9 to 51). Thirty-five patients had significant associated injuries, including extremity fractures, head injury, pneumothorax, spine fracture, and abdominal organ and urogenital injuries. Pelvic arteriography was performed in 11 of the 36 patients (30.5%), and 4 (11.1%) were positive, requiring embolization. Seven patients were treated with acute mechanical stabilization (18%). Patients required an average of 10 units of packed red blood cells (range, 0 to 54 units), 3.2 units of fresh frozen plasma (range, 0 to 30), and 1.9 packs of platelets (range, 0 to 14). The average hospital stay was 17.4 days (range, 0 to 55). The survival rate was 94.4%, with the two deaths occurring on hospital day 10 and 15. Perioperative morbidity was seen in 18 (50%) of the patients, which included infection (8), pneumonia (4), deep venous thrombosis (1), compartment syndrome (1), hip dislocation (1), and heterotopic ossification. In the majority of injuries, combined approaches were performed, allowing the pelvis and acetabular injuries to be addressed simultaneously. Patients were grouped into those that required fixation of either the pelvic or acetabular fractures or both. There were eight patients (22%) with unstable acetabular and stable pelvic fractures (Type I), 5 patients (14%) with unstable pelvic and stable acetabular fractures (Type II), and 23 patients (64%) with both unstable pelvic and acetabular fractures (Type III). When the population of patients was taken as a group, the results showed that, overall, these patients do poorly even at 2-year follow-up, with decreased SF-36 scores. Furthermore, when the patients were divided into three groups, the prognosis was worse for patients with both unstable pelvic and acetabular fractures (Type III). Patients with type III injuries had twice the re-operation rate, most commonly a total hip arthroplasty.They also had a longer recovery time and were able to ambulate in 4 months, compared with 2 1/2 months in type II and I patients.

Discussion/Conclusion: Patients with combined pelvic and acetabular fractures have high injury severity, lengthy ICU stays, and aggressive blood replacement requirements. We found three distinct anatomic patterns of injury within the Tile C3 classification: type I, unstable acetabular fracture with stable pelvic injury; type II, stable acetabular fracture with unstable pelvic injury, and type III, unstable acetabular fracture with unstable pelvic injury. Type III injuries represent a high-energy variant that may require combined approaches and careful preoperative consideration of the sequence of fixation. Follow-up data demonstrated that Tile C3 fractures appear to behave in three distinct ways with a significantly worse prognosis for those that require stabilization of both the pelvis and acetabulum regardless of the ISS score on admission.