Is there a gold standard for addressing the anterior ring when surgical fixation occurs for Young-Burgess lateral compression type 1 (LC1; AO/OTA 61-B1/B2) pelvic ring injuries?

Abstract

To determine if (1) fixation of the anterior ring is required, (2) is indirect (external fixator or InFix) or internal fixation favored, and (3) are there differences between long and short percutaneous screws for stabilization of the anterior ring in patients receiving surgical fixation of lateral compression type 1 (LC1) pelvic ring injuries when the posterior ring is stabilized? A retrospective review of all acute LC1 (AO/OTA 61-B1/B2) pelvic ring injuries from January 2019 to January 2024 managed operatively with posterior ring fixation at Two Level I Trauma Centers. Indications for operative management were radiographic evidence of instability or a failed "trial of mobilization." Minimum three month follow-up and until confirmation of radiographic healing was required. Anterior-posterior, inlet and outlet radiographic imaging at initial, post-operative and final follow-up were assessed. The primary outcome measure was the presence of pelvic ring deformity defined as >1 cm of medial pelvic ring displacement from immediate post-operative radiographs to final radiographs showing fracture healing. Secondary outcomes were major unplanned surgical procedures (reoperation for loss of fixation, deformity, non-union repair, removal of symptomatic implants or infection) and other surgical complications. It was recorded if anterior ring fixation was applied and whether fixation was indirect (external fixator or InFix) or internal. Percutaneous screws were noted to be antegrade or retrograde, and length noted (long or short). A comparison of outcome measures was made between the different anterior ring constructs. 120 patients were included; most were female (n = 69; 58 %) and the mean age was 63.9 years (18.6SD, range 17-93). Surgical fixation of the anterior ring was most common (n = 86, 72 %) and produced lower rates of deformity compared with no fixation (20 % vs. 41 %, p = 0.016), despite the presence of an increased amount of superior ramus fracture comminution (48 % vs. 26 %, p = 0.034) and unstable superior ramus fracture patterns (p = 0.034). Indirect fixation (n = 15, 17 %) had a higher rate of deformity relative to internal fixation (n = 71, 83 %) (53 % vs. 13 %, p < 0.001). A long percutaneous screw (n = 50, 72 %) was most often applied antegrade (p = 0.014), and long screws had lower rates of deformity when compared with short screws (n = 19, 28 %) (4 % vs. 32 %, p = 0.004). When surgical fixation of LC1 injuries was indicated, the application of anterior ring fixation in conjunction with posterior ring fixation decreased the risk of fracture displacement. Long percutaneous screws stabilizing the anterior ring best maintained reduction and prevented deformity. Level III, therapeutic study.