The superior gluteal artery is particularly at risk in pelvic fractures and surgical procedures. We report on a 74-year-old male patient with an unstable pelvic ring fracture, initially treated with an external fixator and bilateral sacroiliac (SI) screws. Postoperatively, persistently elevated inflammatory markers and a persistently low hemoglobin level suggested a hematoma most likely from an iatrogenic cause. Computed tomography (CT) imaging confirmed a 2 × 3 cm pseudoaneurysm of the superior gluteal artery. Hemostasis was successfully achieved through thrombin injection, hematoma evacuation and ligation. This case highlights that careful preoperative planning, detailed knowledge of vascular anatomy and early attention to laboratory parameters are essential for the prevention and detection of vascular injuries during SI screw implantation.

BACKGROUND:The incidence of acetabular fractures has increased, and classification according to Judet and Letournel remains challenging. While 3D CT improves accuracy, virtual reality (VR) may enhance training. This study assessed whether a VR simulator improves classification accuracy and understanding in inexperienced users. MATERIALS AND METHODS:An HTC VIVE Pro headset and an Alienware m15 R4 computer were utilized. Programming was done in Unity (2021.3.4f1 LTS), and segmentation in Slicer3D. In total, 83 ninth-semester medical students, divided into a VR group (n = 44) and a 3D control group (n = 39), took part. Participants had to classify 11 acetabular fractures, supported by pictograms if needed, followed by a user survey. Accuracy was compared. RESULTS:All participants completed the study. Overall, 68% had no prior knowledge of the classification. The control group achieved a median of 27% (interquartile range [IQR]: 14-36%) correct classifications, while the VR group reached 45% (IQR: 36-64%), showing higher accuracy (p < 0.001). In general, essential fractures were classified significantly more accurately than associated fractures (p < 0.001). The VR system was rated as more intuitive than the 3D software (p = 0.025). CONCLUSION:The VR simulator significantly improved acetabular fracture classification among inexperienced users. It is intuitive, easy to use, and offers strong potential for future surgical training.

The incidence of acetabular fractures has increased, and classification according to Judet and Letournel remains challenging. While 3D CT improves accuracy, virtual reality (VR) may enhance training. This study assessed whether a VR simulator improves classification accuracy and understanding in inexperienced users. An HTC VIVE Pro headset and an Alienware m15 R4 computer were utilized. Programming was done in Unity (2021.3.4f1 LTS), and segmentation in Slicer3D. In total, 83 ninth-semester medical students, divided into a VR group (n = 44) and a 3D control group (n = 39), took part. Participants had to classify 11 acetabular fractures, supported by pictograms if needed, followed by a user survey. Accuracy was compared. All participants completed the study. Overall, 68

Background: The increasing incidence of pelvic ring and acetabular fractures represents a major challenge in the field of trauma surgery. Hemorrhage and thrombosis are among the most severe complications associated with these injuries. The common instability of those fractures, together with an anatomic proximity to blood vessels, increases the risk of perioperative bleeding. Vascular wall irritation during surgery additionally adds to a substantial risk for thrombotic events. Therefore, evaluating the risk for hemorrhage and thrombosis in pelvic ring and acetabular fractures is vital to identify an adequate anticoagulation management. Methods: The incidence of hemorrhagic and thrombotic events, as well as the association of patient characteristics with the investigated outcomes of 16,359 cases, were analyzed retrospectively using data from the German Pelvic Trauma Registry. Moreover, a risk assessment survey was conducted among traumatologists experienced in pelvic ring and acetabular surgery. The results were compared to those of the registry study. Results: A high rate of thrombotic events was found in the middle-age decade (41–50 years). In patients with an age ≤ 40 and >50 years, hemorrhage complications predominated. The logistic regression identified pelvic ring fractures in geriatric patients, acetabular fractures, and Injury Severity Score (ISS) ≥ 16 to be associated with bleeding complications. Factors associated with thrombosis included pelvic ring fractures in non-geriatric patients, acetabular fractures in geriatric and non-geriatric patients, ISS, and male gender. The survey demonstrated that preoperatively, the risk for hemorrhage was considered more significant. Perioperatively, however, thrombosis was regarded as more important. Conclusions: Separate guidelines for prophylactic anticoagulation in pelvic ring and acetabular fractures that also consider individual patient characteristics, such as age, gender, and ISS, are necessary to improve perioperative management and reduce the morbidity and mortality associated with these injuries.

Treatment of pelvic fractures requires extensive human and material resources. The weekend is characterized by a reduced availability of these resources. In addition, weekend leisure activities lead to different injury patterns. The ‘weekend effect’, which describes these conditions, is controversially discussed in medicine. However, there is still a paucity of data, especially in traumatology and particularly in relation to pelvic injuries. The aim of this work is to assess the weekend effect on demographics, injury patterns and outcome in relation to the day of the accident. Demographic, clinical and operative parameters from the data of the German Pelvic Trauma Registry were retrospectively evaluated (n = 16,359). Differences between weekend and weekday accidents were statistically evaluated. Weekend accidents affect younger, more severely injured and less often female patients with fewer displaced fractures and a lower proportion of acetabular fractures. This results in less frequent operative treatment, but more emergency and early definitive surgery. In contrast to the numerous and significant differences in baseline conditions, the outcome in terms of quality of surgical treatment, morbidity and mortality showed only marginal and non-significant differences between weekend and weekday accidents. Weekend accidents differ from weekday accidents in their initial conditions. This does not lead to more frequent—yet more emergency and more early definitive surgeries. However, there are no differences in the quality of care or outcome according to the day of the accident.

The incidence of acetabular and pelvic fractures is rising significantly. Pelvic ring fractures rank as the sixth most common fractures in adults, with the majority occurring in the elderly. Due to complications related to surgical approaches, with rates of up to 31

The Pararectus approach has been introduced as an alternative anterior approach to the Stoppa approach in acetabular surgery. There is no evidence which approach should be preferred, especially regarding approach-related complications. Therefore, aim of this registry study was to compare the Pararectus approach to the Stoppa approach regarding complications and quality of reduction. Patients from the German Pelvic Registry with a surgically treated acetabular fracture, either through the Pararectus approach or the Stoppa approach, were analyzed or compared regarding demographic, clinical and operative parameters. In total, 384 patients with an acetabular fracture received a surgical procedure with either the Pararectus approach (n = 120) or the Stoppa approach (n = 264). There were no differences between the two groups regarding demographic parameters and fracture pattern. The overall complication rate (35.0 % vs. 31.4 %), the mortality rate (5.0 % vs. 3.0 %) and the osteosynthesis-associated complication rate (5.8 % vs. 4.2 %) tended to be higher in the Pararectus group with no statistical significance. There were significantly more anatomical reductions in the Pararectus group (56 % vs. 43 %; p = 0.01). However, operation time was significantly longer in the Pararectus group (255 ± 125 vs. 205 ± 103 minutes; p < 0.001). Despite a longer operation time, the Pararectus approach and the Stoppa approach are equivalently applicable for the treatment of acetabular fractures regarding complication rates and quality of reduction. III, retrospective comparative study.

Die Zementaugmentation von transiliosakralen (SI) Schrauben am hinteren Beckenring sorgt in Kadaverstudien nachgewiesenermaßen für eine höhere biomechanische Stabilität. Beckenringfrakturen sind gemessen an der Gesamtzahl der Frakturen eher selten. Dennoch ist die 1‑Jahres-Mortalität insbesondere bei geriatrischen Beckenringfrakturen mit bis zu 27 % sehr hoch und zu einem Großteil auch auf die reduzierte Mobilität aufgrund der Fraktur zurückzuführen. Oberstes Ziel der Behandlung ist die Wiederherstellung der Mobilität der Patientinnen und Patienten. Hierfür ist das Erreichen einer ausreichenden Stabilität des Beckenrings erforderlich. Da oftmals eine Osteoporose mitursächlich für die Beckenringfraktur ist, kann durch eine Zementaugmentation eine stabilere Verankerung der Implantate im osteoporotischen Knochen erreicht werden. In dieser Arbeit werden die Möglichkeiten der Zementaugmentation am Beckenring aufgezeigt und die Technik der zementaugmentierten SI-Schraube beschrieben.

Background Pelvic fractures are often associated with spine injury in polytrauma patients. This study aimed to determine whether concomitant spine injury influence the surgical outcome of pelvic fracture. Methods We performed a retrospective analysis of data of patients registered in the German Pelvic Registry between January 2003 and December 2017. Clinical characteristics, surgical parameters, and outcomes were compared between patients with isolated pelvic fracture (group A) and patients with pelvic fracture plus spine injury (group B). We also compared apart patients with isolated acetabular fracture (group C) versus patients with acetabular fracture plus spine injury (group D). Results Surgery for pelvic fracture was significantly more common in group B than in group A (38.3% vs. 36.6%; p = 0.0002), as also emergency pelvic stabilizations (9.5% vs. 6.7%; p < 0.0001). The mean time to emergency stabilization was longer in group B (137 ± 106 min vs. 113 ± 97 min; p < 0.0001), as well as the mean time until definitive stabilization of the pelvic fracture (7.3 ± 4 days vs. 5.4 ± 8.0 days; p = 0.147). The mean duration of treatment and the morbidity and mortality rates were all significantly higher in group B ( p < 0.0001). Operation time was significantly shorter in group C than in group D (176 ± 81 min vs. 203 ± 119 min, p < 0.0001). Intraoperative blood loss was not significantly different between the two groups with acetabular injuries. Although preoperative acetabular fracture dislocation was slightly less common in group D, postoperative fracture dislocation was slightly more common. The distribution of Matta grades was significantly different between the two groups. Patients with isolated acetabular injuries were significantly less likely to have neurological deficit at discharge (94.5%; p < 0.0001). In-hospital complications were more common in patients with combined spine plus pelvic injuries (groups B and D) than in patients with isolated pelvic and acetabular injury (groups A and C). Conclusions Delaying definitive surgical treatment of pelvic fractures due to spinal cord injury appears to have a negative impact on the outcome of pelvic fractures, especially on the quality of reduction of acetabular fractures.

Pelvic ring injuries or acetabular fractures present a challenge to trauma surgeons. Recently, endoscopic dissection techniques for visualization of the anterior pelvic ring and acetabulum have been presented. Robotic-assisted surgical systems offer advantages in terms of improved visualization and easier instrument handling. The aim of this pilot anatomic study was to verify the feasibility of robotic-assisted plate osteosynthesis on the anterior pelvic ring and acetabulum. The experiment was performed on a human whole body specimen. The DaVinci system with standard instruments as used in RARP was used. After docking the system, the anterior pelvic ring was first prepared as previously described for the endoscopic techniques. This was followed by dissection of both acetabula analogous to pelvic lymphadenectomy as performed during RARP. After the dissection was performed along the pelvic brim up to the iliosacral joint, the complete anterior column of the acetabulum including quadrilateral surface and incisura ischiadica major could be visualized. Finally, robotic-assisted endoscopic plate osteosynthesis was performed on the symphysis and anterior acetabular column as previously described in the endoscopic techniques. Robotic-assisted plate osteosynthesis of the anterior pelvic ring and acetabulum is feasible with the available robotic-assisted systems. Due to the excellent freedom of movement of the robotic arms, combined with the magnifying 3D visualization of the system, highly accurate preparation of the situs in preparation for plate osteosynthesis can be performed. The question of reduction of dislocated fractures remains open and is the subject of further investigation. Compared with conventional laparoscopy, robotic-assisted preparation nevertheless appears to offer an advantage in view of the complexity of the operation.

In many surgical disciplines, the interest among medical students to pursue a surgical career decreases during their medical studies. The same goes for students after graduation. The aim of our cohort study was to evaluate the operating room (OR) experiences of medical students during our curriculum. Over the course of one year 217 senior year medical students were included in our study. All of them took part in our training program for senior year medical students, which consisted of a 1-week clinical rotation including visits to the OR. We developed a Likert-scaled questionnaire, which was evaluated anonymously; free text answers were also possible. Prior to the analysis of the sex and age differences, we confirmed that the evaluation scale provided a coherent measure of the OR evaluation. As a first proxy, we conducted a series of Spearman correlations which revealed high intercorrelations between all of the six items of the questionnaire, r(154) = 0.53 to r(154) = 0.94, all p < 0.001. These high intercorrelations transferred into a very high consistency of the six questions that evaluate the OR teaching; Cronbach’s α = 0.95. There was no main effect of sex, F (1,146) = 2.19, p = 0.141. However, there was a main effect of age, F (2,146) = 3.75, p = 0.026, indicating that older participants evaluated the OR teaching more positively. Finally, there was no correlation between sex and age group, F (2,146) < 1, indicating that the effect of age on the evaluation score was equally pronounced for female and male participants. The aim of this study was to answer the question how mentored OR teaching during the orthopedic trauma curriculum is evaluated by medical students, and whether there are gender-specific differences. For this purpose we prospectively evaluated senior year medical students over a period of 12 months during the orthopedic trauma curriculum with questionnaires. The medical students rated the mentored OR visits mainly positive. Previously published literature as well as our presented data indicate that the interest of medical students in starting a surgical career can only be increased if negative influencing factors are reduced. This includes especially positive communication with medical students and in daily professional interaction.

Severe bleeding is the major cause of death in unstable pelvic ring fractures. Therefore, a quick and efficient emergency stabilization and bleeding control is inevitable. C-clamp and pelvic binder are efficient tools for temporary bleeding control, especially from the posterior pelvic ring. Yet the C-clamp requires more user knowledge, training and equipment. However, whether this makes up for a more efficient bleeding control, is still under debate. Patients with a type-C pelvic ring fracture were identified from the German Pelvic Registry (GPR) and divided into three groups of 40 patients (1. no emergency stabilization, 2. pelvic binder, 3. C-clamp). The matching occurred according to the parameters age, gender, initial RR and initial HB. Complication—and mortality rates were compared especially regarding bleeding control. Regarding ISS and fracture dislocation there was no difference. The use of the C-clamp resulted in more complications, a higher mortality rate due to severe bleeding and more blood transfusions were admitted. Moreover the pelvic binder was established noticeably faster. However, the C-clamp was more often rated as effective. There is no evidence of advantage comparing the C-clamp to the pelvic binder, regarding bleeding control in type-C pelvic ring fractures. In fact, using the pelvic binder even showed better results, as the time until established bleeding control was significantly shorter. Therefore, the pelvic binder should be the first choice. The C-clamp should remain a measure for selected cases only, if an adequate bleeding control cannot be achieved by the pelvic binder.

Fractures of the femoral head are rare injuries, which typically occur after posterior hip dislocation.The Pipkin classification, developed in 1957, is the most commonly used classification scheme to date.The injury is mostly caused by high-energy trauma, such as motor vehicle accidents or falls from a significant height.Emergency treatment consists of urgent closed reduction of the hip joint, followed by non-operative or operative treatment of the femoral head fracture and any associated injuries.There is an ongoing controversy about the suitable surgical approach (anterior vs. posterior) for addressing fractures of the femoral head. Fracture location, degree of displacement, joint congruity and the presence of loose fragments, as well as concomitant injuries are crucial factors in choosing the adequate surgical approach.Long-term complications such as osteonecrosis of the femoral head, posttraumatic osteoarthritis and heterotopic ossification can lead to a relatively poor functional outcome. Cite this article: EFORT Open Rev 2021;6:1122-1131. DOI: 10.1302/2058-5241.6.210034.

Introduction: The approach-related morbidity rate in the care of pelvic fractures is still high. Endoscopic procedures are known to significantly reduce access-related complications. Recently, a new endoscopically assisted implantation technique for plate osteosynthesis on the anterior pelvic ring has been described as the “Endoscopic Approach to the Symphysis”. Case report: We present a case of a 29-year old male with a pelvic injury (AO type 61B2.3a) initially treated with a supraacetabular external fixator. After one week the definitive stabilization was performed by an endoscopically assisted symphyseal plating as well as a percutaneous iliosacral screw on the right side. One year after primary surgery, we performed an endoscopically assisted removal of the symphyseal plate using standard laparoscopic instruments. Results: We demonstrate the feasibility of an endoscopically assisted implant removal at the anterior pelvic ring. No complications occurred during the procedure. The patient was discharged after a regular time of surveillance and with an adequate decline of pain. Discussion: While we were able to show that the endoscopically assisted implantation as well as the removal of a plate osteosynthesis on the anterior pelvic ring is possible, there is still further research necessary, especially regarding the development of specific endoscopic instruments. This should enable operating times similar to the standard open procedures.

Die Kombination aus Glenoidverlust und Rotatorenmanschetten-Defektarthropathie (RM-Defektarthropathie) stellt eine Herausforderung dar. Eine 75-jährige Patientin stellte sich mit einer posttraumatischen Glenoiddestruktion mit RM-Defektarthropathie vor. Anhand von CT-Aufnahmen erfolgte die Anfertigung einer individualisierten Glenoid-Komponente mittels 3D-Printverfahren. 6 Monate nach Implantation der inversen Prothese war die Patientin schmerzfrei bei akzeptabler Beweglichkeit. Die individualisierte Glenoidkomponente aus dem 3D-Druckverfahren stellt bei Glenoidverlust mit ausgeprägter RM-Defektarthropathie eine gute Therapiealternative dar.

Die Indikationen zur Laparoskopie haben sich in den letzten Jahren stetig erweitert. Gleichzeitig bleibt der diagnostische und therapeutische Stellenwert der Laparoskopie beim penetrierenden und stumpfen Abdominaltrauma weiter unklar. Es wurde eine systematische Literaturrecherche über den Zeitraum 2008 bis 2019 in PubMed zum Thema Laparoskopie beim penetrierenden und stumpfen Abdominaltrauma durchgeführt. Die Studien wurden hinsichtlich relevanter perioperativer Ereignisraten (übersehene Verletzungen, Konversionsrate, tatsächlich vorliegende Verletzungen, postoperative Komplikationen) ausgewertet. Auf dieser Basis wurde ein Algorithmus zur Anwendung der Laparoskopie beim Abdominaltrauma erstellt. Es wurden 15 Volltexte mit 5869 Patienten gefunden. Mit einer Rate von 1,4 % waren laparoskopisch übersehene Verletzungen sowohl für das penetrierende als auch für das stumpfe Abdominaltrauma sehr selten. Von allen Traumalaparoskopien wurden 29,3 % zum offen chirurgischen Vorgehen (Laparotomie) konvertiert. Unter den nichtkonvertierten Laparoskopien waren 60,5 % therapeutisch. Komplikationen traten nach Traumalaparoskopie in 8,6 % der Fälle auf. Mittels systematischer laparoskopischer Exploration sind übersehene Verletzungen beim Abdominaltrauma äußerst selten, sodass diesbezügliche Bedenken kaum mehr gerechtfertigt erscheinen. Ein großer Anteil der bestehenden intraabdominalen Verletzungen kann laparoskopisch oder laparoskopisch-assistiert therapiert werden.

Background Pelvic fractures are rare but serious injuries. The influence of a concomitant abdominal trauma on the time point of surgery and the quality of care regarding quality of reduction or the clinical course in pelvic injuries has not been investigated yet. Methods We retrospectively analyzed the prospective consecutive cohort from the multicenter German Pelvic Registry of the German Trauma Society in the years 2003–2017. Demographic, clinical, and operative parameters were recorded and compared for two groups (isolated pelvic fracture vs. combined abdominal/pelvic trauma). Results 16.359 patients with pelvic injuries were treated during this period. 21.6% had a concomitant abdominal trauma. The mean age was 61.4 ± 23.5 years. Comparing the two groups, patients with a combination of pelvic and abdominal trauma were significantly younger (47.3 ± 22.0 vs. 70.5 ± 20.4 years; p < 0.001). Both, complication (21.9% vs. 9.9%; p < 0.001) and mortality (8.0% vs. 1.9%; p < 0.001) rates, were significantly higher. In the subgroup of acetabular fractures, the operation time was significantly longer in the group with the combined injury (198 ± 104 vs. 176 ± 81 min, p = 0.001). The grade of successful anatomic reduction of the acetabular fracture did not differ between the two groups. Conclusion Patients with a pelvic injury have a concomitant abdominal trauma in about 20% of the cases. The clinical course is significantly prolonged in patients with a combined injury, with increased rates of morbidity and mortality. However, the quality of the reduction in the subgroup of acetabular fractures is not influenced by a concomitant abdominal injury. Trial registration ClinicalTrials.gov, NCT03952026 , Registered 16 May 2019, retrospectively registered

Beckenfrakturen sind seltene, aber schwere Verletzungen. Inwieweit eine Kombinationsverletzung aus Abdominaltrauma und Beckentrauma das postoperative Ergebnis und den klinischen Verlauf von Beckenverletzungen beeinflusst, ist bisher nicht hinreichend untersucht worden. Retrospektiv ausgewertet wurden alle Patienten mit Beckenverletzungen der Jahre 2003 bis 2017 aus dem monozentrischen prospektiven Beckenregister der BG Unfallklinik Tübingen. Demografische, klinische und operative Parameter wurden erfasst und in 2 Gruppen (Monoverletzung vs. Kombinationsverletzung) miteinander verglichen. Insgesamt wurden 1848 Patienten mit einer Beckenverletzung behandelt. Davon hatten 18,6 % eine Kombinationsverletzung des Beckens mit einer Abdominalverletzung. Das Durchschnittsalter betrug 62,3 ± 23,1 Jahre. Im Vergleich der beiden Gruppen waren die Patienten mit Kombinationsverletzung deutlich jünger (46,3 ± 20,3 vs. 70,6 ± 20,8 Jahre; p < 0,001). Die Komplikationsrate (31,2 % vs. 9,4 %; p < 0,001) und die Mortalität (5,0 % vs. 1,7 %; p = 0,001) waren jeweils deutlich höher in der Gruppe der Kombinationsverletzungen. Der zeitliche Abstand bis zur definitiven Operation des Beckens war signifikant länger in der Gruppe der Kombinationsverletzungen (6,0 ± 6,4 vs. 4,5 ± 4,4 Tage; p = 0,002). Postoperativ zeigte das Repositionsergebnis keinen signifikanten Unterschied in beiden Gruppen. Patienten mit einer Beckenverletzung erleiden zu etwa 20 % eine Kombinationsverletzung aus Becken- und Abdominaltrauma. Der klinische Verlauf ist deutlich verlängert bei deutlich erhöhter Morbidität und Mortalität in der Gruppe der Kombinationsverletzungen. Das postoperative Ergebnis der osteosynthetischen Versorgung der Beckenverletzung wird jedoch durch eine begleitende Abdominalverletzung nicht beeinflusst.

Background The range of indications for laparoscopic procedures has been continuously widened in recent years. At the same time, however, the diagnostic and therapeutic role of laparoscopy in the management of blunt and penetrating abdominal trauma remains controversial. Methods A systematic literature search was carried out in PubMed from 2008 to 2019 on the use of laparoscopy in blunt and penetrating abdominal trauma. Studies were analyzed in terms of relevant operative and perioperative event rates (rate of missed injuries, conversion rate, postoperative complication rate). On the basis of this analysis, an algorithm for the use of laparoscopy in abdominal trauma was developed for clinical practice. Results A total of 15 full texts with 5869 patients were found. With a rate of 1.4%, laparoscopically missed injuries were very rare for both penetrating and blunt abdominal trauma. Of all trauma laparoscopies 29.3% were converted to open surgery (laparotomy). Among the non-converted laparoscopies 60.5% were therapeutic. Complications occurred after trauma laparoscopy in 8.6% of cases. Conclusion By means of systematic laparoscopic exploration, missed injuries in abdominal trauma are extremely rare, so that concerns in this respect no longer seem justified. A large proportion of intra-abdominal injuries can be treated using laparoscopy or laparoscopically assisted procedures.