Background: Acetabular fractures still are among the most challenging fractures to treat because of complex anatomy, involved surgical access to fracture sites and the relatively low incidence of these lesions. Proper evaluation and surgical planning is necessary to achieve anatomic reduction of the articular surface and stable fixation of the pelvic ring. The goal of this study was to test the feasibility of preoperative surgical planning in acetabular fractures using a new prototype planning tool based on an interactive virtual reality-style environment. Methods: 7 patients (5 male and 2 female; median age 53 y (25 to 92 y)) with an acetabular fracture were prospectively included. Exclusion criterions were simple wall fractures, cases with anticipated surgical dislocation of the femoral head for joint debridement and accurate fracture reduction. According to the Letournel classification 4 cases had two column fractures, 2 cases had anterior column fractures and 1 case had a T-shaped fracture including a posterior wall fracture. The workflow included following steps: (1) Formation of a patient-specific bone model from preoperative computed tomography scans, (2) interactive virtual fracture reduction with visuo-haptic feedback, (3) virtual fracture fixation using common osteosynthesis implants and (4) measurement of implant position relative to landmarks. The surgeon manually contoured osteosynthesis plates preoperatively according to the virtually defined deformation. Screenshots including all measurements for the OR were available. The tool was validated comparing the preoperative planning and postoperative results by 3D-superimposition. Results: Preoperative planning was feasible in all cases. In 6 of 7 cases superimposition of preoperative planning and postoperative follow-up CT showed a good to excellent correlation. In one case part of the procedure had to be changed due to impossibility of fracture reduction from an ilioinguinal approach. In 3 cases with osteopenic bone patient-specific prebent fixation plates were helpful in guiding fracture reduction. Additionally, anatomical landmark based measurements were helpful for intraoperative navigation. Conclusion: The presented prototype planning tool for pelvic surgery was successfully integrated in a clinical workflow to improve patient-specific preoperative planning, giving visual and haptic information about the injury and allowing a patient-specific adaptation of osteosynthesis implants to the virtually reduced pelvis.

Background: The modified Stoppa approach is performed for safe and efficient management of acetabular fractures involving the anterior column. This approach avoids dissection of the inguinal canal, the femoral nerve, and the external iliac vessels as seen in the “second window” of the ilioinguinal approach and has thus been shown to be less invasive than the ilioinguinal approach ¹ . As an intrapelvic approach, it facilitates the management of medial displacement fracture patterns involving the quadrilateral plate and dome impaction that typically occur in the elderly ^2,3 . The reduced morbidity of this approach is of particular relevance for elderly patients who must respond to the stresses of injury and surgery with diminished physiological reserves. Description: The specific surgical steps include preoperative planning, patient positioning and setup, a Pfannenstiel incision, superficial and deep dissection, development of the Retzius space and retraction of the bladder, exposure of the superior pubic ramus and iliopectineal eminence, dissection and ligation of a potential corona mortis, exposure of the obturator nerve and vessels, subperiosteal preparation of the pubic ramus with retraction of the external iliac vessels, subperiosteal exposure of the quadrilateral plate with detachment of the internal obturator muscle and exposure of the posterior column, assessment of residual displacement by fluoroscopic views, longitudinal soft-tissue or lateral skeletal traction (optional) for reduction of medial displacement of the femoral head, disimpaction of the acetabular dome fragment and grafting of the supra-acetabular void (optional) under fluoroscopic and arthroscopic (optional) control, and reduction and fixation of extra-articular components (iliac wing posteriorly and pubic ramus anteriorly), the posterior column (infra-acetabular screw), and the quadrilateral plate (buttress plate). Before wound closure, the urine output is checked for occurrence of hematuria, an indication of bladder penetration. The anterior lamina of the rectus sheath is then sutured, and a layered closure performed. Alternatives: The ilioinguinal approach might be used instead. Rationale: The modified Stoppa approach avoids dissection within the inguinal canal, the second window of the ilioinguinal approach. Therefore, this approach is less invasive and might be an alternative for joint-preserving surgery, especially in the elderly.

Background: Surgical hip dislocation is performed for safe and efficient management of acetabular fractures predominantly involving the posterior column. The dislocation of the femoral head allows for direct visualization of the hip joint during fracture treatment. Description: The patient is placed in the lateral decubitus position with sterile preparation and draping of the ipsilateral leg to allow for dislocation. The skin incision is straight and centered over the greater trochanter. After the skin incision, the interval between the gluteus maximus and medius muscles is developed. The sciatic nerve is identified, and special attention to the course of the medial circumflex femoral artery is given during dissection of the piriformis and triceps coxae muscles (obturator internus and superior and inferior gemelli muscles). The latter are incised 2 cm posterior to their insertion on the posterior aspect of the greater trochanter. The vastus lateralis muscle belly is elevated from the lateral femoral shaft, and a trochanteric osteotomy is performed. The trochanteric medallion is rotated 90°, and the gluteus minimus muscle is released from the capsule. After complete exposure of the hip capsule, a z-shaped capsulotomy is performed whereby any injury to the posterior capsular attachments of a posterior wall fragment is avoided. The posterior column and the greater and lesser sciatic notches are exposed, with the sciatic nerve under protection. The femoral head is dislocated either anteriorly or posteriorly to obtain direct visualization of the hip. Reduction begins at the articular surface, in cases of marginal impaction, and proceeds to the posterior wall and/or posterior column and the anterior column, when involved. For fixation, 3.5-mm cortical screws acting as positioning or lag screws and reconstruction plates are used. The capsule is sutured, the trochanteric fragment is reduced anatomically and stabilized with two 3.5-mm cortical screws, the piriformis and triceps coxae muscles are sutured, and a layered closure is performed. Alternatives: The Kocher-Langenbeck approach might be used instead. Rationale: Surgical hip dislocation facilitates assessment of cartilage damage at the acetabulum, marginal impaction, labral tears and femoral head lesions, removal or reinsertion of free intra-articular fracture fragments, direct visualization of the accuracy of reduction, and verification of extra-articular screw placement.

Background/Objectives: Older trauma patients experience increased in-hospital mortality due to the physiological challenges associated with aging and injury severity. However, limited data exist on long-term mortality rates beyond hospital discharge, particularly among severely injured elderly trauma patients. Understanding these outcomes is essential for improving clinical management and rehabilitation strategies. The objective of this study was to evaluate cumulative mortality rates (in-hospital, 28-day, 1-year, 2-year, and 3-year) in older trauma patients with an Injury Severity Score (ISS) ≥ 16. Independent risk factors for 1-year mortality were also identified. Methods: This retrospective cohort study included all trauma patients aged ≥ 65 years with ISS ≥ 16 admitted to the Emergency Department of our level 1 trauma center between January 2017 and December 2022. Demographic characteristics, injury patterns (Abbreviated Injury Scale (AIS) scores, ISS), and mortality rates were collected from electronic health records. Patients were stratified into two age groups: 65–80 years and >80 years. Mortality rates were compared with those in the corresponding age groups in the general Swiss population. Statistical analysis included Kaplan–Meier survival curves and logistic regression for identifying risk factors associated with 1-year mortality. Results: A total of 1189 older trauma patients with a mean ISS of 24.3 ± 7.9 were included. The most common injury was severe head trauma (AIS head ≥ 3: 70.6%), followed by chest trauma (AIS chest ≥ 3: 28.2%) and extremity injuries (AIS extremity ≥ 3: 17.4%). The overall in-hospital mortality rate was 10.3%. Mortality rates at 28 days, 1 year, 2 years, and 3 years were 15.8%, 26.5%, 31.5%, and 36.3%, respectively. Age-stratified analysis showed significantly higher mortality rates in patients aged > 80 years compared to the 65- to 80-year group at all post-discharge time points (28-day: 22.6% vs. 11.9%, p < 0.001; 1-year: 39.9% vs. 18.8%, p < 0.001; 2-year: 46.5% vs. 22.8%, p < 0.001; 3-year: 56.4% vs. 24.9%, p < 0.001). Compared to the general Swiss population, we observed significantly higher mortality rates at all measured time points in elderly trauma patients, particularly in those aged over 80 years, with 1-year mortality rates of 39.9% vs. 10% in the general population and 3-year mortality rates of 56.4% vs. 30% in the general population. Independent risk factors for 1-year mortality included advanced age and severe head injury (AIS head ≥ 3, p < 0.001). Conclusions: Severely injured elderly trauma patients face high long-term mortality risks, with 1-year mortality rates reaching 26.5% overall and nearly 40% in patients aged > 80 years. These findings highlight the need for research on tailored, holistic management strategies, including comprehensive in-hospital care, specialized neurorehabilitation, and post-discharge follow-up programs to improve survival and functional recovery in this vulnerable population.

Objectives: To present and evaluate the safety and efficacy of our new procedure for treating thoracolumbar burst-split fractures without neurological injury. Methods: Our new surgical technique for the treatment of thoracolumbar burst-split fractures (AO type A4, Magerl classification A3.2.1) involving (1) posterior reduction and bisegmental instrumention, (2) anterior screw fixation of the caudal sagittal split, (3) anterior one-level fusion of the cranial segment, and (4) interval posterior implant removal was presented. In an initial cohort of patients, demographic information, surgical specifics and imaging data were evaluated. Results: Twenty-one patients (mean age 29.5 ± 11.8 years, 38% male, mean follow-up 36 ± 14 months) were included. Anterior column reconstruction involving sagittal split lag screw and monosegmental fusion was performed at a mean of 2.9 ± 2 days after posterior instrumentation. All fractures healed. There were no occurrences of implant failures or migrations. None of the patients required revision surgery. The removal of the temporary posterior instrumentation was performed at a mean of 8.4 ± 1.8 months after the initial surgery. Bisegmental, superior monosegmental, and inferior monosegmental kyphosis angle did not significantly change from six months to 12 months postoperatively after removal of the posterior instrumentation ( p > 0.9). No listhesis or change in bisegmental scoliosis angle were observed. The inferior monosegmental angle was significantly greater in flexion (1.2° ± 5.8°) compared to extension (-3.3° ± 6°) at 12 months postoperatively indicating motion in the inferior, non-fused segment after removal of the posterior instrumentation ( p = 0.0001). The intervertebral disc height at the temporarily fused segment decreased significantly from six (9.2 ± 2.2) to 12 months postoperatively (8.3 ± 2.2; p < 0.0101). Conclusion: Thoracolumbar burst-split fractures can be safely and successfully treated through a treatment protocol that includes (1) posterior reduction and bisegmental instrumention, (2) anterior screw fixation of the caudal sagittal split, (3) anterior one-level fusion of the cranial segment, and (4) interval posterior implant removal. This new surgical technique promotes reliable fracture healing, kyphosis correction and preserves the physiological motion at the caudal segment.

The gull sign was described as a radiographic marker of superomedial dome impaction in acetabular fractures and was considered predictive of failure after osteosynthesis in older patients (≥ 60 years). To determine whether the radiographic gull sign is associated with higher conversion rates to total hip arthroplasty (THA) within 24 months after open reduction and internal fixation (ORIF) for displaced acetabular fractures in patients aged ≥ 60 years. In this retrospective cohort study, 126 patients aged ≥ 60 years (mean 76 years, range 60.1-93.6) underwent ORIF for displaced acetabular fractures via the Pararectus approach between 2009 and 2020. Preoperative pelvic radiographs were assessed for the presence of the gull sign, and CT scans were evaluated for dome impaction. Failure was defined as conversion to total hip arthroplasty (THA) within 24 months after ORIF. Kaplan-Meier analyses with log-rank tests were performed on the entire cohort, and diagnostic performance was analysed in the subset with complete two-year follow-up (n = 93). At two years, 20 of 93 patients (22 %) had undergone THA, occurring on average 12.1 months after the index surgery (range 2-45 months). A radiographic gull sign was identified in 21 patients (23 %). The subsequent THA conversion rate was similar between those with and without the sign (5/21 [24 %] vs 15/72 [21 %]; p = 0.99). Concordance between radiographs and CT was limited: only 12 of 21 gull-positive patients (57 %) showed a true dome impaction on CT, while CT nevertheless revealed impaction in 21 of 72 gull-negative patients (29 %). Among patients with CT-confirmed impaction, 8 of 33 (24 %) underwent THA within 24 months, compared with 12 of 60 (20 %) without impaction (p = 0.79). Kaplan-Meier analysis of the entire cohort (n = 126) likewise showed no difference in THA-free survival between groups. Neither a radiographic gull sign nor CT-confirmed dome impaction predicted early conversion in our series of acetabular fractures managed via Pararectus approach; overall conversion rates were acceptable. Accordingly, the gull sign is not a harbinger per se for failure of osteosynthesis in older adults.