Late reconstruction of severe open-book deformities
of the pelvis — tips and tricks
Ivan S. Tarkin
Received: 16 December 2016 /Accepted: 14 June 2017 /Published online: 5 July 2017
SICOT aisbl 2017
Background The primary goal of treatment for open book
pelvic injuries after high-energy trauma is to control haemor-
rhage and to close the pelvic ring anatomically. Less common-
ly, patients may present late with malunion or non-union.
Methods We reviewed five operatively treated patients with
delayed severe open book deformities who had a diastasis of
more than 6 cm. We describe the pre-operative workup, sur-
gical strategy and challenges experienced. They specifically
include: extensive scar and contracture formation, malunion,
urogenital prolapse and difficult reduction of vertical shear
element. A 5 to 15-point clinical scoring system based on
quality of life regarding pain, ambulation, social function,
continence control and presence of prolapse is proposed.
Results One elderly patient had early mortality after surgery.
The other four patients had quality of life improvement by 3 to
5 points after one year. Correction is often clinically successful
despite technical challenges and unpredictable radiological
Conclusion External fixator and the C-clamp are good reduc-
tion tools. Powerful implants should be used and fixation of
the posterior ring is mandatory. Staged urogenital and pelvic
floor reconstruction is recommended before bony reconstruc-
tion to minimize the risk of wound contamination. Patients
receiving this complex procedure have a good chance for im-
provement in pain and functional status.
Keywords Pelvic ring fractures
Open book injuries of the pelvic ring are usually a result of
high-energy trauma. They are associated with severe haemor-
rhage , with an in-hospital mortality rate of 4 to 14% [2–5].
In the acute stage, closing the pelvic ring is the primary goal.
Patients with anatomical restoration of the pelvic ring enjoy
better functional outcome . This is achieved by C-clamps,
external fixation and internal fixation . Our group has
previously shown that patients with pelvic injuries commonly
suffer from chronic pain and gait problems, with quality of life
and financial impact.
Patients with highly unstable fractures (type 61.C accord-
ing to Tiles and Modified AO/OTA Classifications [9, 10])
may present late with secondary pelvic non-union or displace-
ment for various reasons such as logistics , radiation
* Christian Fang
Ivan S. Tarkin
Department of Orthopaedics and Traumatology, The University of
Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong
Department of Orthopaedic Trauma, RWTH University of Aachen,
30 Pauwels street, 52074 Aachen, Germany
Department of Trauma, University of Zurich Hospital, Rämistrasse
100, 8091 Zürich, Switzerland
Department of Orthopaedic Surgery, Division of Traumatology,
University of Pittsburgh, 3471 Fifth Avenue, Pittsburgh, PA 15213,
International Orthopaedics (SICOT) (2017) 41:1777–1784