REVIEW ARTICLE
Nagoya J. Med. Sci. 85. 35–49, 2023
doi:10.18999/nagjms.85.1.35

A systematic review regarding clinical characteristics,
complications, and outcomes of surgical and non-surgicalpatients with fragility fracture of the pelvis
Takaomi Kobayashi1,2, Takayuki Akiyama1,2, Tadatsugu Morimoto1,2,
Kensuke Hotta3 and Masaaki Mawatari1,2
1
Department of Orthopaedic Surgery, Imari-Arita Kyoritsu Hospital, Arita , Japan
Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan3
Department of Orthopaedic Surgery, Amagi Chuo Hospital, Asakura, Japan

2

ABSTRACT
We conducted this systematic review to clarify the clinical characteristics, complications, and outcomesof surgical and non-surgical patients with fragility fracture of the pelvis (FFP). We searched PubMed,
Google Scholar, Cochrane Library, Web of Science, and MEDLINE for English language articles on FFP.
We calculated pooled odds ratios (ORs) or mean differences (MDs) of surgical patients in comparison
to non-surgical patients for clinical characteristics (Rommens FFP classification, age, sex, dementia,
osteoporosis, diabetes mellitus, pulmonary disease, cardiovascular disease, and malignancy), complications(pneumonia, urinary tract infection, cardiac event, thrombosis, pulmonary embolism, pressure ulcer, multiple
organ failure, anemia caused by surgical bleeding, and surgical site infection), and outcomes (hospitalmortality and one-year mortality). Five studies involving 1,090 patients with FFP (surgical patients, n = 432;
non-surgical patients, n = 658) were included. FFP type III and IV (OR = 8.44; 95% confidence interval [CI]5.99 to 11.88; p<0.00001), a younger age (MD = –3.29; 95% CI –3.83 to –2.75; p<0.00001), the absenceof dementia (OR = 0.36; 95% CI 0.23 to 0.57; p<0.0001), and the presence of osteoporosis (OR = 1.74; 95%
CI 1.29 to 2.35; p = 0.0003) were significantly associated with the surgical patients. Urinary tract infection(OR = 2.06; 95% CI 1.37 to 3.10; p = 0.0005), anemia caused by surgical bleeding (OR = 4.55; 95% CI
1.95 to 10.62; p = 0.0005), and surgical site infection (OR = 16.74; 95% CI 3.05 to 91.87; p = 0.001) weresignificantly associated with the surgical patients. There were no significant differences in the outcomes
between the surgical and non-surgical patients. Our findings may help to further understand the treatment
strategy for FFP and improve clinical outcomes.
Keywords: fragility fracture of the pelvis, review, complication, mobility, surgery
Abbreviations:
FFP: fragility fracture of the pelvis
OR: odds ratio
MD: mean difference
CI: confidence interval
PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses
This is an Open Access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
License. To view the details of this license, please visit (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Received: December 15, 2021; accepted: March 30, 2022
Corresponding Author: Takaomi Kobayashi, MD
Department of Orthopaedic Surgery, Imari-Arita Kyoritsu Hospital,
860 Ninosekou, Arita-cho, Nishimatsuura-gun, Saga 849-4141, Japan
TEL: +81-955-46-2121, Fax: +81-955-46-2123, E-mail: m10036tk@jichi.ac.jp
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Takaomi Kobayashi et al

INTRODUCTION
Fragility fracture of the pelvis (FFP) is a common injury caused by low-energy trauma (eg,fall from standing height or lower) in the elderly with loss of bone mineral density.1-6 The
prevalence has been rising with the aging of the world’s population.7-9 Nevertheless, the treatment
strategy for FFP remains the subject of ongoing debate.10-18 Rommens et al10-13 recently developed
a radiographic classification of FFP and a management protocol (Fig. 1): conservative therapy
is efficacious for FFP types I (anterior lesions only) and II (non-displaced posterior lesions).
If conservative therapy fails after days or weeks in FFP type I, magnetic resonance imaging is
performed to rule out occult sacral fractures. If conservative therapy fails within days in FFP
type II, surgical stabilization is recommended. In contrast, surgical stabilization is recommended
for FFP types III (displaced unilateral posterior lesions) and IV (displaced bilateral posterior
lesions). Surgery is performed after obtaining written informed consent from the patient or theirrelatives in all cases. This treatment strategy is one of the most commonly applied classifications
and management protocols for FFP.10-18 To further understand the treatment strategy of FFP
described by Rommens et al10-13 and to improve the clinical outcomes, the clinical characteristics,

Fig. 1 Rommens classification of fragility fractures of the pelvis (FFP)10–13
FFP type Ia: unilateral anterior pelvic ring disruption
FFP type Ib: bilateral anterior pelvic ring disruption
FFP type IIa: dorsal non-displaced posterior injury only
FFP type IIb: sacral crush with anterior disruption
FFP type IIc: non-displaced sacral, sacroiliac, or iliac fracture with anterior disruption
FFP type IIIa: displaced unilateral iliac fracture and anterior disruption
FFP type IIIb: displaced unilateral sacroiliac disruption and anterior disruption
FFP type IIIc: displaced unilateral sacral fracture together with anterior disruption
FFP type IVa: bilateral iliac fractures or bilateral sacroiliac disruptions together with anterior disruption
FFP type IVb: spinopelvic dissociation together with anterior disruption
FFP type IVc: combination of various posterior instabilities together with anterior disruption
The reproduction of this figure is permitted by Springer Nature (License Number: 5243010021188).
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Fragility fracture of the pelvis

complications, and outcomes of surgical and non-surgical patients with FFP should be clarified.16-24
We therefore conducted the present systematic review.

MATERIALS AND METHODS
Search strategy and criteria
The protocol of the systematic review was registered at the International Prospective Registerof Systematic Reviews (PROSPERO registration no. CRD42021276549). This systematic review
was conducted according to the Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA) statement.25,26 PubMed, Google Scholar, Cochrane Library, Web of Science,and MEDLINE were searched for relevant English language articles that compared the clinicalcharacteristics, complications, and outcomes between surgical and non‑surgical FFP patients,
who were treated according to the strategy described by Rommens et al.10-13 All searches wereconducted on November 1, 2021. The search terms used in PubMed were as follows: (fragility
fracture[Title/Abstract]) OR (osteoporotic fracture[Title/Abstract]) AND (pelvis[Title/Abstract]).
The other databases were searched using similar search strategies. We excluded articles that did
not investigate this topic, as well as review articles, case reports (n<3), commentaries, editorials,
insights articles, and proceedings. We searched for unpublished or gray literature in this systematic
review. We screened websites, organizations, or the reference lists of records identified through the
database search. Two researchers (TK and TA) independently evaluated the eligibility of retrieved
articles and any disagreements were resolved based on a discussion. No ethics committee or
institutional review board approval was required for this systematic review.
Quality assessment
Quality assessment was performed according to the Newcastle−Ottawa Scale,27 as the eligible
studies were not randomized trials (prospective or retrospective cohort studies). Two researchers(TK and TA) independently screened the extracted literature and extracted the data to ensure theconsistency of the results; any disagreements were resolved with a discussion.
Data extraction
The following data were extracted: first author, publication year, study type, patient (ie, numberof patients, Rommens FFP classification,10-13 age, and sex), surgical patients (ie, number of patients,
age, sex, and surgical treatment), non-surgical patients (ie, number of patients, age, sex), clinicalcharacteristics (ie, Rommens FFP classification, age, sex, dementia, osteoporosis, diabetes mellitus,
pulmonary disease, cardiovascular disease, and malignancy), complications (ie, pneumonia, urinary
tract infection, cardiac event, thrombosis, pulmonary embolism, pressure ulcer, multiple organ
failure, anemia caused by surgical bleeding, and surgical site infection), and outcomes (hospitalmortality and one-year mortality). Two researchers (TK and TA) independently extracted the data.
Data analysis and statistical methods
This systematic review was performed using the Review Manager software program (version
5.3; The Cochrane Collaboration, Oxford, United Kingdom). The number of events was enteredfor binary variables and the number of subjects, as well as the mean value and standard deviationof continuous variables and the number of subjects. The X 2 test and I 2 statistic were performed
to assess the heterogeneity level: insignificant (I 2 0% to <25%), low (I 2 25% to <50%), andsignificant (I 2 50–100%). If significant heterogeneity was observed (p<0.10 and I 2>50%), a
random-effects model was used for the analysis. Otherwise, a fixed-effects model was used.
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Takaomi Kobayashi et al

Binary variables were evaluated using odds ratios (ORs) with 95% confidence intervals (CIs).
Continuous variables were evaluated using mean difference (MDs) with 95% CIs. P values of<0.05 were considered to indicate statistical significance. One researcher (TK) performed all of
the statistical analyses.

RESULTS
Search results
Figure 2 shows the PRISMA flow chart for our systematic review. The initial database search
identified 376 records. After screening, 7 records underwent full-text review. Two full-text records

Fig. 2Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart
describing article selection

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FFP, 379 (type I, 56;
type II, 200; type III,58; type IV, 65)
Age (years), 81.3 ± 7.5
Gender (men/women),
74/305

FFP, 362 (type II, 238;
type III/IV, 124)
Age (years), 81
Gender (men/women),
48/314

FFP, 64 (type III, 40;
type IV, 24)
Age (years), 82.6 ± 6.4
Gender (men/women),
6/58

FFP, 151 (type I, 12;
type II, 81; type III,
11; type IV, 47)
Age (years), 81.8 ± 2.4
Gender (men/women),
20/131Retrospective

Retrospective

Retrospective

Prospective

Oberkircher et al,
202120

Gericke et al,
202121

Rommens et al,
202122

Saito et al,
202123

Nuber et al,
202124

Surgical patient

Surgical treatment, 58(N/A)
Age (years), 79.7 ± 1.9
Gender (men/women),
6/52

Surgical treatment, 20(N/A)
Age (years), 81.6 ± 5.6
Gender (men/women),
0/20

Surgical treatment, 138(percutaneous surgery,
118; ORIF, 20)
Age (years), 79
Gender (men/women),
15/123

Surgical treatment, 168(percutaneous surgery,74; ORIF, 94)
Age (years), 79.4 ± 6.6
Gender (men/women),
38/130Surgical treatment, 48(percutaneous surgery,35; ORIF, 13)Age (years), 78.5 ± 7.0
Gender (men/women),
N/A

FFP: fragility fracture of the pelvis
ORIF: open reduction and internal fixation
N/A: not available
Values (age) are expressed as the mean ± standard deviation or the median.

Patient

FFP, 134 (type I, 41;
type II, 81; type III,
10; type IV, 2)
Age (years), 79.9 ± 7.7
Gender (men/women),
52/82

Study design

Prospective

Author, Year

Non-surgical treatment,93
Age (years), 83.1 ± 1.6
Gender (men/women),
14/79

Non-surgical treatment,
44
Age (years), 83.1 ± 6.7
Gender (men/women),
6/38

Non-surgical treatment,
224
Age (years), 82
Gender (men/women),
33/191

Non-surgical treatment,
211
Age (years), 82.8 ± 7.8
Gender (men/women),
36/175

Non-surgical treatment,86
Age (years), 80.7 ± 7.6
Gender (men/women),
N/A

Non-surgical patient

Table 1 Summary of selected studies
Characteristic

Age and sex

Age and sex

Rommens FFP classification, sex, dementia,
osteoporosis, diabetes
mellitus, pulmonary
disease, cardiovasculardisease, and malignancy

Rommens FFP classification, age, sex,dementia, osteoporosis,
diabetes mellitus,
pulmonary disease,cardiovascular disease,and malignancy

Rommens FFP classification and age

Complication

Pneumonia, urinary tract
infection, thrombosis,
anemia caused bysurgical bleeding, andsurgical site infection

Pneumonia, urinary tract
infection, cardiac event,and pressure ulcer

Pneumonia, urinary tract
infection, cardiac event,thrombosis, pulmonary
embolism, and pressure
ulcer

Pneumonia, cardiac event, thrombosis,
pulmonary embolism,
multiple organ failure,anemia caused bysurgical bleeding, andsurgical site infection

Pneumonia, urinary tract
infection, cardiac event,pulmonary embolism,
multiple organ failure,anemia caused bysurgical bleeding, andsurgical site infection

OutcomeOne-yearmortality

One-yearmortality

Hospitalmortality
and one-year
mortality

N/A

Hospitalmortality

Fragility fracture of the pelvis

doi:10.18999/nagjms.85.1.35

Takaomi Kobayashi et al

were excluded due to a lack of comparison (ie, non-surgical cases).16,19 No eligible articles wereidentified from websites, organizations, or the reference lists. Finally, we found 5 publishedstudies20-24 involving 1,090 patients with FFP (surgical patients, n = 432; non-surgical patients,n = 658) that were eligible for inclusion in the present systematic review (Table 1).
Risk-of-bias assessment
Table 2 shows the Newcastle−Ottawa Scale scores for the selected studies. The scores ranged
from 6 to 7. We therefore considered the present systematic review to be of acceptable quality.
Risk of publication bias
Figure 3 shows a funnel plot of age. All values were inside the range of acceptability andclose to the no-effect line. Thus, we considered that this systematic review was associated withan acceptable degree of publication bias.
Table 2 Assessment of the quality of studies according to the Newcastle−Ottawa Scale forcohort studies
Study

Selection

Comparability

OutcomeScore

Oberkircher et al, 2021

•••

•

••

6

Gericke et al, 2021

•••

•••

6

Rommens et al, 202122

••

•

•••

6

Saito et al, 2021

••

•

•••

6

•••

•

•••

7

20

21

23

Nuber et al, 2021

24

Fig. 3

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Funnel plot of age

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Fragility fracture of the pelvis

Main results
Regarding the clinical characteristics, nine factors were identified in this systematic review(Figs. 4 and 5). We found no heterogeneity in FFP type III and IV (I 2 = 0%, p = 0.93), age(I 2 = 0%, p = 0.55), female (I 2 = 44%, p = 0.15), dementia (I 2 = 0%, p = 0.92), osteoporosis (I 2 = 16%,
p = 0.28), diabetes mellitus (I 2 = 0%, p = 0.45), pulmonary disease (I 2 = 0%, p = 0.95), cardiovasculardisease (I 2 = 0%, p = 0.40), or malignancy (I 2 = 0%, p = 0.52). Therefore, a fixed model was used.
FFP type III and IV (OR = 8.44; 95% CI 5.99 to 11.88; p<0.00001), younger age (MD = –3.29;
95% CI –3.83 to –2.75; p<0.00001), absence of dementia (OR = 0.36; 95% CI 0.23 to 0.57;
p<0.0001), and presence of osteoporosis (OR = 1.74; 95% CI 1.29 to 2.35; p = 0.0003) wereassociated with the surgical patients. No significant differences existed in the other clinicalcharacteristics of the surgical and non-surgical patients.
Regarding the complications, nine factors were identified in this systematic review (Figs.
6 and 7). We found no heterogeneity in pneumonia (I 2 = 0%, p = 0.90), urinary tract infection(I 2 = 9%, p = 0.35), cardiac event (I 2 = 0%, p = 0.91), thrombosis (I 2 = 19%, p = 0.29), pulmonary

Fig. 4
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Forest plot of the clinical characteristics

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Takaomi Kobayashi et al

Fig. 5

Forest plot of the clinical characteristics (continued)

embolism (I 2 = 0%, p = 0.54), pressure ulcer (I 2 = 34%, p = 0.22), multiple organ failure (I 2 = 0%,
p = 0.93), anemia caused by surgical bleeding (I 2 = 0%, p = 0.87), or surgical site infection (I 2 = 0%,
p = 0.62). According to these results, a fixed model was used. Urinary tract infection (OR = 2.06;
95% CI 1.37 to 3.10; p = 0.0005), anemia caused by surgical bleeding (OR = 4.55; 95% CI 1.95
to 10.62; p = 0.0005), and surgical site infection (OR = 16.74; 95% CI 3.05 to 91.87; p = 0.001)
were associated with the surgical patients. No significant differences were observed in the othercomplications of the surgical and non-surgical patients.
Regarding the outcomes, two factors were identified in this systematic review (Fig. 7). We
found no heterogeneity in hospital mortality (I 2 = 0%, p = 0.52). According to these results, a fixed
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Fragility fracture of the pelvis

model was used. In contrast, we found a significant heterogeneity in one-year mortality (I 2 = 84%,
p = 0.002), and therefore used a random model. No significant differences were observed in theoutcomes of the surgical and non-surgical patients.

Fig. 6

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Forest plot of the complications

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Takaomi Kobayashi et al

Fig. 7

Forest plot of the complications (continued) and outcomes

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Fragility fracture of the pelvis

DISCUSSION
This systematic review extensively analyzed the clinical characteristics, complications, andoutcomes of FFP patients treated with and without surgery. Nine clinical characteristics were
included in the systematic review, four of which were found to be statistically significant:
FFP type III and IV, younger age, absence of dementia, and presence of osteoporosis. Ninecomplications were included in the systematic review, three of which were identified as statistically significant: urinary tract infection, anemia caused by surgical bleeding, and surgical site
infection. Two outcomes were included in the systematic review, none of which were found to
be statistically significant.
We found that a younger age, the absence of dementia, and the presence of osteoporosis
were associated with the surgical patients having FFP. Interestingly, FFP type III and IV itself isreported to be related to younger age,14,22 absence of dementia,22 and presence of osteoporosis.28
This may be due to the hypothesis proposed in previous studies22,29-31 that a younger age andthe absence of dementia, as well as higher mobility, result in higher stresses on the posterior
pelvis, leading to more unstable fracture types, especially in patients with osteoporosis. Therefore,
we feel that the presence of these clinical characteristics (ie, FFP type III and IV, younger
age, absence of dementia, and presence of osteoporosis) is a viable basis which recommends
surgical treatment for FFP. Furthermore, the osteological diagnosis and possibly anti-osteoporotic
therapy are important in not only non-surgical patients but also surgical patients with FFP. The
administration of anti-osteoporosis medications (eg, calcium and vitamin D supplementation,bisphosphonates, and teriparatide) have a positive effect on healing and provide pain relief
for FFP,32-35 and the failure to administer anti-osteoporosis therapy could result in additional
osteoporotic fractures at secondary sites (eg, hip and vertebrae) within a few years in patientswith FFP.36
We found that urinary tract infection, anemia caused by surgical bleeding, and surgical site
infection were associated with the surgical patients with FFP. Urinary tract infection may be acomplication related to longer length of hospital stay.21-23 Indeed, surgical patients with FFP werereported to be associated with longer length of hospital stay than non-surgical patients (surgicalpatients, mean 18.1–32.7 days; non-surgical patients mean 8.9–23.1 days).20-24 Nevertheless, it
was reported that sepsis was not associated with the surgical patients with FFP.21 Therefore,
urinary tract infection should be a minor complication in most cases, if treated appropriately.
Anemia caused by surgical bleeding is a surgery-related complication.20,21,24 Notably, no significant
difference in anemia caused by surgical bleeding was reported between patients who received
percutaneous and open procedures for FFP.21,37 Surgical site infection is also a surgery-related
complication, especially in patients who undergo open reduction and internal fixation for FFP21,38;
this may occur when the large wound is contaminated by long-term postoperative bed rest and
bed rest excretion. Therefore, minimally invasive surgical treatment (eg, a percutaneous procedure)and getting out of bed early should be prioritized.14,21,39-52
Importantly, other surgery-related complications that have been reported in previous studies
could not be analyzed in this systematic review, including: implant malpositioning (2–7%),16,21,24
superior gluteal artery damage (1%),53 nerve damage (2–15%),21,24 ureteral damage (2%),16,53 bowel
damage,54 wound healing problems,37 instrumentation failure (17–45%),55-57 soft tissue irritation
requiring implant removal,16,38 and cerebrospinal fluid leakage.54 Thus, surgeons should keep inmind these surgery-related complications and apply appropriate prophylaxis and follow-up.
There was no significant difference in the rate of hospital and one-year mortality between
the surgical and non-surgical patients. Furthermore, a previous study reported no significant
difference in two-year or five-year mortality between surgical and non-surgical patients.22 Thus,
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Takaomi Kobayashi et al

the mortality of surgical patients may not be inferior to those of non-surgical patients in thetreatment strategy for FFP.
We could not analyze mobility in this systematic review due to the data of the studies. In
past studies, the improvement in mobility from admission to discharge in surgical patients was
greater than that in non-surgical patients.20,22 Further investigations on this topic will be required.
It is important to clarify the differences between our systematic review and other systematic
reviews on FFP. Booth et al58 searched the literatures on surgical treatment for lateral compression
type one FFP in the Young and Burgess classification of pelvic ring injuries.59 They concluded
that there was insufficient evidence on this topic. Wilson et al17 investigated the literaturesconcerning the surgical treatment for FFP patients who failed a brief period of non-surgicaltreatment. They concluded that surgical treatment for FFP should be considered for FFP patients
who failed a brief period of non-surgical treatment, as it significantly improved pain. We first
focused on the literatures concerning surgical treatment for FFP with the management protocol
described by Rommens et al.10-13 We then investigated the clinical characteristics, complications,and outcomes of surgical and non-surgical patients with FFP. As mentioned above, debate is
ongoing regarding the treatment strategies for FFP. It is necessary to compare the complications
and clinical outcomes of these treatment strategies.
The present systematic review was associated with several limitations. First, a database bias
and English language bias were present. Second, this study was limited based on the quality(selection, comparability, and outcome) of the eligible studies, as shown in Table 2. However,the quality of the present systematic review may be acceptable, as the Newcastle-Ottawa Scalescores ranged from 6 to 7. Third, there was a publication bias in this study. Although we searched
the relevant unpublished or gray literature, all such studies were excluded. However, the riskof publication bias may be acceptable, since all values were inside the range of acceptability
and close to the no-effect line, as illustrated in Fig. 3. Fourth, several surgical techniques ofstabilization were used. Notably, the difference of surgical procedures (ie, percutaneous vs open
procedures) were reported to be significantly associated with the rate of infections, surgical revisions, and mortality.21,37 Accordingly, differences in surgical techniques for stabilization between
surgeons, hospitals, and/or literatures may have affected the results. Additional studies on clinicalcharacteristics, complications, and outcomes based on surgical techniques for stabilization arethus warranted. Fifth, the conservative treatments were not unified, which may have affected our
result. For instance, pain medication managements varied among the eligible literatures, including“not mentioned”,21,22 NSAIDs or acetaminophen,23 and the WHO analgesic ladder.20,24 Similarly,
there were variations in management for delirium among the eligible literatures, including “notmentioned”20–23 and multidisciplinary care by trauma surgeons, geriatrics, specialists in pain
management, physiotherapists, occupational therapists, and speech therapists. 24 However, therehabilitation regimen was similar20-24; early mobilization with full weight bearing assisted byphysiotherapists under pain control. Finally, and most importantly, current evidence on this topic
is still insufficient, possibly due to the fact that the treatment strategy of FFP was first describedin 2013,11 so evidence has only recently been accumulating.60 Further large-sample, high-quality,
and well-documented investigations are necessary to support our findings.

CONCLUSION
The clinical characteristics of FFP type III and IV, younger age, absence of dementia, andthe presence of osteoporosis and the complications of urinary tract infection, anemia caused bysurgical bleeding, and surgical site infection were associated with the surgical patients with FFP.
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Fragility fracture of the pelvis

There were no significant differences in the outcomes between the surgical and non-surgicalpatients. Our findings may help understand the treatment strategy for FFP described by Rommens
et al and be useful for improving the clinical outcomes of FFP patients. The current evidence
is still insufficient on this topic, and further large-sample, high-quality, and well-documented
investigations are therefore necessary to support our findings.

CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.

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