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Fritz T, Orth M, Hopp SJ, Briem J, Hahner J, Osche D, Pohlemann T, Pizanis A. A novel minimally invasive and press-fit method for symphysiodesis - a biomechanical analysis. J Exp Orthop 2023; 10:98. [PMID: 37768379 PMCID: PMC10539247 DOI: 10.1186/s40634-023-00660-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
PURPOSE Does the cylindrical shaped bone block allow a stable construct for the arthrodesis of the pubic symphysis compared to a rectangular shaped bone block. The cylindrical shaped bone block stabilized by a 3.5 symphyseal plate is inferior to the stabilization with an internal fixator. METHODS This study analyzed the arthrodesis of the pubic symphysis on 24 synthetic pelvises, using a rectangular shaped bone block (control group) or a cylindrical shaped bone block, stabilized with a symphysis locking plate (n = 8) as the standard clinical procedure. Additionally we analyzed the stability using an internal fixator. RESULTS This study showed that utilizing a cylindrical shaped synthetic bone graft results in a significant higher contact area and compression force compared to the classical rectangular shaped graft. Furthermore, the stabilization with an internal fixator had the tendency for increases of compression force and contact area, yet without a statistical significance, when compared to the plate fixation. CONCLUSION The novel method of cylindrical symphysis resection and cylindrical bone block implantation allowed an increased biomechanical stability compared to using a classical rectangular bone graft, also resulting in higher contact area. Moreover, this technique would also allow a minimally invasive approach for this purpose, which in turn could preserve perisymphyseal ligaments, thereby improving healing in a clinical context.
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Affiliation(s)
- Tobias Fritz
- Department for Trauma, Hand and Reconstructive Surgery, Saarland University Medical Center, Kirrbergerstr. 1, Homburg, Saarland, 66421, Germany.
| | - Marcel Orth
- Department for Trauma, Hand and Reconstructive Surgery, Saarland University Medical Center, Kirrbergerstr. 1, Homburg, Saarland, 66421, Germany
| | - Sascha J Hopp
- Department for Trauma, Hand and Reconstructive Surgery, Saarland University Medical Center, Kirrbergerstr. 1, Homburg, Saarland, 66421, Germany
- Lutrina Hospital, Kaiserslautern, Brüsseler Str. 7, 67655, Kaiserslautern, Germany
| | - Jeremy Briem
- Department for Trauma, Hand and Reconstructive Surgery, Saarland University Medical Center, Kirrbergerstr. 1, Homburg, Saarland, 66421, Germany
- Department of Trauma and Reconstructive Surgery, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, 72076, Tuebingen, Germany
| | - Jill Hahner
- Department for Trauma, Hand and Reconstructive Surgery, Saarland University Medical Center, Kirrbergerstr. 1, Homburg, Saarland, 66421, Germany
| | - David Osche
- Department for Trauma, Hand and Reconstructive Surgery, Saarland University Medical Center, Kirrbergerstr. 1, Homburg, Saarland, 66421, Germany
| | - Tim Pohlemann
- Department for Trauma, Hand and Reconstructive Surgery, Saarland University Medical Center, Kirrbergerstr. 1, Homburg, Saarland, 66421, Germany
| | - Antonius Pizanis
- Department for Trauma, Hand and Reconstructive Surgery, Saarland University Medical Center, Kirrbergerstr. 1, Homburg, Saarland, 66421, Germany
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Jordan MC, Bröer D, Fischer C, Heilig P, Gilbert F, Hölscher-Doht S, Kalogirou C, Popp K, Grunz JP, Huflage H, Jakubietz RG, Ergün S, Meffert RH. Development and preclinical evaluation of a cable-clamp fixation device for a disrupted pubic symphysis. COMMUNICATIONS MEDICINE 2022; 2:164. [PMID: 36550296 PMCID: PMC9780275 DOI: 10.1038/s43856-022-00227-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Traumatic separation of the pubic symphysis can destabilize the pelvis and require surgical fixation to reduce symphyseal gapping. The traditional approach involves open reduction and the implantation of a steel symphyseal plate (SP) on the pubic bone to hold the reposition. Despite its widespread use, SP-fixation is often associated with implant failure caused by screw loosening or breakage. METHODS To address the need for a more reliable surgical intervention, we developed and tested two titanium cable-clamp implants. The cable served as tensioning device while the clamp secured the cable to the bone. The first implant design included a steel cable anterior to the pubic symphysis to simplify its placement outside the pelvis, and the second design included a cable encircling the pubic symphysis to stabilize the anterior pelvic ring. Using highly reproducible synthetic bone models and a limited number of cadaver specimens, we performed a comprehensive biomechanical study of implant stability and evaluated surgical feasibility. RESULTS We were able to demonstrate that the cable-clamp implants provide stability equivalent to that of a traditional SP-fixation but without the same risks of implant failure. We also provide detailed ex vivo evaluations of the safety and feasibility of a trans-obturator surgical approach required for those kind of fixation. CONCLUSION We propose that the developed cable-clamp fixation devices may be of clinical value in treating pubic symphysis separation.
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Affiliation(s)
- Martin C Jordan
- Department of Orthopaedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
| | - David Bröer
- Department of Orthopaedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Christian Fischer
- Headmade Materials, Langhausstraße 9, 97294, Unterpleichfeld, Germany
| | - Philipp Heilig
- Department of Orthopaedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Fabian Gilbert
- Center of Musculoskeletal Medicine, University Hospital LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Stefanie Hölscher-Doht
- Department of Orthopaedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Charis Kalogirou
- Department of Urology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Kevin Popp
- Additive Manufacturing Research Unit, SKZ Technology Center, Friedrich-Bergius-Ring 22, 97076, Würzburg, Germany
| | - Jan-Peter Grunz
- Department of Radiology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Henner Huflage
- Department of Radiology, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Rafael G Jakubietz
- Department of Orthopaedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Süleyman Ergün
- Institute of Anatomy, Julius-Maximilians-University Würzburg, Koellikerstraße 6, 97070, Würzburg, Germany
| | - Rainer H Meffert
- Department of Orthopaedic Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
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Zheng YQ, Chen LL, Shen JZ, Gao B, Huang XC. Biomechanical evaluation of seven fixation methods to treat pubic symphysis diastasis using finite element analysis. J Orthop Surg Res 2022; 17:189. [PMID: 35346277 PMCID: PMC8961909 DOI: 10.1186/s13018-022-03078-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/16/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pubic symphysis diastasis (PSD) hinders the connection between bilateral ischia and pubic bones, resulting in instability of the anterior pelvic ring. PSD exceeding 25 mm is considered disruptions of the symphyseal and unilateral/bilateral anterior sacroiliac ligaments and require surgical intervention. The correct choice of fixation devices is of great significance to treat PSD. This study aimed to evaluate the construct stability and implant performance of seven fixation methods to treat PSD using finite element analysis.
Methods
The intact skeleton-ligament pelvic models were set as the control group. PSD models were simulated by removing relevant ligaments. To enhance the stability of the posterior pelvic ring, a cannulated screw was applied in the PSD models. Next, seven anterior fixation devices were installed on the PSD models according to standard surgical procedures, including single plates (single-Plate group), single plates with trans-symphyseal cross-screws (single-crsPlate group), dual plates (dual-Plate group), single cannulated screws, dual crossed cannulated screws (dual-canScrew group), subcutaneous plates (sub-Plate group), and subcutaneous pedicle screw-rod devices (sub-PedRod group). Compression and torsion were applied to all models. The construct stiffness, symphyseal relative micromotions, and von Mises stress performance were recorded and analyzed.
Results
The construct stiffness decreased dramatically under PSD conditions. The dual-canScrew (154.3 ± 9.3 N/mm), sub-Plate (147.1 ± 10.2 N/mm), and sub-PedRod (133.8 ± 8.0 N/mm) groups showed better ability to restore intact stability than the other groups (p < 0.05). Regarding regional stability, only single-plate fixation provided unexpected regional stability with a diastasis of 2.1 ± 0.2 mm (p < 0.001) under a compressive load. Under a rotational load, the single-crsPlate group provided better regional angular stability (0.31° ± 0.03°, p < 0.001). Stress concentrations occurred in the single-Plate, sub-Plate, and sub-PedRod groups. The maximum von Mises stress was observed in the single-plate group (1112.1 ± 112.7 MPa, p < 0.001).
Conclusion
The dual-canScrew fixation device offers ideal outcomes to maintain stability and prevent failure biomechanically. The single-crsPlate and dual-Plate methods effectively improved single-Plate device to enhance regional stability and disperse stresses. The subcutaneous fixation devices provided both anterior pelvic ring stability and pubic symphysis strength.
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Jordan MC, Jäckle V, Scheidt S, Gilbert F, Hölscher-Doht S, Ergün S, Meffert RH, Heintel TM. Trans-obturator cable fixation of open book pelvic injuries. Sci Rep 2021; 11:13463. [PMID: 34188088 PMCID: PMC8241833 DOI: 10.1038/s41598-021-92755-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/15/2021] [Indexed: 01/13/2023] Open
Abstract
Operative treatment of ruptured pubic symphysis by plating is often accompanied by complications. Trans-obturator cable fixation might be a more reliable technique; however, have not yet been tested for stabilization of ruptured pubic symphysis. This study compares symphyseal trans-obturator cable fixation versus plating through biomechanical testing and evaluates safety in a cadaver experiment. APC type II injuries were generated in synthetic pelvic models and subsequently separated into three different groups. The anterior pelvic ring was fixed using a four-hole steel plate in Group A, a stainless steel cable in Group B, and a titan band in Group C. Biomechanical testing was conducted by a single-leg-stance model using a material testing machine under physiological load levels. A cadaver study was carried out to analyze the trans-obturator surgical approach. Peak-to-peak displacement, total displacement, plastic deformation and stiffness revealed a tendency for higher stability for trans-obturator cable/band fixation but no statistical difference to plating was detected. The cadaver study revealed a safe zone for cable passage with sufficient distance to the obturator canal. Trans-obturator cable fixation has the potential to become an alternative for symphyseal fixation with less complications.
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Affiliation(s)
- Martin C Jordan
- Department of Orthopaedic Traumatology, University Hospital Würzburg, Julius-Maximilians-University Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany.
| | - Veronika Jäckle
- Department of Orthopaedic Traumatology, University Hospital Würzburg, Julius-Maximilians-University Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Sebastian Scheidt
- Department of Orthopaedic Surgery, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Fabian Gilbert
- Department of Orthopedics, Physical Medicine and Rehabilitation, University Hospital LMU München, Marchioninistr. 15, 81377, München, Germany
| | - Stefanie Hölscher-Doht
- Department of Orthopaedic Traumatology, University Hospital Würzburg, Julius-Maximilians-University Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Süleyman Ergün
- Institute of Anatomy, Julius-Maximilians-University Würzburg, Koellikerstraße 6, 97070, Würzburg, Germany
| | - Rainer H Meffert
- Department of Orthopaedic Traumatology, University Hospital Würzburg, Julius-Maximilians-University Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
| | - Timo M Heintel
- Department of Orthopaedic Traumatology, University Hospital Würzburg, Julius-Maximilians-University Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Germany
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Barrientos-Mendoza C, Brañes J, Wulf R, Kremer A, Barahona M, León S. The role of anterior supra-acetabular external fixator as definitive treatment for anterior ring fixation in unstable pelvic fractures. Eur J Trauma Emerg Surg 2021; 48:3737-3746. [PMID: 34097076 DOI: 10.1007/s00068-021-01711-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Management of anterior ring injuries is still a matter of discussion, and there are only few studies reporting anterior external fixator as definitive treatment for unstable pelvic injuries. This study aimed to describe the clinical and radiological outcomes of a consecutive series of mechanically unstable pelvic injuries that were treated with definitive anterior supra-acetabular external fixator for the anterior ring, and to identify risk factors for failure. METHODS We included a consecutive series of patients with unstable pelvic ring fractures who underwent anterior supra-acetabular external fixation for definitive treatment, between January 2012 and January 2020. All demographics, associated injuries and procedures, injury mechanism, and complications were analysed. Pelvic fracture was classified based on Orthopaedic Trauma Association/Tile AO (OTA/AO) and Young-Burgess classifications. Complications associated with the external fixator were revised. All patients were functionally evaluated at final follow-up and asked to report their clinical outcomes using the Majeed score. RESULTS A total of 47 patients were included, of which 25 were females. The median age was 44 years (interquartile range 23-59). Median follow-up duration was 14 months (interquartile range 6-31). The most frequent aetiology was motor vehicle accident (35), followed by fall from height (8). All fractures required posterior pelvic ring fixation. The median time during which patients had external fixation in situ was 11 weeks (interquartile range 9-13). All patients achieved healing of pelvic fracture at median time of 10 weeks (interquartile range 8-12). At final follow-up, the median displacement of the anterior pelvis was 6 mm (interquartile range 0-11). Superficial infection was the most common complication (n = 7). No washout procedures were needed. No major complication was reported. No patient required reoperation for anterior ring fracture. The median Majeed score was 88 points (range 60-95; interquartile range 80-90) at final follow-up. CONCLUSION Our findings suggest that the use of supra-acetabular external fixator is safe and effective for definitive treatment of the anterior ring in unstable pelvic fractures. It is a method with high proportion of excellent results, regardless of the type of fracture. The rate of complications is low, and it does not compromise functional results.
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Affiliation(s)
- Cristián Barrientos-Mendoza
- Orthopaedics Department, Hospital San José, San Jose 1196, 8380219, Santiago, Region Metropolitana, Chile. .,Orthopaedics Department, Hospital Clínico de La Universidad de Chile, Santiago, Chile. .,Orthopaedics Department, Hip and Pelvis Unit, Clínica Santa María, Santiago, Chile.
| | - Julián Brañes
- Orthopaedics Department, Hospital San José, San Jose 1196, 8380219, Santiago, Region Metropolitana, Chile.,Orthopaedics Department, Hospital Clínico de La Universidad de Chile, Santiago, Chile
| | - Rodrigo Wulf
- Orthopaedics Department, Hospital Clínico de La Universidad de Chile, Santiago, Chile
| | - Alex Kremer
- Orthopaedics Department, Hospital San José, San Jose 1196, 8380219, Santiago, Region Metropolitana, Chile
| | - Maximiliano Barahona
- Orthopaedics Department, Hospital Clínico de La Universidad de Chile, Santiago, Chile
| | - Sebastián León
- Orthopaedics Department, Hospital San José, San Jose 1196, 8380219, Santiago, Region Metropolitana, Chile.,Orthopaedics Department, Hospital Clínico de La Universidad de Chile, Santiago, Chile
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Jordan MC, Jäckle V, Scheidt S, Eden L, Gilbert F, Heintel TM, Jansen H, Meffert RH. [Outcome after plate stabilization of symphyseal diastasis]. Unfallchirurg 2020; 123:870-878. [PMID: 32347368 PMCID: PMC7653790 DOI: 10.1007/s00113-020-00804-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Hintergrund Die Symphysensprengung mit entsprechender Diastase kann durch eine Symphysenplatte stabilisiert werden. Fragestellung Welche Beckenverletzungen werden mit einer Symphysenplatte stabilisiert und wie ist das Outcome? Material und Methoden Retrospektive Auswertung von 64 Patienten über einen Untersuchungszeitraum von 24 Monaten. Ergebnisse Es waren 56 Patienten männlich, 8 weiblich und das mittlere Alter betrug 44 Jahre (SD ± 17). Unfälle im Straßenverkehr waren der führende Grund für die Beckenverletzung. Die Verteilung nach AO-Klassifikation zeigte sich wie folgt: 14-mal B1-, 10-mal B2-, 5‑mal B3-, 23-mal C1-, 9‑mal C2- und 3‑mal C3-Verletzungen. Die Verteilung nach Young und Burgess ergab: 9‑mal APC-I-, 18-mal APC-II-, 13-mal APC-III-, 9‑mal LC-I-, 3‑mal LC-II-, 2‑mal LC-III- und 10-mal VS-Verletzungen. Der mittlere Injury Severity Score (ISS) betrug 32 und die mittlere stationäre Verweildauer 29 Tage (pos. Korrelation p ≤ 0,001). Im Verlauf war eine radiologische Implantatlockerung bei 52 Patienten nachweisbar. Therapierelevante Komplikationen gab es in 14 Fällen. Hierbei war das Implantatversagen (n = 8) der Hauptgrund für eine operative Revision. Diskussion Obwohl die radiologische Implantatlockerung häufig beobachtet wird, ist sie nur selten Grund für einen Revisionseingriff. Kommt es hingegen zum vollständigen Implantatversagen, tritt dies meist innerhalb der ersten postoperativen Wochen auf und ist revisionsbedürftig. Eine frühzeitige Abklärung durch Röntgenbildgebung sollte bei Verdacht erfolgen.
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Affiliation(s)
- Martin C Jordan
- Klinik und Poliklinik für Unfall‑, Hand‑, Plastische und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 8, 97080, Würzburg, Deutschland.
| | - Veronika Jäckle
- Klinik und Poliklinik für Unfall‑, Hand‑, Plastische und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 8, 97080, Würzburg, Deutschland
| | - Sebastian Scheidt
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Venusberg-Campus 1, 53127, Bonn, Deutschland
| | - Lars Eden
- Klinik und Poliklinik für Unfall‑, Hand‑, Plastische und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 8, 97080, Würzburg, Deutschland
| | - Fabian Gilbert
- Klinik und Poliklinik für Unfall‑, Hand‑, Plastische und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 8, 97080, Würzburg, Deutschland
| | - Timo M Heintel
- Klinik und Poliklinik für Unfall‑, Hand‑, Plastische und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 8, 97080, Würzburg, Deutschland
| | - Hendrik Jansen
- Klinik und Poliklinik für Unfall‑, Hand‑, Plastische und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 8, 97080, Würzburg, Deutschland
| | - Rainer H Meffert
- Klinik und Poliklinik für Unfall‑, Hand‑, Plastische und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 8, 97080, Würzburg, Deutschland
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Hopp SJ, Pizanis A, Briem J, Hahner J, Mettelsiefen L, Herath SC, Histing T, Pohlemann T, Fritz T. A novel press-fit minimally-invasive symphysiodesis technique. J Exp Orthop 2020; 7:67. [PMID: 32940814 PMCID: PMC7498525 DOI: 10.1186/s40634-020-00284-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/01/2020] [Indexed: 11/17/2022] Open
Abstract
Objective Instability of the pubic symphysis often results in a poor outcome and reduced mobility of the patient. In some cases, an arthrodesis of the pubic symphysis is required. Until today, there is no data published how many of these procedures are performed annually and there is also no data about the outcome after this extensive surgery. Methods We developed a novel surgical technique to address the arthrodesis of the pubic symphysis in a minimally invasive approach. Therefore, we used for this purpose modified instruments and performed the transplantation of a cylindrical bone substitute into the pubic symphysis, without an extensive approach or dissecting the anterior or posterior symphyseal ligaments. Results Using this novel technique, a minimally invasive symphysiodesis was achieved in radiological findings, after the procedure. Conclusion Thus, this actually minimally invasive surgical technique seems to be a promising advancement for the arthrodesis of the pubic symphysis.
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Affiliation(s)
- Sascha J Hopp
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital of Saarland, Kirrbergerstr 1, 66421, Homburg/Saar, Germany.,Groin Pain and Core Injury Center, Lutrina Clinic, Karl-Marx-Straße 33, 67655, Kaiserslautern, Germany
| | - Antonius Pizanis
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital of Saarland, Kirrbergerstr 1, 66421, Homburg/Saar, Germany
| | - Jeremy Briem
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital of Saarland, Kirrbergerstr 1, 66421, Homburg/Saar, Germany
| | - Jill Hahner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital of Saarland, Kirrbergerstr 1, 66421, Homburg/Saar, Germany
| | - Laura Mettelsiefen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital of Saarland, Kirrbergerstr 1, 66421, Homburg/Saar, Germany
| | - Steven C Herath
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital of Saarland, Kirrbergerstr 1, 66421, Homburg/Saar, Germany
| | - Tina Histing
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital of Saarland, Kirrbergerstr 1, 66421, Homburg/Saar, Germany
| | - Tim Pohlemann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital of Saarland, Kirrbergerstr 1, 66421, Homburg/Saar, Germany
| | - Tobias Fritz
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital of Saarland, Kirrbergerstr 1, 66421, Homburg/Saar, Germany.
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A novel internal fixation method for open book injuries of the pubic symphysis- A biomechanical analysis. Clin Biomech (Bristol, Avon) 2020; 77:105009. [PMID: 32454345 DOI: 10.1016/j.clinbiomech.2020.105009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 04/06/2020] [Accepted: 04/09/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pelvic fractures in adults are common injuries and account for up to 3.64% of all fractures. Usually, the treatment of open book injuries (Types B1.1 and B1.2 AO-Classification) is open reduction and plate stabilization using dynamic compression plates, with or without interlocking screws. These implants seem to enhance the outcome of such injuries, but also variety of complications occurs. To reduce complications and achieve appropriate reduction and stabilization, this study compared established stabilization techniques to a novel minimally invasive internal fixation method using an internal fixator system that is already being utilized for spinal fractures. METHODS This study was performed on 32 composite pelvises in a bilateral stance biomechanical model. The pelvises were variously stabilized with an internal fixator, a 4.5 mm dynamic compression plate and a 3.5 mm symphyseal locking dynamic compression plate. The contact area and loading forces were assessed by a sensor film inside the symphyseal gap. FINDINGS This study showed significantly greater reduction and loading capabilities of the internal fixator compared to the other implants (p < 0.05). There was also significantly greater contact area with the use of an internal fixator compared to the other implants (p < 0.05). The 3.5 mm interlocking plate showed significantly greater contact area compared to the 4.5 mm plate (p < 0.05). INTERPRETATION The internal fixator that is already proven in spinal surgery is biomechanically superior to conventional implants used in pelvic surgery. The contact area analysis furthermore showed a more physiological loading pattern, which can improve ligamentous healing in a clinical context.
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Fritz T, Braun BJ, Veith NT, Hopp SJ, Mettelsiefen L, Strobel F, Pohlemann T, Pizanis A. Stabilization of a Type B1.1 Injury in a Morbidly Obese Patient Using an Internal Fixator in a Minimally Invasive Technique: A Case Report. JBJS Case Connect 2020; 9:e0075. [PMID: 31469666 DOI: 10.2106/jbjs.cc.18.00075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
CASE In this case report, we present a novel stabilization technique of the pubic symphysis using an internal spinal fixator in a 78-year-old morbidly obese woman having a pelvic disruption type B1.1 (AO classification). We treated the disruption using an internal fixator to reduce the extent of the incision and soft-tissue damage. CONCLUSIONS The use of an internal fixator, known from percutaneous spinal fixation, for the stabilization of the pubic symphysis in cases of disruption ("open book" injuries) may be an alternative to the standard plate fixation as a novel minimally invasive stabilization technique.
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Affiliation(s)
- Tobias Fritz
- Department of Trauma, Hand and Reconstrutive Surgery, Saarland University Hospital, Homburg, Germany
| | - Benedikt J Braun
- Department of Trauma, Hand and Reconstrutive Surgery, Saarland University Hospital, Homburg, Germany
| | - Nils T Veith
- Department of Trauma, Hand and Reconstrutive Surgery, Saarland University Hospital, Homburg, Germany
| | - Sascha J Hopp
- Department of Trauma, Hand and Reconstrutive Surgery, Saarland University Hospital, Homburg, Germany.,Lutrina Clinic, Kaiserslautern, Germany
| | - Laura Mettelsiefen
- Department of Trauma, Hand and Reconstrutive Surgery, Saarland University Hospital, Homburg, Germany
| | - Friedemann Strobel
- Department of Trauma, Hand and Reconstrutive Surgery, Saarland University Hospital, Homburg, Germany
| | - Tim Pohlemann
- Department of Trauma, Hand and Reconstrutive Surgery, Saarland University Hospital, Homburg, Germany
| | - Antonius Pizanis
- Department of Trauma, Hand and Reconstrutive Surgery, Saarland University Hospital, Homburg, Germany
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Petryla G, Uvarovas V, Šatkauskas I, Masionis P, Porvaneckas N. Non-anatomic fixation for longstanding traumatic pubic diastasis using a bone graft: A report of two cases. Chin J Traumatol 2017; 20:362-365. [PMID: 29198716 PMCID: PMC5832458 DOI: 10.1016/j.cjtee.2017.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 07/03/2017] [Accepted: 07/14/2017] [Indexed: 02/04/2023] Open
Abstract
The incidence of internal fixation failure of symphysis diastasis varies from 6% to 75%. Hardware breakage or migration and symphysis disruption recurrence are often asymptomatic and only in a few cases reoperation is required. This report describes the managements of two cases after failed internal fixation and neglected traumatic symphysis diastasis when it was technically impossible to achieve anatomical reduction of the anterior pelvic ring. Internal fixation and a bone graft for the symphysis without anatomical reposition were performed. Both of the patients achieved good results and had no complaints of pain during daily activities. Restoration of the anatomy should not be the aim in treating recurrence of the symphysis diastasis after failed fixation. The aim of the surgery was static fixation of the anterior pelvic ring with bone grafting.
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Affiliation(s)
- Giedrius Petryla
- Department of Orthopedics and Traumatology, Vilnius University Faculty of Medicine, Republican Vilnius University Hospital, Šiltnamių Str. 29, 04130, Vilnius, Lithuania
| | - Valentinas Uvarovas
- Department of Orthopedics and Traumatology, Vilnius University Faculty of Medicine, Republican Vilnius University Hospital, Šiltnamių Str. 29, 04130, Vilnius, Lithuania
| | - Igoris Šatkauskas
- Department of Orthopedics and Traumatology, Vilnius University Faculty of Medicine, Republican Vilnius University Hospital, Šiltnamių Str. 29, 04130, Vilnius, Lithuania
| | - Povilas Masionis
- Department of Orthopedics and Traumatology, Vilnius University Faculty of Medicine, Republican Vilnius University Hospital, Šiltnamių Str. 29, 04130, Vilnius, Lithuania.
| | - Narūnas Porvaneckas
- Department of Orthopedics and Traumatology, Vilnius University Faculty of Medicine, Republican Vilnius University Hospital, Šiltnamių Str. 29, 04130, Vilnius, Lithuania
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11
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Abstract
Chronic anterior pelvic ring instability can cause pain and disability. Pain typically is localized to the suprapubic area or inner thigh; often is associated with lower back or buttock pain; and may be exacerbated by activity, direct impact, or pelvic ring compression. Known etiologies of chronic anterior pelvic ring instability include pregnancy, parturition, trauma, insufficiency fractures, athletics, prior surgery, and osteitis pubis. Diagnosis often is delayed. Physical examination may reveal an antalgic or waddling gait, tenderness over the pubic bones or symphysis pubis, and pain with provocative maneuvers. AP pelvic radiographs may demonstrate chronic degenerative changes at the pubic symphysis or nonhealing fractures. Standing single leg stance (flamingo view) radiographs can demonstrate pathologic motion at the pubic symphysis. CT may be useful in assessing posterior pelvic ring involvement. The initial management is typically nonsurgical and may include the use of an orthosis, activity modification, medication, and physical therapy. If nonsurgical modalities are unsuccessful, surgery may be warranted, although little evidence exists to guide treatment. Surgical intervention may include internal fixation alone in select patients, the addition of bone graft to fixation, or symphyseal arthrodesis. In some patients, additional stabilization or arthrodesis of the posterior pelvic ring may be indicated.
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Weng PW, Chen CH, Luo CA, Sun JS, Tsuang YH, Cheng CK, Lin SC. The effects of tibia profile, distraction angle, and knee load on wedge instability and hinge fracture: A finite element study. Med Eng Phys 2017; 42:48-54. [DOI: 10.1016/j.medengphy.2017.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 10/16/2016] [Accepted: 01/01/2017] [Indexed: 11/26/2022]
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Michelitsch C, Nguyen-Kim TDL, Jentzsch T, Simmen HP, Werner CML. Computed tomography-based three-dimensional visualisation of bone corridors and trajectories for screws in open reduction and internal fixation of symphysis diastasis: a retrospective radiological study. Arch Orthop Trauma Surg 2016; 136:1673-1681. [PMID: 27628459 DOI: 10.1007/s00402-016-2568-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Typical stabilisation of pelvic open book injuries consists of plate fixation of the symphysis. No previous literature has been published about the evaluation of screw placement and their trajectory with four oblique 4.5 mm screws using a four-hole plate in symphysis diastasis. The aim of this study was to define insertion points and angles of trajectory for crossed screw placement regardless of any plate design based on an analysis of three-dimensional computed tomography data sets. METHODS One hundred human pelvic CT data sets were collected. Unilateral and bilateral placements of crossed 4.5 mm screws were simulated. Primary outcome measure was successful simulated screw placement without cortical breach. Secondary outcome measures included the anatomical measurements of the screw positions. RESULTS Simulated screw placement of two oblique screws on each side of the pubic symphysis without cortical breach was achieved in all (100 %) cases. There were a total of 400 screw simulations. Medial screws were longer, lateral screws had higher coronal angles, and the distance between both screws was higher on the right side (p < 0.001 each). The lengths of the right lateral, right medial, left lateral, and left medial screws were 44.9, 65.8, 45.4, and 67.4 mm, respectively. The sagittal angles to the dorsal surface area of the pubic rami were 10.5°, 11.1°, 9.0°, and 11.0°. The coronal angles to the vertical axis of the symphysis measured 39.5°, 16.0°, 33.8°, and 16.8°. The distances between these screws and the medial edge of the pubic crest were 33.5, 8.6, 29.5, and 7.3 mm. Furthermore, certain sex- and side-related differences were noted. CONCLUSIONS This series provides results about the feasibility and a detailed anatomical description of crossed screw placement. This is of special interest in pelvic surgery for choosing the entry points, safe screw channel parameters, and trajectories.
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Affiliation(s)
- Christian Michelitsch
- Department of Surgery, Division of Trauma Surgery, University Hospital, Zurich, Switzerland.
| | - Thi Dan Linh Nguyen-Kim
- Department of Diagnostic and Interventional Radiology, University Hospital, Zurich, Switzerland
| | - Thorsten Jentzsch
- Department of Surgery, Division of Trauma Surgery, University Hospital, Zurich, Switzerland
| | - Hans-Peter Simmen
- Department of Surgery, Division of Trauma Surgery, University Hospital, Zurich, Switzerland
| | - Clément M L Werner
- Department of Surgery, Division of Trauma Surgery, University Hospital, Zurich, Switzerland
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Böhme J, Lingslebe U, Steinke H, Werner M, Slowik V, Josten C, Hammer N. The extent of ligament injury and its influence on pelvic stability following type II anteroposterior compression pelvic injuries--A computer study to gain insight into open book trauma. J Orthop Res 2014; 32:873-9. [PMID: 24664964 DOI: 10.1002/jor.22618] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 02/20/2014] [Indexed: 02/04/2023]
Abstract
Surgical stabilization of the pelvis following type II anteroposterior compression pelvic injuries (APCII) is based on the assumption that the anterior sacroiliac, sacrospinous, and sacrotuberous ligaments disrupt simultaneously. Recent data on the ligaments contradict this concept. We aimed at determining the mechanisms of ligament failure in APCII computationally. In an individual osteoligamentous computer model of the pelvis, ligament load, and strain were observed for the two-leg stance, APCII with 100-mm symphyseal widening and for two-leg stance with APCII-related ligament failure, and validated with body donors. The anterior sacroiliac and sacrotuberous ligaments had the greatest load with 80% and 17% of the total load, respectively. APCII causes partial failure of the anterior sacroiliac ligament and the pelvis to become horizontally instable. The other ligaments remained intact. The sacrospinous ligament was negligibly loaded but stabilized the pelvis vertically. The interosseous sacroiliac and sacrotuberous ligaments are likely responsible for reducing the symphysis and might serve as an indicator of vertical stability. The sacrospinous ligament appears to be of minor significance in APCII but plays an important role in vertical stabilization. Further research is necessary to determine the influence of alterations in ligament and bone material properties.
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Affiliation(s)
- Jörg Böhme
- Department of Trauma and Reconstructive Surgery, University of Leipzig, Liebigstraße 20, 04103, Leipzig, Germany
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15
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Stuby FM, Doebele S, Agarwal Y, Windolf M, Gueorguiev B, Ochs BG. Influence of flexible fixation for open book injury after pelvic trauma--a biomechanical study. Clin Biomech (Bristol, Avon) 2014; 29:657-63. [PMID: 24852652 DOI: 10.1016/j.clinbiomech.2014.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 04/14/2014] [Accepted: 04/22/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Implant loosening is frequently detected after fixation of open book injuries. Though many authors do not see this as a complication, it is often the reason for hardware removal or reinstrumentation in the case of remaining instability. We hypothesized that the flexibility of the implant has an influence on loosening and thus on failure of the construct. METHODS We used 6 fresh-frozen pelvic specimens and tested them with our recently introduced test setup for two-leg alternate loading. We subjected them to a non-destructive quasi-static test in the intact condition followed by a non-destructive cyclic test under axial sinusoidal loading with progressive amplitude. Afterwards we simulated an open book injury and performed fixation with three different configurations of a modular fixation system (1-, 2- or 4-rod configuration) in randomized order. Subsequently, the specimens were subjected to 3 cyclic tests with the same loading protocol as previously defined. Finally, each construct was cyclically tested to failure keeping the final rod configuration. FINDINGS We detected significantly greater mobility after 1-rod-fixation and no significant differences after 2-rod or 4-rod-fixation compared to the intact symphysis condition. In the destructive test series the 4-rod-fixation failed first followed by the 1-rod-fixation. The 2-rod-fixation sustained almost 3 times as many load cycles prior to failure as the 4-rod-fixation, whereas the 1-rod-fixation sustained twice as many cycles as the 4-rod-fixation. INTERPRETATION In conclusion, flexible fixation of the ruptured pubic symphysis in human specimens shows superior behavior with respect to load bearing capacity and ability to withstand cyclic loading compared to stiff constructs.
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Affiliation(s)
- Fabian M Stuby
- BG Trauma Center, Eberhard Karls University, Schnarrenbergstrasse 95, D-72076 Tuebingen, Germany.
| | - Stefan Doebele
- BG Trauma Center, Eberhard Karls University, Schnarrenbergstrasse 95, D-72076 Tuebingen, Germany.
| | - Yash Agarwal
- AO Research Institute Davos, Clavadelerstrasse 8, CH-7270 Davos, Switzerland.
| | - Markus Windolf
- AO Research Institute Davos, Clavadelerstrasse 8, CH-7270 Davos, Switzerland.
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, CH-7270 Davos, Switzerland.
| | - Bjoern Gunnar Ochs
- BG Trauma Center, Eberhard Karls University, Schnarrenbergstrasse 95, D-72076 Tuebingen, Germany.
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Moed BR, O'Boynick CP, Bledsoe JG. Locked versus standard unlocked plating of the symphysis pubis in a Type-C pelvic injury: a cadaver biomechanical study. Injury 2014; 45:748-51. [PMID: 24326027 DOI: 10.1016/j.injury.2013.11.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 06/07/2013] [Accepted: 11/11/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The benefits of locked plating for pubic symphyseal disruption have not been established. The purpose of this biomechanical study was to determine whether locked plating offers any advantage over conventional unlocked plating of the pubic symphysis in the vertically unstable, Type-C pelvic injury. METHODS In each of eight embalmed cadaver pelvis specimens, sectioning of the pubic symphysis in conjunction with a unilateral release of the sacroiliac, sacrospinous, and sacrotuberous ligaments and pelvic floor was performed to simulate a vertically unstable Type-C (Orthopaedic Trauma Association 61-C1.2) pelvic injury. The disrupted SI joint was then reduced and fixed using two 6.5mm cannulated screws inserted into the S1 body. Using a six-hole 3.5mm plate specifically designed for the symphysis pubis having both locked and unlocked capability, four pelvises were fixed with locked screws and four pelvises were fixed with standard unlocked bicortical screws. Both groups were similar based on a dual-emission X-ray absorptiometry evaluation (P=0.69). Each pelvis was then mounted on a servohydraulic materials-testing apparatus using a bilateral stance model to mainly stress the symphyseal fixation and was cycled up to 1 million cycles or failure, whichever occurred first. RESULTS Five specimens experienced failure at the jig mounting/S1 vertebral body interface, occurring between 360,000 and 715,000 cycles. Frank failure of the anterior or posterior instrumentation did not occur. However, end-trialing diastasis of the initial pubic symphysis reduction was found in all pelvises. There were no differences between the groups with respect to this loss of symphyseal reduction (P=0.69) or average cycles to failure (P=1.0). CONCLUSION Pubic symphyseal locked plating does not appear to offer any advantage over standard unlocked plating for a Type-C (OTA 61-C1.2) pelvic ring injury.
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Affiliation(s)
- Berton R Moed
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista Avenue, 7th Floor Desloge Towers, St. Louis 63110, Missouri, United States; Department of Biomedical Engineering, Parks College of Engineering, Aviation and Technology, Saint Louis University, 3450 Lindell Boulevard, St. Louis 63103, Missouri, United States.
| | - Christopher P O'Boynick
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista Avenue, 7th Floor Desloge Towers, St. Louis 63110, Missouri, United States
| | - J Gary Bledsoe
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista Avenue, 7th Floor Desloge Towers, St. Louis 63110, Missouri, United States; Department of Biomedical Engineering, Parks College of Engineering, Aviation and Technology, Saint Louis University, 3450 Lindell Boulevard, St. Louis 63103, Missouri, United States
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