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Rüwald J, Ploeger MM, Hischebeth GT, Tüllmann M, Roos J, Gathen M, Kabir K. Description of Standardized Planes and Angles for Percutaneous Supra-acetabular Screw Placement. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2024; 162:419-425. [PMID: 37463591 DOI: 10.1055/a-2107-0948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Percutaneous screw fixation for pelvic fractures has become a minimally invasive alternative to an open operation. The complex anatomy of the pelvis renders this procedure challenging. The objective of this study was to assess standardized angles and dimensions of safety zones within a 3 D computed tomography model for optimal supra-acetabular screw placement. METHODS Computed tomography scans of 107 patients that suffered major trauma without showing any bone injury of the pelvis were collected. Using a software-based analysis, raw computed tomography data were transformed into 3 D models to set standardized landmarks and determine the possible insertion corridor. RESULTS Screws not exceeding a length of 97 mm in females and 106.4 mm in males were, in 95% of the evaluated cases, insertable without cortical bone penetration. The safety zone was 6.6 mm for females and 7.9 mm for males. Screws not exceeding these diameters were safely insertable in 95% of the cases. For the midsagittal plane, the angle was 36.4 ± 5.1 on the left and 34.7 ± 2.9 on the right (p = 0.008). For the anterior pelvic plane, the angle was 31.3 ± 4.5° on the left and 34.0 ± 4.8° on the right (p = 0.008). CONCLUSIONS Percutaneous fixation using supra-acetabular screws is a promising method to treat simple supra-acetabular fractures. These results may improve its safe utilization and could facilitate its broader clinical application.
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Affiliation(s)
- Julian Rüwald
- Department of Anesthesiology and Intensive Care Medicine, Essen, Germany, University Hospital Essen, Essen, Germany
| | - Milena Maria Ploeger
- Department for Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Gunnar T Hischebeth
- Institute for Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
| | - Mareike Tüllmann
- Department for Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Jonas Roos
- Department for Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Martin Gathen
- Department for Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
| | - Koroush Kabir
- Department for Orthopaedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany
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Berk T, Zderic I, Schwarzenberg P, Pastor T, Drenchev L, Skulev HK, Richards G, Hierholzer C, Halvachizadeh S, Pape HC, Gueorguiev B. Antegrade anterior column acetabulum fracture fixation with cannulated compression headless screws-A biomechanical study on standardized osteoporotic artificial bone. PLoS One 2024; 19:e0300256. [PMID: 38829845 PMCID: PMC11146729 DOI: 10.1371/journal.pone.0300256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 02/23/2024] [Indexed: 06/05/2024] Open
Abstract
PURPOSE Due to the increase in life expectancy and high-energy traumas, anterior column acetabular fractures (ACFs) are also increasing. While open reduction and internal fixation (ORIF) is still the standard surgical procedure, minimally invasive, percutaneous fixation of osteoporotic acetabulum fractures (AF) are growing in popularity. The aim of this biomechanical study was to evaluate the biomechanical competence following antegrade fixation with a standard screw versus a cannulated compression headless screw. METHODS Eight anatomical osteoporotic composite pelvises were given an anterior column fracture. Two groups of eight specimens each (n = 8) for fixation with either a 6.5 mm cannulated compression headless screw in group Anterior Acetabulum Canulated Compression Headless Screw (AACCH), or with a 6.5 mm partially threaded cannulated screw in group Anterior Acetabulum Standard Screw (AASS) where compared. Each specimen was biomechanically loaded cyclically at a rate of 2 Hz with monotonically increasing compressive load until failure. Motions were assessed by means of optical motion tracking. RESULTS Initial construct stiffness trended higher in group AACCH at 152.4 ± 23.1 N/mm compared to group AASS at 118.5 ± 34.3 N/mm, p = 0.051. Numbers of cycles and corresponding peak load at failure, were significantly higher in group AACCH at 6734 ± 1669 cycles and 873.4 ± 166.9 N versus group AASS at 4440 ± 2063 cycles and 644.0 ± 206.3 N, p = 0.041. Failure modes were breakout of the screws around the proximal entry point. CONCLUSION From a biomechanical perspective, group AACCH was associated with superior biomechanical competence compared to standard partially threaded cannulated screws and could therefore be considered as valid alternative for fixation of anterior acetabulum fractures.
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Affiliation(s)
- Till Berk
- AO Research Institute Davos, Davos, Switzerland
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | | | - Torsten Pastor
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | | | - Hristo Kostov Skulev
- Bulgarian Academy of Sciences, Institute of Metal Science ’’Acad. A. Balevski’’, Sofia, Bulgaria
| | | | | | - Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Zurich, Switzerland
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David G, Rony L, Moullac D, Letissier H, Di Francia R. The "Metaizeau trick" to facilitate medullary pubic ramus screw insertion: A technical note. Orthop Traumatol Surg Res 2024:103879. [PMID: 38579984 DOI: 10.1016/j.otsr.2024.103879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 02/21/2024] [Accepted: 03/29/2024] [Indexed: 04/07/2024]
Abstract
Minimally invasive procedures have recently seen an increase in the treatment of pelvic ring disruptions and select acetabular fractures. Similar to ilio-sacral screws, the superior pubic ramus screw is becoming a preferred method for treating unstable pelvic ring fractures. While the osteology of the superior pubic ramus is well understood and has inherent variability, standard screw insertion techniques work effectively in most cases. If the anatomy prevents the standard approach, there are alternative methods that can be employed for successful screw placement, or there might be a need for an open reduction and internal fixation with plates. Such techniques can be material-intensive and time-consuming. In this paper, we introduce a straightforward method that utilizes the Metaizeau nail as a guide wire to facilitate screw insertion in most instances, termed the "Metaizeau trick". Metaizeau nails, commonly found in trauma centers, are designed to locate a pathway effortlessly using this method. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Guillaume David
- Service de chirurgie orthopédique et traumatologie, CHU d'Angers, Angers, France
| | - Louis Rony
- Service de chirurgie orthopédique et traumatologie, CHU d'Angers, Angers, France
| | - Dylan Moullac
- Service de chirurgie orthopédique et traumatologie, CHRU de Brest, boulevard Tanguy-Prigent, Brest, France
| | - Hoel Letissier
- Service de chirurgie orthopédique et traumatologie, CHRU de Brest, boulevard Tanguy-Prigent, Brest, France
| | - Rémi Di Francia
- Service de chirurgie orthopédique et traumatologie, CHRU de Brest, boulevard Tanguy-Prigent, Brest, France.
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4
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David G, Milliot N, Rony L, Fournier HD, Demondion X, Bernard F. Corona mortis and pelvic dissection: Understanding the relationship between anatomical structures and bone areas. J Anat 2024; 244:458-467. [PMID: 37990973 PMCID: PMC10862173 DOI: 10.1111/joa.13978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/26/2023] [Accepted: 11/02/2023] [Indexed: 11/23/2023] Open
Abstract
Pelvic fractures are becoming increasingly frequent. The gold standard for surgical managements remains open procedures. Despite its excellent biomechanically results, it can lead to many complications. Minimally invasive surgery could reduce these complications. For complex pelvic trauma, extraperitoneal endoscopic technique has never been described. The aim of this study is to determine anatomical landmarks which are useful for endoscopic pelvic ring surgery using an extraperitoneal approach. The second objective is to compare this minimally invasive procedure to expose the bone versus a traditional open approach. After preparing the vessels with latex injections, 10 specimens are dissected alternately, using an endoscopic method (MIS) on one side and an open method on the other side. Both procedures are performed on the same subject. The visualized bone areas are drilled with burr holes. The marked surfaces are measured with photogrammetry. Finally, the data are processed (surface analysis). An extraperitoneal endoscopic dissection that follows anatomical landmarks can be performed. Bone area (mm2 ) visualized by endoscopy was 74 ± 14 (59-94) compared to 71 ± 16 (48-94) by open method. Paired t-test was performed with no significant difference between the two methods. Skin and muscular incisions were significantly lower in the MIS group (5.1, IC95% [4.1; 6.1], p < 0.001). An extraperitoneal endoscopic dissection of the pelvis can be performed. We also find no significant difference between our method and an open traditional approach concerning bone exposure. We offer a holistic approach to treat pelvic fractures by identifying key anatomical structures.
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Affiliation(s)
- Guillaume David
- Laboratoire d'Anatomie, Faculté de Médecine, Angers, France
- Département de Chirurgie Osseuse, Centre Hospitalo-Universitaire, Angers, France
| | - Nathan Milliot
- Laboratoire d'Anatomie, Faculté de Médecine, Angers, France
- Département de Chirurgie Osseuse, Centre Hospitalo-Universitaire, Angers, France
| | - Louis Rony
- Département de Chirurgie Osseuse, Centre Hospitalo-Universitaire, Angers, France
| | - Henri-Dominique Fournier
- Laboratoire d'Anatomie, Faculté de Médecine, Angers, France
- Service de Neurochirurgie, Centre Hospitalo-Universitaire, Angers, France
| | - Xavier Demondion
- Laboratoire d'Anatomie, Faculté de Médecine, Lille, France
- Service de Radiologie ostéoarticulaire, Hôpital Roger Salengro, CHRU de Lille, Lille, France
| | - Florian Bernard
- Laboratoire d'Anatomie, Faculté de Médecine, Angers, France
- Service de Neurochirurgie, Centre Hospitalo-Universitaire, Angers, France
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Wier JR, Firoozabadi R, Patterson JT. Cirrhosis is independently associated with complications and mortality following operative treatment of acetabular fractures. Injury 2023; 54:S0020-1383(23)00171-7. [PMID: 36878732 DOI: 10.1016/j.injury.2023.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/19/2023] [Indexed: 03/08/2023]
Abstract
INTRODUCTION Patients with cirrhosis are at higher risk for morbidity after injury. Acetabular fractures represent a highly morbid injury pattern. Few studies have specifically examined an effect of cirrhosis on risk of complications after acetabular fracture. We hypothesized that cirrhosis is independently associated with increased risk of inpatient complications following operative treatment of acetabular fractures. METHODS Adults patients with acetabular fracture who underwent operative treatment were identified from Trauma Quality Improvement Program data from 2015 to 2019. Patients with and without cirrhosis were matched on a propensity score predicting cirrhotic status and inpatient complications based on patient, injury, and treatment characteristics. The primary outcome was overall complication rate. Secondary outcomes included serious adverse event rate, overall infection rate, and mortality. RESULTS After propensity score matching, 137 cirrhosis+ and 274 cirrhosis- remained. No significant differences existed in observed characteristics after matching. Compared to cirrhosis- patients, cirrhosis+ patients experienced 43.4% (83.9 vs 40.5%, p < 0.001) greater absolute risk difference of any inpatient complication, 29.9% (51.8 vs 21.9%, p < 0.001) greater absolute risk difference of serious adverse events, 28.5% (41.6 vs 13.1%, p < 0.001) greater absolute risk difference of any infection, and 2.9% (2.9% vs 0.0%, p = 0.02) greater absolute risk difference of inpatient mortality. CONCLUSION Cirrhosis is associated with higher rates of inpatient complications, serious adverse events, infection, and mortality among patients undergoing operative repair of acetabular fracture. LEVEL OF EVIDENCE Prognostic Level III.
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Affiliation(s)
- Julian R Wier
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Reza Firoozabadi
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
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Chen CH, Lien FC. Subcutaneous anterior pelvic bridge — an innovative technique for fixation of selective acetabular fracture: a case series and literature review. INTERNATIONAL ORTHOPAEDICS 2022; 46:1863-1872. [PMID: 35674913 PMCID: PMC9174027 DOI: 10.1007/s00264-022-05460-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022]
Abstract
Introduction The aim of the study was to introduce an innovative technique involving the use of a subcutaneous anterior pelvic bridge (SAPB) in the treatment of selective acetabular fractures. Methods We performed a retrospective study of 21 patients with acetabular fracture who were treated with SAPB between January 2016 and March 2021. The patients’ data were retrieved from electronic charts. Radiological results were evaluated according to the Matta system to assess the quality of the reduction and time of union. Functional outcomes were assessed in line with the d’Aubigné and Postel scoring system. Post-operative complications were also recorded. Results SAPB required around 60 minutes, with minimal blood loss and short learning curve. Matta score revealed excellent radiological outcomes in seventeen displaced fractures with seven excellent outcomes and nine good outcomes. Functional outcomes were excellent in twelve hips, good in seven hips, and fair in two hips. Six patients had transient lateral femoral cutaneous nerve palsy. Discussion The innovative SAPB method for the treatment of selective acetabular fracture is proven to be a feasible method with promising outcomes. SAPB is a minimally invasive technique and strengthens the stability of fixation, with less blood loss and fewer intra-operative/post-operative complications.
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Affiliation(s)
- Chien Han Chen
- Present Address: Department of Neurosurgery, Chung Shan Medical University Hospital, 402 Taichung, Taiwan
| | - Fang Chieh Lien
- Department of Orthopedics, Ditmanson Medical Foundation Chia-Yi Christian Hospital, 600 Chiayi, Taiwan
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Goldsztajn F, Mariolani JRL, Belangero WD. Placas anteriores são mais efetivas do que parafusos iliossacrais na fixação da articulação sacroilíaca? Estudo Biomecânico. Rev Bras Ortop 2020; 55:497-503. [PMID: 32904809 PMCID: PMC7458741 DOI: 10.1055/s-0039-1697973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 07/18/2019] [Indexed: 11/24/2022] Open
Abstract
Introduction
Sacroiliac joint dislocations are caused by high energy trauma and commonly treated with the iliosacral screw fixation or the anterior plating of the sacroiliac joint (SIJ). However, there is a lack of consensus regarding which procedure is the most successful in treating sacroiliac joint dislocations. This aims to compare stiffness and maximum load of pelvises with sacroiliac joint dislocations treated with both procedures in a synthetic bone model.
Methods
Synthetic pelvises were mounted and divided into 2 treatment groups (
n
= 5): a model with two orthogonal plates placed anteriorly to the SIJ (PPS group) and another with two iliosacral screws fixating the SIJ (SPS group), both with pubic symphysis fixation. The maximum load supported by each sample was observed and the stiffness was calculated from the curve load vs displacement. The mean values of load to failure and stiffness for each group were compared with the Mann-Whitney U test (
p
< 0.05 was considered significant for all analysis).
Results
The mean load to failure supported by the PPS group was 940 ± 75 N and the SPS was 902 ± 56 N, with no statistical difference. The SPS group showed higher values of stiffness (68.6 ± 11.1 N/mm) with statistical significant difference in comparison to the PPS sample (50 ± 4.0 N/mm). The mode of failure was different in each group tested.
Conclusion
Despite lower stiffness, the anterior plating fixation of the sacroiliac joint can be very useful when the iliosacral screw fixation cannot be performed. Further studies are necessary to observe any differences between these two procedures on the clinical and surgical setting.
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Affiliation(s)
- Flavio Goldsztajn
- Departamento de Ortopedia, Américas Medical City, Rio de Janeiro, RJ, Brasil
| | - Jose Ricardo L. Mariolani
- Laboratório de Biomateriais em Ortopedia, Escola de Ciências Médicas, Universidade de Campinas, Campinas, SP, Brasil
| | - William Dias Belangero
- Laboratório de Biomateriais em Ortopedia, Escola de Ciências Médicas, Universidade de Campinas, Campinas, SP, Brasil
- Departamento de Ortopedia, Escola de Ciências Médicas, Universidade de Campinas, Campinas, SP, Brasil
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Percutaneous Versus Open Treatment of Posterior Pelvic Ring Injuries: Changes in Practice Patterns Over Time. J Orthop Trauma 2018; 32:457-460. [PMID: 29912737 DOI: 10.1097/bot.0000000000001236] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine how the utilization of open versus percutaneous treatment of posterior pelvic ring injuries in early-career orthopaedic surgeons has changed over time. METHODS Case log data from surgeons testing in the trauma subspecialty for part II of the American Board of Orthopaedic Surgery examination from 2003 to 2015 were evaluated. Current procedural terminology codes for percutaneous fixation (27216) and open fixation (27218) of the posterior pelvic ring were evaluated using a regression analysis. RESULTS A total of 377 candidates performed 2095 posterior ring stabilization procedures (1626 percutaneous, 469 open). Total case volume was stable over time [β = -1.7 (1.1), P = 0.14]. There was no significant change in the number of posterior pelvic ring fracture surgery cases performed per candidate per test year [β = 0.1 (0.1), P = 0.50]. The proportion of posterior pelvic ring cases performed percutaneously increased significantly from 49% in 2003 to 79% in 2015 [β = 1.0 (0.4), P = 0.03]. There was a significant decrease in the number of open cases reported per candidate [β = -0.07 (0.03), P = 0.008]. DISCUSSION AND CONCLUSION Early-career orthopaedic surgeons are performing more percutaneous fixation of the posterior pelvic ring and less open surgery. The impact of this change in volume on surgeon proficiency is unknown and warrants additional research.
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Mauffrey C, Hake M, Kim FJ. Flexible 3D laparoscopic assisted reduction and percutaneous fixation of acetabular fractures: Introduction to a new surgical option. Injury 2016; 47:2203-2211. [PMID: 27418454 DOI: 10.1016/j.injury.2016.06.033] [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: 06/13/2016] [Accepted: 06/26/2016] [Indexed: 02/02/2023]
Abstract
The gold standard for fractures of the acetabulum is to perform an open reduction and internal fixation in order to achieve anatomical reduction. In a well-defined subset of patients, percutaneous techniques may be employed but achieving reduction by closed means can be challenging especially for fractures with large degrees of displacement. Such patient may include elderly patients who may not have the physiologic reserve to withstand open approaches. In our paper, we present a new option using laparoscopic assisted reduction of the acetabular fracture and percutaneous fixation. The young obese patient refused all forms of blood products transfusion and presented with a displaced transverse posterior wall fracture. While we do not recommend routine use of such technique and recognize its numerous limitations, we present it as an alternative strategy in a small subset of patients.
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Affiliation(s)
- C Mauffrey
- Department of Orthopaedics, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204 USA.
| | - M Hake
- Department of Orthopaedics, University of Michigan, 1500 E Medical Center Dr Ann Arbor, MI, 48109 USA
| | - F J Kim
- Department of Urology, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204 USA
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Abstract
PURPOSE There has recently been an increase in the number of fellowship trained orthopaedic trauma surgeons, raising concerns that the surgical experience of early career surgeons may be diluted. We sought to evaluate the change in complex trauma case volume of orthopaedic trauma surgeons sitting for Part II of the American Board of Orthopaedic Surgeons certification examination. METHODS The case log data from all surgeons taking Part II of the American Board of Orthopaedic Surgeons examination over a 13-year period (2003-2015) was evaluated. Any surgeon who examined in the trauma subspecialty was included. We defined pelvis, acetabulum, and periarticular fracture surgeries as complex trauma procedures and evaluated changes in case volume over time. RESULTS We included 468 candidates who examined as trauma subspecialists and performed 90,261 procedures. The number of candidates testing in trauma per year ranged from 15 to 65 and increased significantly over time [β = 4.05 (0.37), P < 0.0001]. Their case volume was stable over time [β = -1.7 (1.1), P = 0.16]. The number of acetabulum fracture surgeries performed decreased significantly over time from a mean of 10.1 cases in 2003 to 5.2 cases in 2015 [β = -0.34 (0.08), P = 0.0015]. There was no significant change in the number of pelvic fracture surgeries [β = -0.1 (0.1), P = 0.285]. There was a trend toward less periarticular fracture surgeries [β = -0.3 (0.1), P = 0.072]. CONCLUSIONS Although pelvic ring and periarticular fracture case volume have remained stable, early career surgeons have experienced a significant decrease in acetabular fracture case volume. The implications of this decreased surgical experience warrant careful consideration as the orthopaedic trauma workforce evolves.
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