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Barber LA, Katsuura Y, Qureshi S. Sacral Fractures: A Review. HSS J 2023; 19:234-246. [PMID: 37065102 PMCID: PMC10090841 DOI: 10.1177/15563316221129607] [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: 04/23/2022] [Accepted: 08/05/2022] [Indexed: 04/18/2023]
Abstract
At the cornerstone of the pelvis and spine, the sacrum may be fractured in patients of all ages. Sacral fractures range from high-energy injuries, with mortality rates of up to 18%, to low-energy insufficiency fractures. The intricate geometry of the sacrum, the breadth of morphotypes, and the presence of congenital anomalies all can complicate the treatment of these fractures. Agreement on the surgical indications for these injuries is limited. This narrative review aims to update orthopedic surgeons on the clinical evaluation and the non-surgical and surgical management of these fractures.
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Affiliation(s)
| | | | - Sheeraz Qureshi
- Emory Spine Center, Atlanta, GA, USA
- Department of Orthopaedic Surgery, Hospital
for Special Surgery, Weill Cornell Medicine, New York City, NY, USA
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Mitsuzawa S, Kusakabe K, Matsuda S. Minimally invasive transiliac anatomical locking plate for posterior pelvic ring injury: A technical trick of the gull wing plate. J Clin Orthop Trauma 2022; 33:101991. [PMID: 36061970 PMCID: PMC9436802 DOI: 10.1016/j.jcot.2022.101991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/05/2022] [Accepted: 08/16/2022] [Indexed: 10/15/2022] Open
Abstract
Posterior pelvic ring injuries commonly involve sacral fractures, which are difficult to reduce and stabilize. Because conservative treatment requires long-term bedrest and leads to unsatisfactory outcomes, surgical intervention is a beneficial option to protect neurological structures and provide sufficient stability for early mobilization. Several studies have investigated a variety of internal fixation techniques, such as iliosacral screws, transiliac bars, spinal instruments, and transiliac plates. The gull wing plate (GWP) is a pre-contoured anatomical locking plate with two cancellous screws (φ6.5 mm) and four locking screws (φ5.0 mm), the design of which is unique among posterior tension-band plates. The GWP provides reliable stability of the posterior construct of the pelvic ring and accelerates rehabilitation. Compared to alternative surgical techniques for posterior fixation, the simple surgical procedure of the GWP is minimally invasive and highly reproducible, which leads to fewer complications and less radiation exposure.
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Affiliation(s)
- Sadaki Mitsuzawa
- Department of Orthopaedic Surgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kenji Kusakabe
- Department of Orthopaedic Trauma, Senshu Trauma and Critical Care Center, Rinku General Medical Center, Osaka, Japan
| | - Shuichi Matsuda
- Department of Orthopaedic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Steelman K, Bray R, Vaidya R. Technical Note on Placement of Low-Profile Triangular Osteosynthesis for Unstable Posterior Pelvic Ring Injuries. J Orthop Trauma 2022; 36:e337-e342. [PMID: 35191661 PMCID: PMC9249073 DOI: 10.1097/bot.0000000000002298] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2021] [Indexed: 02/02/2023]
Abstract
SUMMARY Triangular osteosynthesis is a technique used to stabilize posterior pelvic ring injuries. Conventional triangular fixation can be problematic for several reasons, including the need for advanced skill sets to place instrumentation, difficulty with pelvic reduction and placing the connecting construct, and prominent instrumentation. The purpose of this study is 2-fold: (1) to describe in detail a technique for lumbopelvic fixation using implants that are easy to connect, allow distraction for complex lumbosacral displacements, and are placed in a location minimizing soft tissue prominence and (2) to present our initial case series using this technique. We present a retrospective review of 18 consecutively treated patients with this technique. Inclusion criteria were patients with complete disruption through the sacrum or sacroiliac joint from blunt trauma (OTA/AO type C injuries). Outcomes included pelvic reduction/malreduction, wound healing, and complications. Fourteen patients underwent unilateral fixation (81%), and 4 patients underwent bilateral fixation (19%). All patients (18 of the 18) had a well-reduced pelvis after fixation. No patient (0%) required a return trip to the operating room for loss of reduction/malreduction, wound breakdown, or implant failure. This study presents an updated technique for a low-profile triangular osteosynthesis construct with straightforward application for unstable posterior pelvic ring injuries. This technique does not require rod bending, results in a consistently more recessed iliac screw and connecting rod, and can be used in a wide variety of unstable posterior pelvic ring injuries, including comminuted sacral fractures, L5/S1 facet fractures, and vertical shear injuries.
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Affiliation(s)
- Kevin Steelman
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI
| | - Ryan Bray
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI
| | - Rahul Vaidya
- Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI
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Kim CH, Kim JJ, Kim JW. Percutaneous posterior transiliac plate versus iliosacral screw fixation for posterior fixation of Tile C-type pelvic fractures: a retrospective comparative study. BMC Musculoskelet Disord 2022; 23:581. [PMID: 35705948 PMCID: PMC9202151 DOI: 10.1186/s12891-022-05536-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 06/10/2022] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND This study aimed to compare the clinical outcomes and complications between two minimally invasive surgical techniques: percutaneous transiliac plate fixation and iliosacral (IS) screw fixation for the treatment of Tile C-type pelvic bone fractures. METHODS We retrospectively reviewed the data of 77 consecutive patients with Tile C pelvic ring injuries who underwent either percutaneous transiliac plate fixation or IS screw fixation in a single academic center between November 2007 and January 2018. We recorded patients' demographics, surgery-related data, and postoperative surgical outcomes and compared the incidence of complications and revision surgery rates between the two groups. RESULTS Overall, 14 patients were included in the plate group, while 63 were included in the IS screw fixation group. No significant differences were observed in the patients' demographics between the two groups except for a longer interval from injury to surgery (13.5 days vs. 5.4 days, P = 0.001). Both groups acquired fracture union in all cases. There was one case of infection requiring surgical debridement in the plating group. Notably, nerve injury (n = 3) and implant loosening (n = 5) occurred in the IS screw group, but the difference was not significant. CONCLUSIONS Both percutaneous posterior transiliac plating and IS screw fixation in patients with Tile C-type pelvic bone fractures showed good results. We recommend IS screw fixation as the primary treatment and propose posterior plating as treatment for sacral dysmorphism and bilateral sacral alar fractures in patients with spinopelvic dissociation. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Chul-Ho Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jung Jae Kim
- Samsong Seoul Orthopedic Clinic, Goyang, Republic of Korea
| | - Ji Wan Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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Unilateral lumbopelvic fixation for AO/OTA Type C1 and C2 pelvic fractures: Clinical efficacy and preliminary experiences in 23 patients. Injury 2021; 52:2333-2338. [PMID: 34053773 DOI: 10.1016/j.injury.2021.05.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/08/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the clinical outcomes and preliminary experiences of unilateral lumbopelvic fixation for patients with AO/OTA Type C1 and C2 pelvic fractures. MATERIALS AND METHODS Between May 2014 and Dec 2017, 23 consecutive patients with AO/OTA Type C1 and C2 pelvic factures were treated by unilateral lumbopelvic fixation. Estimated blood loss, operation duration, reduction quality, functional outcomes using Majeed scores and complications were evaluated. Subgroup analysis was used to assess the influence of unilateral lumbopelvic fixation on different type of pelvic fractures. RESULTS Fifteen patients with Type C1 pelvic fractures and eight patients with Type C2 fractures underwent unilateral lumbopelvic fixation respectively. The mean follow-up time till May 2019 was 34.3 ± 9.9 months (range 17-60 months). Mean estimated blood loss was 473 ml and mean operation duration was 156 min during unilateral lumbopelvic fixation. The mean vertical displacement of pelvis decreased from 10.1 ± 4.9 mm to 3.1 ± 1.9 mm after unilateral lumbopelvic fixation. Majeed score assessments were available for 22 patients. Of these, 13 patients were graded as excellent, 8 were good and one was fair. The results of subgroup analysis showed that there was no difference of estimated blood loss, operation duration, postoperative displacements of pelvis and Majeed scores between the patients with Type C1 and C2 fractures. CONCLUSION Unilateral lumbopelvic fixation could provide a well reduction quality and was an effective treatment for AO/OTA Type C1 and C2 pelvic fractures. STUDY DESIGN Retrospective evaluation of 23 consecutive patients with AO/OTA Type C1 and C2 pelvic fractures treated by unilateral lumbopelvic fixation.
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Minimally invasive posterior locked compression plate osteosynthesis shows excellent results in elderly patients with fragility fractures of the pelvis. Eur J Trauma Emerg Surg 2020; 47:37-45. [PMID: 33104870 PMCID: PMC7851100 DOI: 10.1007/s00068-020-01498-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/08/2020] [Indexed: 02/06/2023]
Abstract
Purpose Fragility fractures of the pelvis (FFP) are common in older patients. We evaluated the clinical outcome of using a minimally invasive posterior locked compression plate (MIPLCP) as therapeutic alternative. Methods 53 Patients with insufficiency fractures of the posterior pelvic ring were treated with MIPLCP when suffering from persistent pain and immobility under conservative treatment. After initial X-ray, CT-scans of the pelvis were performed. In some cases an MRI was also performed to detect occult fractures. Postoperatively patients underwent conventional X-ray controls. Data were retrospectively analyzed for surgical and radiation time, complication rate, clinical outcome and compared to the literature. Results Patients (average age 79.1 years) underwent surgery with operation time of 52.3 min (SD 13.9), intra-operative X-ray time of 9.42 s (SD 9.6), mean dose length product of 70.1 mGycm (SD 57.9) and a mean hospital stay of 21.2 days (SD 7.7). 13% patients (n = 7) showed surgery-related complications, such as wound infection, prolonged wound secretion, irritation of the sacral root or clinically inapparent screw malpositioning. 17% (n = 9) showed postoperative complications (one patient died due to pneumonia 24 days after surgery, eight patients developed urinal tract infections). 42 patients managed to return to previous living situation. 34 were followed-up after a mean period of 31.5 (6–90) months and pain level at post-hospital examination of 2.4 (VAS) with an IOWA Pelvic Score of 85.6 (55–99). Conclusion We showed that MIPLCP osteosynthesis is a safe surgical alternative in patients with FFP 3 and FFP 4. This treatment is another way of maintaining a high level of stability in the osteoporotic pelvic ring with a relatively low complication rate, low radiation and moderate operation time and a good functional outcome.
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Posterior transiliac plating in vertically unstable sacral fracture. Orthop Traumatol Surg Res 2020; 106:85-88. [PMID: 31405747 DOI: 10.1016/j.otsr.2019.06.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 04/28/2019] [Accepted: 06/05/2019] [Indexed: 02/02/2023]
Abstract
The aim of the present technical note is to describe the posterior transiliac plating method. Acute-phase clinical and radiological results in a continuous series of 10 vertically unstable fractures are presented. Reduction was good or excellent in 70% of cases, and clinical results were good or excellent in 80% on Hannover and Majeed scores, with mean Majeed score of 71.8±17. Complications comprised 3 cases of early postoperative sepsis requiring surgical lavage, and 4 cases of hardware removal due to discomfort. At last follow-up, consolidation was systematic. Reduction was more difficult with longer time to surgery and greater initial displacement. Posterior transiliac plating provided immediately effective fixation in vertically unstable pelvic fracture.
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Affiliation(s)
- Pol Maria Rommens
- Department of Orthopaedics and Traumatology, University Medical Center, Johannes Gutenberg-University, Mainz, Germany
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Wu T, Su K, Zhang YZ, Yang ZY, Li HJ, Han YT. Biomechanical comparison of three kinds of fixation in fracture-dislocation of the sacroiliac joint. Technol Health Care 2019; 27:89-99. [PMID: 30507595 DOI: 10.3233/thc-181274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although there are several different kinds of fixation techniques for the sacroiliac fracture-dislocation, the treatment remains a challenge for orthopedic surgeons. OBJECTIVE The purpose of this study was to compare the stability of sacroiliac fracture-dislocation fixed with two iliosacral (IS) screws, tension band plate (TBP), and minimally invasive adjustable plate (MIAP). METHODS Five human cadavers (L4-pelvic-femora) were used to compare biomechanical stability. The pubic symphysis separation and left sacroiliac dislocation were created. The symphysis pubis was stabilized with a five-hole plate. The sacroiliac joint dislocation fracture was fixed with three kinds of internal fixation in a randomized design. The specimens were fastened in a biomechanical machine with a cycle vertical load. Displacements of the whole specimen and shifts in the fracture gap were recorded. RESULTS Under different vertical loads, the shifts in the fracture gap and the displacements of the pelvis fixed with MIAP were similar to those in fractures fixed with two IS screws. However, the shifts in the fracture gap and the displacements of the pelvis fixed with MIAP were significantly smaller than those fixed with TBP. CONCLUSIONS The stability of the sacroiliac joint dislocation fixed with MIAP was similar to that of dislocation fixed with two IS screws, and MIAP performed better than the TBP under vertical load.
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Hu P, Wu T, Wang HZ, Qi XZ, Yao J, Cheng XD, Chen W, Zhang YZ. Biomechanical Comparison of Three Internal Fixation Techniques for Stabilizing Posterior Pelvic Ring Disruption: A 3D Finite Element Analysis. Orthop Surg 2019; 11:195-203. [PMID: 30895703 PMCID: PMC6594476 DOI: 10.1111/os.12431] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/16/2019] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE To compare the biomechanical stability and compatibility of two iliosacral screws (ISS), a tension band plate (TBP), and a minimally invasive adjustable plate (MIAP) for treating Tile C pelvic fractures. METHODS Three groups of finite element models of the intact pelvis, including the main ligament and the proximal one-third of both femurs, were developed to simulate vertical sacral fractures and treated with the three abovementioned internal fixation techniques. A 500 N vertical load, a 500 N vertical load plus a 10 Nm moment of forward sagittal direction, and 500 N vertical load plus a 10 Nm moment of right lateral direction were applied to the sacrum to simulate standing status, bending status, and flexion status, respectively. The maximum displacement value, the stress value, and the stress value of the fracture interface were compared among the three internal fixation techniques. RESULTS The results showed that all three internal fixation techniques effectively restored the biomechanical transmission of the injured pelvis. The stress on the implants in the TBP model was 167.47% and 53.41% higher than that in the ISS model and the MIAP model, respectively, and the stress shielding phenomenon of the TBP model was more obvious than in the other two models. Meanwhile, the stress between the fracture interfaces in the TBP fixation models was apparently higher than that in the other two models. However, the vertical displacement of the MIAP model was not significantly different from that in the ISS and TBP model; therefore, strong fixation could be obtained in all three models. CONCLUSION Based on our results, we believe that the stability of Tile C pelvic fracture fixed with MIAP was similar to that of fractures fixed with ISS and TBP, but the stress shielding phenomenon and safety of implants in the TBP models were inferior to those in the MIAP and ISS fixation models. Meanwhile, MIAP and ISS fixation were more helpful to the healing processing than was TBP fixation, especially at the fracture interface of the second and third vertebral body levels.
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Affiliation(s)
- Pan Hu
- Department of Orthopaedics, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Tao Wu
- Department of Orthopaedics, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hui-Zhi Wang
- International Research Center for Implantable and Interventional Medical Devices, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Xin-Zheng Qi
- International Research Center for Implantable and Interventional Medical Devices, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Jie Yao
- International Research Center for Implantable and Interventional Medical Devices, School of Biological Science and Medical Engineering, Beihang University, Beijing, China
| | - Xiao-Dong Cheng
- Department of Orthopaedics, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wei Chen
- Department of Orthopaedics, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ying-Ze Zhang
- Department of Orthopaedics, Third Hospital of Hebei Medical University, Shijiazhuang, China
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Zhang R, Yin Y, Li S, Li A, Hou Z, Zhang Y. Lumbopelvic Fixation Versus Novel Adjustable Plate for Sacral Fractures: A Retrospective Comparative Study. J INVEST SURG 2019; 33:784-792. [PMID: 30885021 DOI: 10.1080/08941939.2019.1569737] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: The purpose of this study is to compare the therapeutic effects of the lumbopelvic technique and a novel adjustable plate for sacral fractures. Materials and Methods: Patients with unilateral sacral fractures fixed via the lumbopelvic technique or using a novel adjustable plate from June 2011 to June 2017 were recruited into this study and were divided into two groups: group A (lumbopelvic fixation) and group B (novel adjustable plate). Surgical time, intraoperative blood loss, frequency of intraoperative fluoroscopy, reduction quality, and related complications were reviewed. Fracture healing was assessed by the radiographs conducted at follow-up. Functional outcome was evaluated according to the Majeed score at the final follow-up. Results: The mean blood loss and frequency of intraoperative fluoroscopy in group B were reduced compared with group A (both P < 0.001). The mean surgical time was 122.22 ± 13.09 minutes in group A and 103.96 ± 24.80 minutes in group B (P = 0.007). All patients healed well in this study, and no difference in the fracture healing time was noted between the two groups (P = 0.685). Satisfactory rates of reduction quality and functional outcome did not differ (both P > 0.05) in this study. The complication rate was 22.22% (4/18) in group A and 4.16% (1/24) in group B (P = 0.191). Conclusion: For patients with unilateral sacral fractures, satisfactory radiographic appearance and functional outcome could be obtained by both the lumbopelvic technique and a novel adjustable plate. However, the novel adjustable plate represents a less invasive technique with lower radiograph exposure.
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Affiliation(s)
- Ruipeng Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China
| | - Yingchao Yin
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China
| | - Shilun Li
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China
| | - Ao Li
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.,Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China
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Zhang R, Yin Y, Li S, Guo J, Hou Z, Zhang Y. Sacroiliac screw versus a minimally invasive adjustable plate for Zone II sacral fractures: a retrospective study. Injury 2019; 50:690-696. [PMID: 30792004 DOI: 10.1016/j.injury.2019.02.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 01/13/2019] [Accepted: 02/12/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Fracture line of the sacrum always involves the Zone II region because sacral foramina are anatomically and physiologically weak regions of the sacrum. The purpose of this study is to compare the therapeutic effects of a sacroiliac screw and a minimally invasive adjustable plate (MIAP) for Zone II sacral fractures. METHODS Patients with unilateral Zone II sacral fractures fixed with a unilateral sacroiliac screw or MIAP from August 2009 to January 2016 were recruited into this study and were divided into two groups: group A (sacroiliac screw) and group B (MIAP). Surgical time, blood loss, frequency of intraoperative fluoroscopy, and relative complications were reviewed. Radiographs and CT scans were routinely acquired to evaluate the fracture displacement and reduction quality. Fracture healing was evaluated in the radiographs at each follow-up. Functional outcome was assessed based upon the Majeed scoring system at the final follow-up. RESULTS Thirty-one patients in group A and thirty-nine patients in group B were included in this study. No significant differences in average surgical time (P = 0.221) or blood loss (P = 0.234) were noted between group A and group B. The mean frequency of intraoperative fluoroscopy was 15.74±2.98 in group A and 6.08±1.94 in group B (P = 0.000). All fractures healed well within four months in all patients, and the healing time exhibited no significant difference between the two groups (P = 0.579). Satisfactory rates of reduction quality and functional outcome were not statistically different between the two groups (P > 0.05). The complication rate was 16.13% (5/31) in group A and 5.13% (2/39) in group B (P = 0.222). CONCLUSION MIAP has a fixation effect and exhibits reduction potential for Zone II sacral fractures. Favourable radiographic and functional results could be obtained through the MIAP technique, which is easy to conduct without pre-contouring. Compared with the unilateral S1 sacroiliac screw technique, repeated projections and iatrogenic sacral injury can be avoided.
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Affiliation(s)
- Ruipeng Zhang
- Third Hospital of Hebei Medical University, Department of Orthopaedic Surgery, Shijiazhuang, Hebei, 050051, China; Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.
| | - Yingchao Yin
- Third Hospital of Hebei Medical University, Department of Orthopaedic Surgery, Shijiazhuang, Hebei, 050051, China; Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.
| | - Shilun Li
- Third Hospital of Hebei Medical University, Department of Orthopaedic Surgery, Shijiazhuang, Hebei, 050051, China; Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.
| | - Jialiang Guo
- Third Hospital of Hebei Medical University, Department of Orthopaedic Surgery, Shijiazhuang, Hebei, 050051, China; Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.
| | - Zhiyong Hou
- Third Hospital of Hebei Medical University, Department of Orthopaedic Surgery, Shijiazhuang, Hebei, 050051, China; Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.
| | - Yingze Zhang
- Third Hospital of Hebei Medical University, Department of Orthopaedic Surgery, Shijiazhuang, Hebei, 050051, China; Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, China.
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Rickman M, Link BC, Solomon LB. Patient Weight-bearing after Pelvic Fracture Surgery-A Systematic Review of the Literature: What is the Modern Evidence Base? Strategies Trauma Limb Reconstr 2019; 14:45-52. [PMID: 32559267 PMCID: PMC7001596 DOI: 10.5005/jp-journals-10080-1414] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background Little attention in the literature appears to have been paid to the issue of postoperative weight-bearing protocols for different injury patterns after pelvic fracture surgery. The primary aim of this study is to review the currently available literature to define the level of available evidence used to inform surgical decisions on weight-bearing after pelvic fracture surgery. Secondary aims are to assess the published methods of fracture classification, surgical management, and assessment or reporting of patient outcomes. Methods A systematic review of the English language literature from 1990 to 2016 was undertaken. Eligible papers were all papers reporting minimum 6-month outcomes following surgery for pelvic fractures in adults. Exclusion criteria included pathological fractures or those resulting from penetrating injury, solely osteoporotic fractures, or series with less than 6 months of follow-up data. Results There is very little published scientific data to inform the treating surgeon on postoperative weight-bearing protocols after pelvic fracture surgery, with no randomized trials and only 1 paper out of 122 stating this as a primary aim. More than half of the papers published did not state what postoperative protocol was employed. There is no standardization of outcome measures, with less than 20% of papers using the most common validated outcome scoring system; in contrast, there is good agreement on the use of either the Tile (75%) or Burgess and Young (20%) classification. Limitations Due to the lack of published studies looking at the topic of postoperative weight-bearing after pelvic fractures, no specific recommendations are possible. As large numbers of papers were included, they were not individually assessed for bias. Conclusion A review of postoperative weight-bearing regimes reveals a nonexistent scientific evidence base from which to make recommendations, although a consensus strategy has been identified. Future research needs to be directed at this topic, as has already been the case in numerous other fracture areas, since the advantages of early mobility are potentially significant. The reported methodology for assessing and reporting patient outcomes after pelvic fracture surgery reveals no consistent standards, and the majority of papers use no specific outcome scoring system. How to cite this article Rickman M, Link B-C, Solomon LB. Patient Weight-bearing after Pelvic Fracture Surgery-A Systematic Review of the Literature: What is the Modern Evidence Base? Strategies Trauma Limb Reconstr 2019;14(1):45-52.
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Affiliation(s)
- Mark Rickman
- Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
| | - Bjorn-Christian Link
- Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
| | - Lucian B Solomon
- Centre for Orthopaedic and Trauma Research, Discipline of Orthopaedics and Trauma, University of Adelaide, Adelaide, Australia; Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
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Chaiyamongkol W, Kritsaneephaiboon A, Bintachitt P, Suwannaphisit S, Tangtrakulwanich B. Biomechanical Study of Posterior Pelvic Fixations in Vertically Unstable Sacral Fractures: An Alternative to Triangular Osteosynthesis. Asian Spine J 2018; 12:967-972. [PMID: 30322262 PMCID: PMC6284134 DOI: 10.31616/asj.2018.12.6.967] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/22/2018] [Indexed: 11/23/2022] Open
Abstract
Study Design Biomechanical study. Purpose To investigate the relative stiffness of a new posterior pelvic fixation for unstable vertical fractures of the sacrum. Overview of Literature The reported operative fixation techniques for vertical sacral fractures include iliosacral screw, sacral bar fixations, transiliac plating, and local plate osteosynthesis. Clinical as well as biomechanical studies have demonstrated that these conventional techniques are insufficient to stabilize the vertically unstable sacral fractures. Methods To simulate a vertically unstable fractured sacrum, 12 synthetic pelvic models were prepared. In each model, a 5-mm gap was created through the left transforaminal zone (Denis zone II). The pubic symphysis was completely separated and then stabilized using a 3.5-mm reconstruction plate. Four each of the unstable pelvic models were then fixed with two iliosacral screws, a tension band plate, or a transiliac fixation plus one iliosacral screw. The left hemipelvis of these specimens was docked to a rigid base plate and loaded on an S1 endplate by using the Zwick Roell z010 material testing machine. Then, the vertical displacement and coronal tilt of the right hemipelves and the applied force were measured. Results The transiliac fixation plus one iliosacral screw constructions could withstand a force at 5 mm of vertical displacement greater than the two iliosacral screw constructions (p=0.012) and the tension band plate constructions (p=0.003). The tension band plate constructions could withstand a force at 5° of coronal tilt less than the two iliosacral screw constructions (p=0.027) and the transiliac fixation plus one iliosacral screw constructions (p=0.049). Conclusions This study proposes the use of transiliac fixation in addition to an iliosacral screw to stabilize vertically unstable sacral fractures. Our biomechanical data demonstrated the superiority of adding transiliac fixation to withstand vertical displacement forces.
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Affiliation(s)
- Weera Chaiyamongkol
- Department of Orthopaedic Surgery and Physical Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Apipop Kritsaneephaiboon
- Department of Orthopaedic Surgery and Physical Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Piyawat Bintachitt
- Department of Orthopaedic Surgery and Physical Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Sitthiphong Suwannaphisit
- Department of Orthopaedic Surgery and Physical Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Boonsin Tangtrakulwanich
- Department of Orthopaedic Surgery and Physical Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Verbeek DO, Routt ML. High-Energy Pelvic Ring Disruptions with Complete Posterior Instability: Contemporary Reduction and Fixation Strategies. J Bone Joint Surg Am 2018; 100:1704-1712. [PMID: 30278001 DOI: 10.2106/jbjs.17.01289] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Diederik O Verbeek
- Trauma Research Unit, Department of Surgery, Erasmus University Medical Center, Erasmus University, Rotterdam, the Netherlands
| | - Milton L Routt
- Department of Orthopedic Surgery, University of Texas Health - McGovern Medical School, Houston, Texas
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Iliac screw for reconstructing posterior pelvic ring in Tile type C1 pelvic fractures. Orthop Traumatol Surg Res 2018; 104:923-928. [PMID: 29913269 DOI: 10.1016/j.otsr.2018.04.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/20/2018] [Accepted: 04/30/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is often difficult to achieve stable fixation in Tile type C1 pelvic fractures and there is no standard fixation technique for these types of injuries. HYPOTHESIS Iliac screw fixation can be used for treating Type C1 pelvic fractures. PATIENTS AND METHODS A retrospective review was performed on 47 patients who underwent iliac screw fixation in posterior column of ilium (PCI) for Tile type C1 pelvic fractures from July 2007 to December 2014. All patients were treated with fracture reduction, sacral nerve root decompression (if needed), internal fixation by iliac screw and connecting rod. The data on surgical time, intraoperative bleeding volume, postoperative neurologic functions and postoperative complications were analyzed. Patients were follow-up for at least 12months. RESULTS The mean surgical time was 148minutes, and the mean intraoperative bleeding volume was 763ml. Patients were encouraged in-bed activities immediately after surgery. The postoperative Majeed functional score was 48-100 points (mean 80.2), corresponding to an excellent and good recovery of 91.5%. Postoperative X-radiographs and CT scans indicated satisfactory fracture reduction. DISCUSSION Iliac screw fixation combined with sacral nerve canal decompression could effectively restore pelvic alignment and improve neurological functions for complex pelvic trauma.
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Crist BD, Pfeiffer FM, Khazzam MS, Kueny RA, Della Rocca GJ, Carson WL. Biomechanical evaluation of location and mode of failure in three screw fixations for a comminuted transforaminal sacral fracture model. J Orthop Translat 2018; 16:102-111. [PMID: 30723687 PMCID: PMC6350021 DOI: 10.1016/j.jot.2018.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/12/2018] [Accepted: 06/20/2018] [Indexed: 12/04/2022] Open
Abstract
Background Pelvic ring–comminuted transforaminal sacral fracture injuries are rotationally and vertically unstable and have a high rate of failure. Objective Our study purpose was to use three-dimensional (3D) optical tracking to detect onset location of bone–implant interface failure and measure the distances and angles between screws and line of applied force for correlation to strength of pelvic fracture fixation techniques. Methods 3D relative motion across sacral–rami fractures and screws relative to bone was measured with an optical tracking system. Synthetic pelves were used. Comminuted transforaminal sacral–rami fractures were modelled. Each pelvis was stabilised by either (1) two iliosacral screws in S1, (2) one transsacral screw in S1 and one iliosacral screw in S1 and (3) one trans-alar screw in S1 and one iliosacral screw in S1; groups 4–6 consisted of fixation groups with addition of anterior inferior iliac pelvic external fixator. Eighteen-instrumented pelvic models with right ilium fixed simulate single-leg stance. Load was applied to centre of S1 superior endplate. Five cycles of torque was initially applied, sequentially increased until permanent deformation occurred. Five cycles of axial load compression was next applied, sequentially increased until permanent deformation occurred, followed by axial loading to catastrophic failure. A Student t test was used to determine significance (p < 0.05). Results The model, protocol and 3D optical system have the ability to locate how sub-catastrophic failures initiate. Our results indicate failure of all screw-based constructs is due to localised bone failure (screw pull-in push-out at the ipsilateral ilium–screw interface, not in sacrum); thus, no difference was observed when not supplemented with external fixation. Conclusion Inclusion of external fixation improved resistance only to torsional loading. Translational Potential of this Article Patients with comminuted transforaminal sacral–ipsilateral rami fractures benefit from this fixation.
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Affiliation(s)
- Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - Ferris M Pfeiffer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - Michael S Khazzam
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, 1801 Inwood Road, Dallas, TX 75390, USA
| | - Rebecca A Kueny
- Institute of Biomechanics, TUHH Hamburg University of Technology, Denickestraße 15, 21073, Hamburg, Germany
| | - Gregory J Della Rocca
- Department of Orthopaedic Surgery, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - William L Carson
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
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Vertical shear pelvic injury: evaluation, management, and fixation strategies. INTERNATIONAL ORTHOPAEDICS 2018; 42:2663-2674. [PMID: 29582114 DOI: 10.1007/s00264-018-3883-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 03/08/2018] [Indexed: 01/27/2023]
Abstract
Vertical shear pelvic ring fractures are rare and account for less than 1% of all fractures. Unlike severely displaced antero-posterior compression and lateral compression pelvic fractures, patients' mortality is lower. Nevertheless, patients must be managed acutely using well-defined ATLS protocols and institution-specific protocols for haemodynamically unstable pelvic ring fractures. The definitive treatment of vertical shear pelvic fractures is however more controversial with a paucity of literature to recommend the ideal reduction and fixation strategy. While the majority of injuries can be reduced and fixed in a closed manner, orthopaedic traumatologists should be familiar with the contraindications to those techniques as well as options such as tension band plating and lumbo pelvic fixation. Our paper reviews the acute management, associated injuries and definitive reduction and fixation strategies of vertical shear pelvic fractures. In addition, we propose a treatment algorithm for the selection of the most appropriate fixation technique.
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Wang H, Fu YH, Ke C, Zhuang Y, Zhang K, Wei X, Li Z, Lei JL, Zhang BF, Liu P. Minimally invasive stabilisation of posterior pelvic ring instabilities with pedicle screws connected to a transverse rod. INTERNATIONAL ORTHOPAEDICS 2017; 42:681-686. [DOI: 10.1007/s00264-017-3714-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 12/03/2017] [Indexed: 11/30/2022]
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Yu YH, Lu ML, Tseng IC, Su CY, Hsu YH, Yeh WL, Wu CC. Effect of the subcutaneous route for iliac screw insertion in lumbopelvic fixation for vertical unstable sacral fractures on the infection rate: A retrospective case series. Injury 2016; 47:2212-2217. [PMID: 27375014 DOI: 10.1016/j.injury.2016.06.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/17/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To report the perioperative results and surgical outcomes of patients with vertical unstable sacral fractures who underwent lumbopelvic fixation through a modified subcutaneous route for iliac screw fixation. SUMMARY OF BACKGROUND DATA Treating vertical unstable sacral fractures is still challenging for orthopedic surgeons. Among various methods for treating these fractures, lumbopelvic fixation provides a high reduction quality and promising stability for early weight-bearing ambulation. However, wound healing disturbance and surgical site infection (SSI) are the drawbacks of this extensive technique, especially after inserting iliac screws. METHODS Here, we provide an alternative subcutaneous route for iliac screw insertion during lumbopelvic fixation surgery to lessen soft tissue retraction and injury, and thus decrease soft tissue complications. RESULTS Using this modified technique, 28 patients with vertical unstable sacral fractures were treated between 2012 and 2014. One patient had an SSI (infection rate: 3.5%). All fractures were united with a mean sacral kyphosis correction angle of 10.5°. The mean Majeed score of the 17 patients during the 12-month follow-up was 84.5. CONCLUSIONS The subcutaneous route for iliac screw insertion is a simple, safe, and effective technique when performing lumbopelvic fixation for vertical unstable sacral fractures.
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Affiliation(s)
- Yi-Hsun Yu
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - Meng-Ling Lu
- Division of Spine, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - I-Chuan Tseng
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - Chun-Yi Su
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - Yung-Heng Hsu
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - Wen-Lin Yeh
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - Chi-Chung Wu
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
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Transsacral-Transiliac Screw Stabilization: Effective for Recalcitrant Pain Due to Sacral Insufficiency Fracture. J Orthop Trauma 2016; 30:469-73. [PMID: 27551916 DOI: 10.1097/bot.0000000000000596] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of transsacral-transiliac screw fixation for the treatment of sacral insufficiency fractures that fail nonoperative treatment. DESIGN A pilot study series of consecutive patients identified over 5 years were treated and followed prospectively. SETTING Academic-affiliated, tertiary referral, level 1 trauma center in Dallas, TX. PATIENTS/PARTICIPANTS Patients were selected on the basis of presenting diagnosis, and failure of nonoperative treatment of their sacral insufficiency fracture. Eleven patients entered to the study, and 10 completed follow-up. INTERVENTION Placement of transsacral-transiliac screws for sacral insufficiency fracture. MAIN OUTCOME MEASUREMENTS Comparison of preoperative and postoperative Visual Analog Scale scores and Oswestry Low Back Disability Index scores. RESULTS Patients experienced statistically significant improvement in both outcome measures after intervention. No complications encountered. CONCLUSIONS Transsacral-transiliac screw fixation seems to be a safe and effective treatment for sacral insufficiency fractures recalcitrant to nonoperative management. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Baek DH, Choi BW, Kim JW. Treatment of traumatic lumbosacral spondyloptosis combined with unstable pelvic ring injury. J Orthop Sci 2015; 20:776-80. [PMID: 24468977 DOI: 10.1007/s00776-014-0530-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 01/04/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Dong-Hoon Baek
- Department of Orthopedic Surgery, Inje University Haeundae Paik Hospital, Inje University College of Medicine, 875 Haeun-daero, Haeundae-gu, Busan, 612-862, Korea
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The effect of implant placement on sacroiliac joint range of motion: posterior versus transarticular. Spine (Phila Pa 1976) 2015; 40:E525-30. [PMID: 25705956 DOI: 10.1097/brs.0000000000000839] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A human cadaveric biomechanical study of 2 sacroiliac (SI) joint fusion implant placement techniques. OBJECTIVE To evaluate and compare the biomechanical properties of 2 implant placement techniques for SI joint fusion. SUMMARY OF BACKGROUND DATA Minimally invasive placement of SI joint fusion implants is a potential treatment of SI joint disruptions and degenerative sacroiliitis. Biomechanical studies of screw fixation within the sacrum have shown that placement and trajectory are important in the overall stability of the implant. Although clinical results have been promising, there is the possibility that a more optimal arrangement of implants may exist. METHODS Bilateral SI joints in 7 cadaveric lumbopelvic (L4-pelvis) specimens were tested using a single leg stance model. All joints were tested intact, pubic symphysis sectioned, and treated (3 SI joint fusion implants). The implants were laterally placed using either a posterior or transarticular placement technique. The posterior technique places the implants inline in the inlet view, parallel in the outlet view, and parallel to the posterior sacral body in the lateral view. The transarticular technique places all implants across the articular portion of the SI joint. For all conditions, the range of motion was tested in flexion-extension, lateral bending, and axial rotation. RESULTS The posterior technique significantly reduced the range of motion in flexion-extension, lateral bending, and axial rotation by 27% ± 24% (P = 0.024), 28% ± 26% (P = 0.028), and 32% ± 21% (P = 0.008), respectively. The transarticular technique significantly reduced the range of motion in flexion-extension, lateral bending, and axial rotation by 41% ± 31% (P = 0.013), 36% ± 38% (P = 0.049), and 36% ± 28% (P = 0.015), respectively. No significant differences were detected between the posterior and transarticular placement techniques (P > 0.25). CONCLUSION Posterior and transarticular placement of SI joint fusion implants stabilized the SI joint in flexion-extension, lateral bending, and axial rotation. LEVEL OF EVIDENCE N/A.
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Ueno FH, Pisani MJ, Machado AN, Rodrigues FL, Fujiki EN, Rodrigues LMR. Biomechanical study of the sacroiliac fracture fixation with titanium rods and pedicle screws. ACTA ORTOPEDICA BRASILEIRA 2015. [PMID: 26207094 PMCID: PMC4503609 DOI: 10.1590/1413-78522015230300970] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To assess biomechanically different fixations means of the sacroiliac joint with pedicle screws and to compare the traditional head height with reduced ones. METHODS We used a polyethylene model representing the pelvic ring and simulated a unilateral sacroiliac dislocation. We set up three different constructions: 1) two screws attached to a rod; 2) two rods connected to two small head screws each; and 3) two rods connected to two average headed screws each. We conducted tests in a biomechanical testing and a mechanized processing laboratory. RESULTS Group 1 supported an average maximum load of 99.70 N. Group 2 supported an average maximum load of 362.46 N. Group 3 endured an average maximum load of 404.15 N. In the assembly with one rod, the resistance decreased as compared with the one with two bars: 72.5 % compared to small-headed screws and 75.3 % to the traditional screw. CONCLUSION The assembly with a single bar presented inferior results when compared to the double bar assembly. There was no statistical difference in the results between the screws used. Experimental Study.
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Abstract
INTRODUCTION This survey was conducted during the 38(th) Brazilian Congress of Orthopaedics and Traumatology to identify the opinion of Brazilian orthopaedic surgeons on the standard treatment of pelvic fractures. MATERIALS AND METHODS Participants were randomly selected and invited to voluntarily answer a questionnaire of 10 multiple choice questions addressing the main aspects of the treatment of pelvic fractures: classification, fixation methods in unstable patients, optimal surgical timing in stable patients, and fixation methods in different types of anterior and posterior pelvic injuries. RESULTS/CONCLUSION Three hundred and fifty-two questionnaires were completed, and the following main observations were made: most orthopaedists prefer to use an external fixator in the iliac crest for the emergency stabilisation of pelvic injuries in haemodynamically unstable patients (79.5%); they consider a period of up to one week as optimal for fixation in stable patients (55.1%); they use a plate for the fixation of fractures of the iliopubic rami through a Pfannenstiel or ilio-inguinal approach (53.9%); and they use reconstruction plates for the fixation of fractures of the iliac wing (63.1%). Regarding other studied aspects, there was no predominance of more than 50% of the choices among respondents.
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Chen W, Hou Z, Su Y, Smith WR, Liporace FA, Zhang Y. Treatment of posterior pelvic ring disruptions using a minimally invasive adjustable plate. Injury 2013; 44:975-80. [PMID: 23669139 DOI: 10.1016/j.injury.2013.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 01/31/2013] [Accepted: 04/13/2013] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Iliosacral (IS) screw fixation and posterior tension band plate (TBP) technique are two treatment alternatives for posterior pelvic ring injuries. However, IS screw fixation requires continuous fluoroscopic guidance for appropriate screw insertion and carries a risk of neurovascular injuries. TBP technique also has some disadvantages, including limited reduction potential, difficulty in precontouring the plate and a higher rate of symptomatic implants. To address these limitations, we introduced a minimally invasive adjustable plate (MIAP). This study aims to present the preliminary radiological and clinical results of posterior pelvic ring disruptions treated with MIAP. METHODS The MIAP conforms to the irregular shape of posterior pelvic ring and can be used without prebending. This plate has a role in reducing compressed or separated fractures/dislocations. Sixteen patients, including seven males and nine females, were treated with MIAP through a minimally invasive approach. The fracture patterns consisted of six Type B and ten Type C fractures according to OTA classification of fracture. Preoperative and postoperative radiography was taken to assess the fracture displacement and reduction quality. Postoperative rehabilitation programme was individualised and early exercise was encouraged. Patients were followed up and the functional outcome was evaluated based upon the scoring system proposed by Lindahl and associates. RESULTS All posterior pelvic ring disruptions were reduced and fixed with MIAP. The average duration of surgery was 49 min, the average radiation exposure was 6s, and the average blood loss was 80 mL for the treatment of posterior pelvic ring injuries. Overall radiological results of the reduction were excellent in eleven patients and good in five. The patients were followed up for 30 months on average. All fractures healed. The functional outcome was excellent in ten patients, good in four and fair in two. There were no iatrogenic neurovascular injuries, implant failures, irritative symptoms or pressure sores due to subcutaneous implantation. CONCLUSION Favourable clinical and radiological outcomes can be achieved in treating posterior pelvic disruptions with MIAP. This plate is effective in view of its simplicity, less radiation exposure, safety, minimal invasion and stable fixation.
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Affiliation(s)
- Wei Chen
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, PR China.
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Chen HW, Liu GD, Fei J, Yi XH, Pan J, Ou S, Zhou JH. Treatment of unstable posterior pelvic ring fracture with percutaneous reconstruction plate and percutaneous sacroiliac screws: a comparative study. J Orthop Sci 2012; 17:580-7. [PMID: 22810807 DOI: 10.1007/s00776-012-0257-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 05/30/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The aim of this study is to compare the clinical effects of percutaneous reconstruction plate and percutaneous sacroiliac screws in treatment of unstable posterior pelvic ring fracture. METHODS Fifty-eight patients with unstable posterior pelvic ring fracture treated with two methods from March 2002 to October 2007 were enrolled in the study and divided into two groups according to two kinds of internal fixation: percutaneous reconstruction plate (20 males and 9 females, at mean age 37.3 ± 11.3 years) and percutaneous sacroiliac screws (21 males and 8 females, at mean age 39.3 ± 10.4 years). Causes of injury included traffic accident in 38 patients, fall from height in 17, and crush in 3. The correlative data of operation duration, number of X-ray exposures, intraoperative bleeding volume, length of incision, Majeed postoperative functional evaluation, and postoperative complications were analyzed statistically. RESULTS All 58 patients were followed up for 12-36 months (mean duration 21.3 months). There was statistical difference for operation duration, number of X-ray exposures, size of incision, and intraoperative bleeding volume between the two groups. Majeed postoperative functional evaluation indicated excellent and good rates of 86.1% for percutaneous reconstruction plate and 88.2% for percutaneous sacroiliac screws. CONCLUSIONS The clinical effect of the two methods is similar in treatment of Tile C pattern posterior pelvic ring fracture. However, the percutaneous reconstruction plate has lower risk of damaging nerves and blood vessels than the percutaneous sacroiliac screws. Moreover, intraoperative fluoroscopy is rarely performed.
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Affiliation(s)
- Hong-wei Chen
- Department of Orthopedics, Central Hospital of Yiwu City, Yiwu, Zhejiang Province, China
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Kobbe P, Hockertz I, Sellei RM, Reilmann H, Hockertz T. Minimally invasive stabilisation of posterior pelvic-ring instabilities with a transiliac locked compression plate. INTERNATIONAL ORTHOPAEDICS 2011; 36:159-64. [PMID: 21626391 DOI: 10.1007/s00264-011-1279-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Accepted: 05/04/2011] [Indexed: 11/27/2022]
Abstract
PURPOSE Sacroiliac screw fixation is the method of choice for the definitive treatment of unstable posterior pelvic-ring injuries; however, this technique is demanding and associated with a high risk of iatrogenic neurovascular damage. This study evaluates whether minimally invasive transiliac locked compression plate stabilisation may be an alternative to sacroiliac screw fixation in unstable posterior pelvic-ring injuries. METHODS We performed a retrospective analysis of patients with unstable pelvic-ring injuries treated with a transiliac locked compression plate at a level I trauma centre. Outcome evaluation was assessed using the Pelvic Outcome Score and analysis of complications, intraoperative fluoroscopic time, and duration of the surgical procedure. RESULTS Twenty-one patients were available for follow-up after an average of 30 months. The main findings were as follows: Overall outcome for the Pelvic Outcome Score was excellent in 47.6% (ten patients), good in 19% (four patients), fair in 28.6% (six patients), and poor in 4.8% (one patient). Average operation time was 101 min and intraoperative fluoroscopic time averaged 74.2 s. No iatrogenic neurovascular injuries were observed. CONCLUSION Minimally invasive transiliac locked compression plate stabilisation may be a good alternative to sacral screw fixation because it is quick, safe and associated with a good functional outcome.
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Affiliation(s)
- Philipp Kobbe
- Department of Orthopaedic Trauma Surgery, Städtisches Klinikum Braunschweig, Brunswick, Germany.
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Berber O, Amis AA, Day AC. Biomechanical testing of a concept of posterior pelvic reconstruction in rotationally and vertically unstable fractures. ACTA ACUST UNITED AC 2011; 93:237-44. [DOI: 10.1302/0301-620x.93b2.24567] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The purpose of this study was to assess the stability of a developmental pelvic reconstruction system which extends the concept of triangular osteosynthesis with fixation anterior to the lumbosacral pivot point. An unstable Tile type-C fracture, associated with a sacral transforaminal fracture, was created in synthetic pelves. The new concept was compared with three other constructs, including bilateral iliosacral screws, a tension band plate and a combined plate with screws. The pubic symphysis was plated in all cases. The pelvic ring was loaded to simulate single-stance posture in a cyclical manner until failure, defined as a displacement of 2 mm or 2°. The screws were the weakest construct, failing with a load of 50 N after 400 cycles, with maximal translation in the craniocaudal axis of 12 mm. A tension band plate resisted greater load but failure occurred at 100 N, with maximal rotational displacement around the mediolateral axis of 2.3°. The combination of a plate and screws led to an improvement in stability at the 100 N load level, but rotational failure still occurred around the mediolateral axis. The pelvic reconstruction system was the most stable construct, with a maximal displacement of 2.1° of rotation around the mediolateral axis at a load of 500 N.
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Affiliation(s)
- O. Berber
- St George’s Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
| | - A. A. Amis
- Department of Mechanical Engineering and Musculoskeletal Surgery Imperial College London, London SW7 2AZ, UK
| | - A. C. Day
- St George’s Hospital, Blackshaw Road, Tooting, London SW17 0QT, UK
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Abstract
STUDY DESIGN Technical note and retrospective first cases study. OBJECTIVE To present a novel surgical procedure for treating rare and challenging U-shaped fractures of the sacrum. SUMMARY OF BACKGROUND DATA U-shaped fractures of the sacrum are not frequent and usually seen in the context of high energy trauma (high-fall injury). There is no consensus about the therapeutic strategy. When surgery is decided on selected patients, the technique raises several issues for the neural decompression, reduction, and fixation. The L5-S1 mobility has to be sacrificed for most authors. METHODS Based on anatomic considerations, the authors present here the original surgical technique they have been using at their institution and a consecutive series of patients. The procedure associates a shortening osteotomy of the sacrum at the site of the fracture and a sacro-sacral fixation. RESULTS The proposed procedure was simple, safe, and effective. CONCLUSIONS Performing the osteotomy helps in the reduction and allows a short fixation, which spares the mobility of the lumbo-sacral junction.
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Papathanasopoulos A, Tzioupis C, Giannoudis VP, Roberts C, Giannoudis PV. Biomechanical aspects of pelvic ring reconstruction techniques: Evidence today. Injury 2010; 41:1220-7. [PMID: 21288466 DOI: 10.1016/j.injury.2010.10.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2010] [Indexed: 02/07/2023]
Abstract
Despite the remarkable advances achieved within the boundaries of the new discipline of Pelvic surgery, pelvic ring disruptions remain challenging and complex problems in orthopaedics. The long-term complications related to reconstruction techniques of these injuries have motivated researchers and surgeons to explore various alternative treatment modalities. Several biomechanical studies have addressed these issues. We performed a medline search including studies published during the last 30 years. Our search yielded 114 studies, 39 of which met the pre-specified inclusion criteria and were further critically analysed and discussed regarding the biomechanical aspects of pelvic ring reconstruction techniques. Based on observational approach and evaluation of the studies specific keypoints are highlighted comprising the clinical translation of the biomechanical supported findings.
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Affiliation(s)
- A Papathanasopoulos
- Academic Department of Trauma & Orthopaedic Surgery, LIMM section Musculoskeletal Disease, School of Medicine, University of Leeds, UK
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32
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Successful laparoscopic exploration and screw extraction for intractable pain after anterior iliosacral arthrodesis. J Orthop Trauma 2010; 24:e83-5. [PMID: 20871241 DOI: 10.1097/bot.0b013e3181c1d518] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We report on the case of a patient suffering from L5 radicular pain after previous anterior sacroiliac arthrodesis using 2, 4-hole plates. Technical investigations indicated loosening and migration of a screw from the upper sacroiliac plate, irritating the L5 nerve root. The problem was managed by removal of the screw using an anterior transperitoneal laparoscopic approach.
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33
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Gänsslen A. [Biomechanical principles for treatment of osteoporotic fractures of the pelvis]. Unfallchirurg 2010; 113:272-80. [PMID: 20309516 DOI: 10.1007/s00113-010-1763-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Fractures of the pelvis are of increasing interest, especially in older patients due to the often concomitant osteoporosis. The low bone quality can be a problem in several fixation situations. In this review the present and relevant literature on biomechanical data of unstable pelvic ring injuries and all biomechanical data dealing with osteosynthesis for acetabular fractures are discussed.
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Affiliation(s)
- A Gänsslen
- Klinik für Unfallchirurgie, Orthopädie und Neurotraumatologie, Allgemeines Krankenhaus Celle, Siemensplatz 4, 29223, Celle, Deutschland.
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Locked plates reduce displacement of vertically unstable pelvic fractures in a Mechanical Testing Model. ACTA ACUST UNITED AC 2010; 69:1230-4. [PMID: 20489663 DOI: 10.1097/ta.0b013e3181d3cc07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The purpose of this study is to compare a locked screw construct to a single iliosacral screw for fixation of a vertically unstable pelvic ring injury in a transforaminal sacral fracture model. METHODS Orthopaedic Trauma Association type 61-C1.3a2c5 fractures were created in 10 fresh frozen cadaveric pelvis specimens. Specimens were divided into two groups of five. In both groups, the anterior ring was stabilized with a six-hole 3.5-mm reconstruction plate. In the locked plate (LP) group, the posterior injury was stabilized using a two-hole locking plate with one solid 5.0-mm locking iliosacral screw directed onto the S1 body and a second locking screw directed into the lateral sacral ala. In the iliosacral screw group, the posterior injury was stabilized using a single cannulated 7.3-mm screw. Testing was conducted on a Materials Testing System. Values for displacement and rotation were recorded. Each pelvis was axially loaded with a compressive sine wave from 175 N to 350 N for 10,000 cycles to simulate limited weight bearing, with data recorded at 1,000 cycle increments. RESULTS Two specimens in the iliosacral screw group displaced more than 1 cm during the first 1,000 cycles. These two specimens displayed gross fracture motion in all planes. All five specimens in the LP group completed 10,000 cycles of testing with less than 1 cm of displacement. A vector displacement calculation from the plane displacement data revealed that the LP group had significantly less displacement (median 1.9 mm) than the specimens in the iliosacral group (median 6.7 mm; p = 0.008) after 10,000 cycles. CONCLUSIONS A two-hole plate locked head screw construct resulted in less displacement than a single iliosacral screw in a transforaminal sacral fracture model.
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Treatment of posterior pelvic ring injuries with minimally invasive percutaneous plate osteosynthesis. INTERNATIONAL ORTHOPAEDICS 2009; 33:1435-9. [PMID: 19352659 DOI: 10.1007/s00264-009-0756-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 03/03/2009] [Accepted: 03/04/2009] [Indexed: 10/20/2022]
Abstract
From January 2004 to July 2007, 21 patients with injuries at the posterior pelvic ring were treated with locking compression plate osteosynthesis through a minimally invasive approach and followed up for a mean of 12.2 months. Preoperative and postoperative radiography was conducted to assess the reduction and union. The mean operation time was 60 minutes (range: 40-80). Intraoperative blood loss was 50-150 ml. All patients achieved union at the final follow-up. The overall radiological results were excellent or good in 17 patients (85%). The functional outcome was excellent or good in 18 patients (90%). There was no iatrogenic nerve injury, deep infection or failure of fixation. We believe that fixation with a locking compression plate is an effective method for the treatment of injuries of the posterior pelvic ring in view of its convenience, minimal traumatic invasion and lower morbidity.
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Suzuki T, Hak DJ, Ziran BH, Adams SA, Stahel PF, Morgan SJ, Smith WR. Outcome and complications of posterior transiliac plating for vertically unstable sacral fractures. Injury 2009; 40:405-9. [PMID: 19095233 DOI: 10.1016/j.injury.2008.06.039] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 05/23/2008] [Accepted: 06/12/2008] [Indexed: 02/02/2023]
Abstract
Vertically unstable sacral fractures often make it difficult to achieve rigid fixation and there is no consensus on the optimal fixation technique for these injuries. The purpose of this study was to evaluate complication rate and short-term outcome of vertically unstable sacral fractures treated by posterior transiliac plate fixation. We performed a retrospective review of prospectively collected data of patients who underwent posterior transiliac plating for sacral fractures at two institutions. All patients were treated with the standard posterior approach using a 4.5-mm reconstruction plate and followed for at least 12 months. Patients' demographics, Majeed functional questionnaire surveys, and radiographic outcomes were collected. There were 19 patients with a mean age of 37.5-years. The mean follow-up was 26.3 months. The most frequent mechanism of injury was a fall from a height. According to the AO/OTA classification, there were 10 C1, 6 C2, and 3 C3, which were classified as 2 Denis I, 20 Denis II, and 2 Denis III, including 5 bilateral sacral fractures. Neurological deficit at the initial examination was recorded in 10 patients. The mean ISS was 20.7 and the mean timing of the internal fixation was 6.4 days. Anterior internal fixation of pelvic ring was added in eight patients. A Morel-Lavallee lesion was identified in 5 patients during the operation. Reductions were graded as nine excellent, seven good, and three fair according to the method of Tornetta. There were two postoperative surgical wound infections, both occurring in patients with a Morel-Lavallee lesion. All the sacral fractures united eventually and no implant failure occurred, though there were two patients with a small loss of reduction (<5mm) over the follow-up period. A total of 18 patients completed the functional assessment with a mean score of 78.5 points. Posterior plate fixation of vertically unstable sacral fractures is effective in maintaining fracture reduction even in the presence of significant posterior comminution. We caution its use in the presence of a known Morel-Lavallee lesion, as this may increase the wound complication and infection risk.
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Affiliation(s)
- Takashi Suzuki
- Department of Orthopaedic Surgery, Denver Health Medical Centre, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA.
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Abstract
STUDY DESIGN Consecutive case series. OBJECTIVE To report a new percutaneous sacroiliac joint (SIJ) arthrodesis technique utilizing a Hollow Modular Anchorage screw. SUMMARY OF BACKGROUND DATA A variety of SIJ arthrodesis techniques have been reported in the established academia to treat intractable SIJ pain. None combines minimal surgical exposure, instrumented fixation, and bone grating. METHODS We describe a new percutaneous SIJ arthrodesis technique for patients with intractable SIJ pain. Preoperative and postoperative Oswestry Disability Index (ODI), Visual Analog Scale (VAS) for pain, and postoperative subjective patients' satisfaction were assessed for all patients. Minimum 2 years follow-up is documented. RESULTS Nine patients underwent SIJ arthrodesis with the new technique. The mean ODI value dropped from 59 (range: 34 to 70) preoperatively to 45 (range: 28 to 60) postoperatively (P<or=0.005). The mean VAS value dropped from 8.1 (range: 7 to 9) preoperatively to 4.6 (range: 3 to 7) postoperatively (P<or=0.002). The mean patients' satisfaction was 6.8 (range: 5 to 8). CONCLUSIONS The new technique may offer a safe and effective treatment for intractable SIJ pain.
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Schildhauer TA, Bellabarba C, Selznick HS, McRoberts D, Vedder NB, Chapman JR. Unstable pediatric sacral fracture with bone loss caused by a high-energy gunshot injury. ACTA ACUST UNITED AC 2008; 63:E95-9. [PMID: 17308489 DOI: 10.1097/01.ta.0000246879.13468.32] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Thomas A Schildhauer
- Chirurgische Klinik und Poliklinik, BG-Kliniken Bergmannsheil, Ruhr-Universität Bochum, Germany.
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Hungerer S, Woltmann A, Bühren V. Bilateral Sacroiliac Joint Dislocation in an Adolescent after a Skiing Accident. Eur J Trauma Emerg Surg 2007; 34:181-7. [PMID: 26815627 DOI: 10.1007/s00068-007-7055-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2006] [Accepted: 09/02/2007] [Indexed: 10/22/2022]
Abstract
A bilateral sacroiliac joint (SI joint) dislocation is a rare injury pattern, in contrast to bilateral fracture dislocations of the SI joint. The incidence of pelvic dislocation of the SI joint without significant bone structural damage would most likely be observed in young children or adolescents after receiving a blunt, high energy impact. These young patients often suffer life threatening injuries to the intestines, neural or vascular systems or severe injury of the urinary tract. In these scenarios, plain projection radiographic imaging often leads to an inconclusive diagnosis making computer tomography indispensable to plan the treatment strategy. These strategies vary and the optimal approach is a subject to dispute. A surgical treatment of these injuries should ensure an immediate primary stability to allow early ambulation. The following study reports a unique trauma pattern with an isolated bilateral SI dislocation without fracture of the posterior or anterior pelvic ring nor concomitant injuries. This rare injury is a consequence of a pure vertical shear impact. This case report describes a technical pitfall of the iliolumbar transfixation and a solution to the problem. A dorso-ventro-dorsal approach, which utilizes both iliolumbar transfixation and ventral bilateral double plating osteosynthesis will be presented.
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Affiliation(s)
- Sven Hungerer
- BG Trauma Center Murnau, Professor-Küntscher-Strasse 8, 82418, Murnau, Germany.
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40
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Minimally invasive transiliac plate osteosynthesis for type C injuries of the pelvic ring: a clinical and radiological follow-up. J Orthop Trauma 2007; 21:595-602. [PMID: 17921833 DOI: 10.1097/bot.0b013e318158abcf] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate radiological and functional outcome in patients treated with minimally invasive transiliac plate osteosynthesis for unstable pelvic injuries. DESIGN Retrospective analysis of a prospective treatment protocol in a consecutive patient series. SETTING Level 1 trauma center. PATIENTS Between January 1998 and December 2005, 31 patients with type C injuries of the pelvic ring were treated with minimally invasive transiliac plate osteosynthesis. According to the AO classification, 16 patients had a C1-injury, 9 had a C2 fracture, and 6 patients sustained a C3 injury of the pelvic ring. Anterior-posterior, inlet, and outlet radiographs were obtained preoperatively, immediately postoperatively, and during follow-up. Clinical outcome was determined according to the Hannover pelvic outcome score. INTERVENTION Posterior plate osteosynthesis for type C injuries of the pelvic ring. MAIN OUTCOME MEASUREMENT Preoperative and postoperative dislocation of the posterior pelvic ring, loss of reduction, implant failure, implant removal, clinical results of the pelvic injury and general limitations following the trauma. RESULTS Maximum average dislocation of the posterior pelvic ring was 16.1 mm preoperatively; postoperatively, it was 6.1 mm. A total of 23 patients (74.2%) could be followed up after an average of 20 months (range 7-57 months). Seven patients underwent follow-up treatment at other hospitals closer to their respective residences, whereas 1 patient passed away in the early postoperative phase due to multiorgan failure. Loss of reduction occurred in 2 cases. The clinical outcome regarding the pelvis was very good in 8 cases, good in 9 cases, fair in 4 cases, and poor in 2 cases. Social reintegration according to the Hannover pelvic outcome score was complete in 9 cases, poor in 10 cases, and incomplete in 10 cases. CONCLUSION Posterior plate osteosynthesis is a sufficiently stable method for the treatment of unstable pelvic ring injuries with a low risk of iatrogenic nervous tissue and vascular lesions. The disadvantages are limited reduction possibilities, the necessity of bilateral bridging of the sacroiliac joint in a unilateral injury, as well as a higher rate of symptomatic hardware.
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41
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Gardner MJ, Kendoff D, Ostermeier S, Citak M, Hüfner T, Krettek C, Nork SE. Sacroiliac joint compression using an anterior pelvic compressor: a mechanical study in synthetic bone. J Orthop Trauma 2007; 21:435-41. [PMID: 17762472 DOI: 10.1097/bot.0b013e318126bb8e] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Pelvic external fixation pins placed in the supraacetabular region, directed posteriorly, and mounted with a femoral distractor as a compressor may impart compression forces across the sacroiliac joint. This would be useful for indirect reduction and stabilization of the posterior pelvis. The purpose of this study was to determine the forces achieved by this construct compared with other forms of fixation. DESIGN Mechanical study. SETTING University laboratory. PATIENTS Synthetic pelvis models. INTERVENTION A complete symphyseal and unilateral sacroiliac joint disruption was created in 6 synthetic pelves. Five different fixation constructs were applied, and a pressure-sensitive film (TekScan) was fixed in the sacroiliac joint. Each construct was compressed in a standardized fashion. MAIN OUTCOME MEASUREMENTS After maximal compression of each trial, the magnitude and regional distribution of the force was recorded. RESULTS Standard 2-bar external fixation did not allow for any compression across the sacroiliac joint in any specimen. The pelvic compressor delivered 86.3 N (SD, 12.1 N) of force across the sacroiliac joint when the pins were inserted half way, and 85.8 N (SD, 11.0 N) with full pin insertion. Iliosacral screws led to 145 N of compression on average (SD, 69.9 N), but this was not statistically different from the pelvic compressor groups. A C-clamp generated compression of 206 N (SD, 31.9 N), which was significantly greater than both the pelvic compressor groups (P < 0.005). CONCLUSIONS A simple modification of pelvic external fixation, placing a femoral distractor as a compressor on supraacetabular pins, allows for indirect medial translation of the innominate bone and compression across the sacroiliac joint. The force achieved is less than with a C-clamp, but it is safer, involves techniques familiar to most surgeons, and may be useful in the acute management of unstable pelvic fractures.
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Affiliation(s)
- Michael J Gardner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York 10021, USA.
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42
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Tötterman A, Glott T, Madsen JE, Røise O. Unstable sacral fractures: associated injuries and morbidity at 1 year. Spine (Phila Pa 1976) 2006; 31:E628-35. [PMID: 16915078 DOI: 10.1097/01.brs.0000231961.03527.00] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective, longitudinal single-cohort study of 32 patients treated with internal fixation for unstable sacral fractures. OBJECTIVES To describe the prevalence of associated injuries in blunt pelvic trauma with unstable sacral fractures, and to characterize late impairments. SUMMARY OF BACKGROUND DATA In high-energy pelvic ring injury, the close association of the spine, the intrapelvic organs and the bony pelvic ring result in high risk for additional injuries. These injuries may result in long-term sequels pertaining to mobility, voiding, bowel function, and sexual function. However, little is known about the components of long-term morbidity after unstable sacral fractures. METHODS The minimum 1-year follow-up included 32 patients surgically treated for unstable sacral fractures. Patients were analyzed for associated injuries, fracture classification, severity of trauma, and long-term measures of neurologic recovery, mobility, and functions pertaining to voiding, defecation, and sexual function. RESULTS Additional injuries occurred in 84%. Injury Severity Score was 27 (range, 9-57). At follow-up, sensory impairments were observed in 91%; impaired gait in 63%, and bladder, bowel, or sexual impairments in 59%. Sacral radiculopathies explained only 60% to 69% of these impairments. The presence of late impairments correlated to the severity of injury and to the presence of associated injuries, but not to fracture characteristics. CONCLUSIONS Unstable fractures of the sacrum are frequently associated with additional injuries. These injuries have a significant effect on morbidity still 1 year after injury. The multifactor etiology of impairments after sacral fractures should be acknowledged in the assessment of these patients.
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Affiliation(s)
- Anna Tötterman
- Ulleval University Hospital, Orthopaedic Centre, Oslo, Norway.
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44
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Abstract
UNLABELLED Sacroiliac joint dysfunction is believed to be a significant source of low back and posterior pelvic pain. METHODS To assess the clinical presentation, diagnostic testing, and treatment options for sacroiliac joint dysfunction, a systematic literature review was performed using MEDLINE. RESULTS Presently, there are no widely accepted guidelines in the literature for the diagnosis and treatment of sacroiliac instability. Establishing management guidelines for this disorder has been complicated by the large spectrum of different etiologic factors, the variability of patient history and clinical symptoms, limited availability of objective testing, and incomplete understanding of the biomechanics of the sacroiliac joint. CONCLUSIONS A reliable examination technique to identify the sacroiliac joint as a source of low back pain seems to be pain relief following a radiologically guided injection of a local anaesthetic into the sacroiliac joint. Most patients respond to non-operative treatment. Patients who do not respond to non-operative treatment should be considered for operative sacroiliac joint stabilization.
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Affiliation(s)
- Boris A Zelle
- Department of Orthopaedic Surgery, Division of Orthopaedic Traumatology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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van Zwienen CMA, van den Bosch EW, Hoek van Dijke GA, Snijders CJ, van Vugt AB. Cyclic loading of sacroiliac screws in Tile C pelvic fractures. ACTA ACUST UNITED AC 2005; 58:1029-34. [PMID: 15920420 DOI: 10.1097/01.ta.0000158515.58494.11] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND To investigate the stiffness and strength of completely unstable pelvic fractures fixated both anteriorly and posteriorly under cyclic loading conditions, the authors conducted a randomized, comparative, cadaveric study. METHODS In 12 specimens, a Tile C1 pelvic fracture was created. The authors compared the intact situation to anterior plate fixation combined with one or two sacroiliac screws. In 2,000 measurements, each pelvis was loaded with a maximum of 400 N. The translation and rotation stiffness of the fixations were measured using a three-dimensional video system. Furthermore, the load to failure and the number of cycles before failure were determined. RESULTS Both translation and rotation stiffness of the intact pelvis were superior to the fixated pelvis. No difference in stiffness was found between the techniques with one or two sacroiliac screws. However, a significantly higher load to failure and significantly more loading cycles before failure could be achieved using two sacroiliac screws compared with one screw. CONCLUSION Although the combination of anterior plate fixation combined with two sacroiliac screws is not as stable as the intact pelvis, in this study, embalmed aged pelves could be loaded repeatedly with physiologic forces. Given the fact that the average trauma patient is younger and given the fact that the quality (or grip) of the fixation was a significant covariable for longer endurance of the fixation, this suggests that direct postoperative weight bearing could be possible if these results are confirmed in further research.
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Affiliation(s)
- C M A van Zwienen
- Biomedical Physics and Technology, Erasmus University Rotterdam, The Netherlands
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Loegters T, Briem D, Gatzka C, Linhart W, Begemann PG, Rueger JM, Windolf J. Treatment of unstable fractures of the pelvic ring in pregnancy. Arch Orthop Trauma Surg 2005; 125:204-8. [PMID: 15761733 DOI: 10.1007/s00402-005-0808-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2004] [Indexed: 02/09/2023]
Abstract
Unstable fractures of the posterior pelvic ring during pregnancy are rare. Pregnancy increases the high demands on the therapy of these types of fractures. The aim of the therapeutic strategy in such a situation is a good functional outcome of the mother without influencing the fetal health. Some osteosynthetic techniques result in good functional outcomes, but they are associated with high amounts of ionizing radiation. We report the case of a pregnant woman who sustained a vertical unstable fracture of the posterior pelvic ring as a result of a traffic accident. The fracture was treated surgically by open reduction and internal fixation with two transiliac reconstruction plates with minimal radiographic exposure to the fetus. One year later, a good functional result concerning the mother was shown. The child was healthy without any signs of prenatal impairment. Surgical treatment of an unstable fracture of the pelvic ring during pregnancy is possible with a justifiable risk to the mother and the child. Consideration of the expected fetal radiation exposure in the course of the therapy is particularly recommended. Using minimal doses of ionizing radiation, the described method results in a good clinical outcome of the mother while simultaneously reducing the radiation exposure of the fetus to an acceptable level.
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Affiliation(s)
- Tim Loegters
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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van Zwienen CMA, van den Bosch EW, Snijders CJ, Kleinrensink GJ, van Vugt AB. Biomechanical comparison of sacroiliac screw techniques for unstable pelvic ring fractures. J Orthop Trauma 2004; 18:589-95. [PMID: 15448446 DOI: 10.1097/00005131-200410000-00002] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the stiffness and strength of various sacroiliac screw fixations to compare different sacroiliac screw techniques. DESIGN Randomized comparative study on embalmed human pelvises. MATERIALS AND METHODS In 12 specimens, we created a symphysiolysis and sacral fractures on both sides. Each of these 24 sacral fractures was fixed with 1 of the following methods: 1 sacroiliac screw in the vertebral body of S1, 2 screws convergingly in S1, or 1 screw in S1 and 1 in S2. On the left and right side of a pelvis, different techniques were used. The pubic symphysis was not stabilized. We measured the translation and rotation stiffness of the fixations and the load to failure using a 3-dimensional video system. RESULTS The stiffness of the intact posterior pelvic ring was superior to any screw technique. Significant differences were found for the load to failure and rotation stiffness between the techniques with 2 screws and a single screw in S1. The techniques utilizing 2 screws showed no differences. CONCLUSIONS Based on the results of this study, we can conclude that a second sacroiliac screw in completely unstable pelvic fractures increases rotation stiffness and improves the load to failure.
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Affiliation(s)
- C M A van Zwienen
- Biomedical Physics and Technology, Erasmus University Rotterdam, Rotterdam, The Netherlands
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48
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Chiu FY, Chuang TY, Lo WH. Treatment of Unstable Pelvic Fractures: Use of a Transiliac Sacral Rod for Posterior Lesions and an External Fixator for Anterior Lesions. ACTA ACUST UNITED AC 2004; 57:141-4; discussion 144-5. [PMID: 15284564 DOI: 10.1097/01.ta.0000123040.23231.eb] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study sought to define the role of transiliac sacral rods used in combination with an external fixator for the management of unstable pelvic fractures. METHODS This retrospective study evaluated cases in which the surgical strategy was open reduction and internal fixation of posterior lesions with two transiliac sacral rods and closed reduction and external fixation of anterior lesions with an AO external fixator. The data for 65 cases were analyzed. Comprehensive Classification (AO) identified 42 C1 cases, 21 C2, cases and 2 C3 cases. Fractures with iliac bone involvement that impeded the application of an external fixator or transiliac sacral rods were excluded. The follow-up period was 85 months (range, 24-140 months). RESULTS All the fractures/dislocations healed well. The complications involved 17 cases (26.2%) of persistent posterior pain, 16 cases (24.6%) of irreversible neurologic deficit, 2 cases (3.1%) of posterior wound infection, 3 cases (4.6%) of pin tract infection, and 4 cases (6.2%) of irreversible urologic deficit. The functional results showed that the surgical results were satisfactory in 42 cases (64.6%) and unsatisfactory in 23 cases (35.4%). CONCLUSIONS For type C pelvic fractures without significant iliac bone involvement, surgical management with posterior transiliac fixation using sacral rods and anterior external fixation yields good radiologic results. The functional results correlated primarily with avoidance of complications and not necessarily with the radiologic results.
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Affiliation(s)
- Fang-Yao Chiu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, and the National Yang-Ming University, Taiwan, Republic of China.
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49
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Giannikas KA, Khan AM, Karski MT, Maxwell HA. Sacroiliac joint fusion for chronic pain: a simple technique avoiding the use of metalwork. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2004; 13:253-6. [PMID: 14648303 PMCID: PMC3468135 DOI: 10.1007/s00586-003-0620-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2003] [Revised: 06/02/2003] [Accepted: 07/31/2003] [Indexed: 11/25/2022]
Abstract
A previously undescribed method for posterior fusion of the sacroiliac joint (SIJ) utilizing the Cloward instrumentation is presented, suitable for cases with chronic pain and intact ligamental structures of the SIJ. The advantages of the method in comparison with other described options include minimal disturbance of the periarticular structures, avoidance of introduction of metalwork and preservation of the iliac crest contour. This technique has been used in five cases with follow-up longer than 2 years (mean 29 months, range 25-41 months). In all cases there was resolution of their painful symtomatology.
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Affiliation(s)
- K A Giannikas
- Department of Orthopaedics, Hope Hospital, Salford, UK.
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Sagi HC, Ordway NR, DiPasquale T. Biomechanical analysis of fixation for vertically unstable sacroiliac dislocations with iliosacral screws and symphyseal plating. J Orthop Trauma 2004; 18:138-43. [PMID: 15091266 DOI: 10.1097/00005131-200403000-00002] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine the effects of various iliosacral screw configurations with and without symphyseal plating on sacroiliac (SI) motion and hemipelvis stability in the vertically unstable pelvic model. DESIGN Biomechanical, human cadaver. SETTING Level 1 trauma center. INTERVENTION Hemipelvis and SI motion were analyzed on a Materials Testing System before and after creation of a vertically unstable APC III pelvic injury. Posterior fixation constructs consisted of iliosacral screws: (1). one into S1, (2). two into S1, or (3). one into S1 and one into S2. Results were obtained for all posterior constructs with and without a two-hole symphyseal plate. MAIN OUTCOME MEASUREMENT Hemipelvis and SI motion with axial loading. RESULTS There was no statistically significant difference between one or two iliosacral screws when hemipelvis rotational or linear displacement was examined at the SI joint. The two-hole symphyseal plate significantly increased the stability of the fixation construct in resisting linear displacement in all three planes. Without the symphyseal plate, an abnormal loading response was seen at the SI joint, resulting in paradoxical posterior translation and sagittal plane rotation. The addition of the plate restored the normal response, and anterior rotation and translation were observed as in the intact state. CONCLUSIONS Anterior symphyseal plating for the vertically unstable hemipelvis significantly increases the stability of the fixation construct and restores the normal response of the hemipelvis to axial loading. A significant benefit to supplementary iliosacral screws in addition to a properly placed S1 iliosacral screw was not shown.
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Affiliation(s)
- H C Sagi
- UCSF-Fresno Medical Education Program, Fresno, CA 93702, USA.
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