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Xing B, Shen X, Ma L, Qi X. TiRobot-Assisted Percutaneous Cannulated Screw Fixation for Elderly Patients with Fragility Fractures of the Pelvis: A Retrospective Study. Orthop Surg 2024; 16:662-674. [PMID: 38384135 PMCID: PMC10925510 DOI: 10.1111/os.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/13/2024] [Accepted: 01/18/2024] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVE The incidence of fragility fractures of the pelvis (FFPs) is increasing in the elderly population, and FFPs that require fixation are a challenge for orthopedic surgeons. The insertion of implants is not risk free due to the complex anatomical and osteoporotic bones and requires a steep learning curve. This study aimed to investigate the clinical efficacy of TiRobot-assisted percutaneous cannulated screw fixation in the treatment of elderly FFP patients. METHOD The clinical data of 46 elderly FFP patients who had been treated with percutaneous cannulated screw fixation from May 2020 to September 2022 were retrospectively analyzed. Twenty-four patients were treated with percutaneous cannulated screw fixation assisted by the TiRobot (TiRobot-assisted group) and 22 patients were treated with conventional freehand surgery (freehand group). Postoperative outcomes, including Matta value, excellent and good rate (EGR) of fracture reduction, and accuracy of screw placement (ASP), were compared. Changes in the Visual analog scale (VAS) pain score and the Majeed score were recorded and compared between groups before and after surgery and during the 24-week follow-up. Repeated-measures analysis of variance (ANOVA) and effect sizes were used as analysis methods. RESULTS A total of 90 screws were implanted, 51 screws in the TiRobot-assisted group and 39 screws in the freehand group. The operation time of the two groups was 34.1 ± 2.67 min versus 64.5 ± 4.19 min (p < 0.001). There were no screw-related complications or revision surgeries in any group. The Matta value of the TiRobot-assisted group was 5.13 ± 3.52, which was significantly lower than that of the freehand group (9.00 ± 3.68, p < 0.001), while the EGR was 91.67% versus 72.73%, with statistical significance (p < 0.001). The ASP was 100% in the TiRobot-assisted group, better than that in the freehand group, where it was 85.7% (p = 0.043). At each timepoint in the early postoperative period, the VAS score of the TiRobot-assisted group was significantly lower than that of the freehand group and was close to consistent by the last follow-up; the Majeed score of the former was significantly higher than that of the latter at each timepoint of follow-up, with statistical significance (p < 0.001). CONCLUSION TiRobot-assisted percutaneous cannulated screw fixation of elderly FFP patients is advantageous over conventional freehand surgery, with less invasion, more accurate screw placement, better fracture reduction, early pain relief, and rapid recovery, suggesting that Freehand method to stabilize FFP in the elderly population.
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Affiliation(s)
- Baorui Xing
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
- Department of Orthopaedic SurgeryHebei Cangzhou Hospital of Integrated Traditional Chinese and Western MedicineCangzhouChina
| | - Xiaoyu Shen
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Lijie Ma
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
| | - Xiangbei Qi
- Department of Orthopedic SurgeryThe Third Hospital of Hebei Medical UniversityShijiazhuangChina
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Chen PH, Chen CY, Lin KC, Hsu CJ. Quantification of the Safe Zone of the First to Third Sacral Segments for Transiliac-Transsacral Screw Fixation in Normal and Dysmorphic Sacra. Orthopedics 2024; 47:e13-e18. [PMID: 37276441 DOI: 10.3928/01477447-20230531-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Transiliac-transsacral screw fixation is widely used to stabilize unstable posterior pelvic ring injuries. Preoperative radiographic assessment of the safe osseous corridor is necessary because the safe space of sacrum is narrower for transiliac-transsacral screw placement than for traditional iliosacral screw placement. However, the radiographic assessment has rarely been studied in the Taiwanese population. We retrospectively analyzed 100 patients with pelvic computed tomography images and divided them into normal and dysmorphic pelvis groups. To determine the safe osseous space, we recorded cross-section area, cross-sectional diameter of the safe zone (CS-szD), and safe zone width on axial view (Ax-szW) in the S1 to S3 segments. The prevalence of dysmorphic pelvis was 48% among all patients. In the S1 segment, no differences were found in the cross-section area and CS-szD been the two groups. However, the Ax-szW was significantly smaller in the dysmorphic pelvis group. In the S2 segment, the cross-section area, CS-szD, and Ax-szW were all significantly larger in the dysmorphic pelvis group. In the S3 segment, the cross-section area and CS-szD of the normal pelvis group were both significantly smaller. No differences were found in the Ax-szW between the two groups. Based on our findings in a Taiwanese population, S1 was the most suitable segment for transiliac-transsacral screw fixation in a normal pelvis, whereas S2, followed by S3, was most suitable in a dysmorphic pelvis. This study offers surgeons information on identifying the optimal sacral segment for transiliac-transsacral screw placement for each pelvic morphology. [Orthopedics. 2024;47(1):e13-e18.].
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Cintean R, Fritzsche C, Zderic I, Gueorguiev-Rüegg B, Gebhard F, Schütze K. Sacroiliac versus transiliac-transsacral screw osteosynthesis in osteoporotic pelvic fractures: a biomechanical comparison. Eur J Trauma Emerg Surg 2023; 49:2553-2560. [PMID: 37535095 PMCID: PMC10728224 DOI: 10.1007/s00068-023-02341-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023]
Abstract
INTRODUCTION Pelvic fractures were often associated with high-energy trauma in young patients, but data show a significant increase in osteoporotic pelvic fractures in old age due to the progressive demographic change. There is an ongoing discussion about the best fixation techniques, which are ranging from lumbopelvic fixation to sacral bars or long transiliac-transsacral (TITS) screws. This study analyzes TITS screw osteosynthesis and sacroiliac screw osteosynthesis (SI), according to biomechanical criteria of fracture stability in osteoporotic human pelvic cadavers ex vivo. METHODS Ten osteoporotic cadaveric pelvises were randomized into two groups of 5 pelvises each. An FFP-IIc fracture was initially placed unilaterally and subsequently surgically treated with a navigated SI screw or a TITS screw. The fractured side was loaded in a one-leg stance test setup until failure. Interfragmentary movements were assessed by means of optical motion tracking. RESULTS No significant difference in axial stiffness were found between the SI and the TITS screws (21.2 ± 4.9 N and 18.4 ± 4.1 N, p = 0.662). However, there was a significantly higher stability of the fracture treatment in the cohort with TITS-screws for gap angle, flexion, vertical movement and overall stability. The most significant difference in the cycle interval was between 6.000 and 10.000 for the gap angle (1.62 ± 0.25° versus 4.60 ± 0.65°, p = 0.0001), for flexion (4.15 ± 0.39 mm versus 7.60 ± 0.81 mm, p = 0.0016), interval 11.000-15.000 for vertical shear movement (7.34 ± 0.51 mm versus 13.99 ± 0.97 mm, p < 0.0001) and total displacement (8.28 ± 0.66 mm versus 15.53 ± 1.07 mm, p < 0.0001) for the TITS and the SI screws. CONCLUSIONS The results of this biomechanical study suggest a clear trend towards greater fracture stability of the TITS screw with significantly reduced interfragmentary movement. The application of a TITS screw for the treatment of the osteoporotic pelvic ring fracture may be prioritized to ensure the best possible patient care.
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Affiliation(s)
- Raffael Cintean
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - Cornelius Fritzsche
- Department of Handsurgery, Upper Extremities and Foot Surgery, Krankenhaus Waldfriede, Argentinische Allee 40, 14163, Berlin, Germany
| | - Ivan Zderic
- AO Research Institute (ARI), Clavandelerstrasse 8, 7270, Davos Platz, Switzerland
| | | | - Florian Gebhard
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
| | - Konrad Schütze
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081, Ulm, Germany
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Thiesen DM, Althoff G, Strahl A, Rolvien T, Frosch KH, Koepke LG, Arras C, Ballhause TM, Dalos D, Hartel MJ. Conservative versus operative treatment of FFP II fractures in a geriatric cohort: a prospective randomized pilot trial. Sci Rep 2023; 13:16124. [PMID: 37752331 PMCID: PMC10522702 DOI: 10.1038/s41598-023-43249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 09/21/2023] [Indexed: 09/28/2023] Open
Abstract
A clear recommendation regarding treatment strategy of fragility fractures of the pelvic ring is missing. The most typical fracture pattern is a lateral compression type injury with non-displaced fractures of the anterior pubic rami and a unilateral os sacrum fracture (FFP II). We hypothesized that operative treatment would be superior to conservative treatment. From October 2017 to April 2020, a randomized prospective non-blinded trial with n = 39 patients was carried out. Two arms with 17 operative versus 22 conservative cases were created. Inclusion criteria were a posterior pelvic ring fracture FFP type II, age over 60 years and acute fracture (< 3 weeks). Barthel index, pain level (VAS), quality of life (EQ-5D-3L), and Tinetti-Gait Test were determined on admission, at discharge, and after 3, 6, 12 and 24 months. Median follow-up was 12.9 months. The Barthel index (= 0.325), VAS (p = 0.711), quality of life (p = 0.824), and Tinetti-Gait Test (p = 0.913) showed no significant differences between the two groups after 12 months. Two patients switched from the conservative to the operative arm due to persistent immobilization and pain. The one-year mortality rate showed no significant difference (p = 0.175). Our hypothesis that surgical treatment is superior was refuted. No significant benefit was shown in terms of quality of life, mortality and pain levels. The results suggest a more differentiated treatment approach in the future, with initial conservative treatment preferred. A larger multi-center trial is required to confirm these findings.Trial registration: The study was retrospectively registered with the German Clinical Trials Registry (DRKS00013703) on 10/12/2018.
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Affiliation(s)
- Darius M Thiesen
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Gerrit Althoff
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - André Strahl
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Tim Rolvien
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Trauma, Orthopaedic Surgery, and Sports Traumatology, BG Trauma Hospital Hamburg, Hamburg, Germany
| | - Leon-Gordian Koepke
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Christian Arras
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Tobias M Ballhause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Dimitris Dalos
- UKE Athleticum, Center for Athletic Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian J Hartel
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Trauma, Orthopaedic Surgery, and Sports Traumatology, BG Trauma Hospital Hamburg, Hamburg, Germany
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Kramer A, Naisan M, Kindel S, Richter M, Ringel F, Hartung P. Retrospective evaluation of percutaneous 3D-navigated screw fixation for fragility fractures of the sacrum: technical notes and four-year experience. Sci Rep 2023; 13:12254. [PMID: 37507446 PMCID: PMC10382507 DOI: 10.1038/s41598-023-39165-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
The incidence of fragility fractures of the sacrum is increasing due to demographic changes. In this study, we introduce the 3D-navigated monoportal percutaneous sacroiliac screw fixation (PSS) as a technical advancement for treating fragility fractures of the sacrum. We included all patients who underwent the 3D-navigated monoportal PSS for fragility fractures of the sacrum. The fractures were classified using the Fragility Fractures of the Pelvis score (FFP). We provide a step-by-step illustration of the surgical technique. The objective of this study was to assess the feasibility and safety of the investigated technique. Forty-six patients (36 female, 10 male) with a median age of 81.5 years were included in the study. The fracture classification revealed 23 FFP2 (50%), 5 FFP3 (11%), and 18 FFP4 (39%) fractures. In 35 cases (76%), only transsacral screws were implanted in S1 and S2, with an average incision-to-suture time of 52.6 min. The remaining eleven patients underwent additional anterior pelvic ring fixation, lumbar instrumentation, or kyphoplasty. There were no instances of nerve root, vascular, or pelvic organ injuries. The median postoperative in-hospital stay was six days. Out of the 36 patients who were followed up, four patients required revision surgery due to screw loosening. No significant risk factor for screw loosening was identified in the multiple regression analysis. The presented monoportal PSS technique for fragility fractures of the sacrum is a promising minimally invasive approach with a low complication rate and excellent short-term outcomes.
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Affiliation(s)
- Andreas Kramer
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstraße. 1, 55131, Mainz, Germany.
- Spine Center, St.-Josefs Hospital, Wiesbaden, Germany.
| | - Martin Naisan
- Spine Center, St.-Josefs Hospital, Wiesbaden, Germany
| | - Stefan Kindel
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstraße. 1, 55131, Mainz, Germany
| | | | - Florian Ringel
- Department of Neurosurgery, University Medical Center Mainz, Langenbeckstraße. 1, 55131, Mainz, Germany
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Kim YH. Teriparatide treatment for postmenopausal women with sacral insufficiency fracture. Osteoporos Sarcopenia 2023; 9:76. [PMID: 37496988 PMCID: PMC10366427 DOI: 10.1016/j.afos.2023.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/26/2023] [Indexed: 07/28/2023] Open
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Lambrechts MJ, Schroeder GD, Conaway W, Kothari P, Paziuk T, Karamian BA, Canseco JA, Oner C, Kandziora F, Bransford R, Vialle E, El-Sharkawi M, Schnake K, Vaccaro AR. Management of C0 Sacral Fractures Based on the AO Spine Sacral Injury Classification: A Narrative Review. Clin Spine Surg 2023; 36:43-53. [PMID: 36006406 PMCID: PMC9949526 DOI: 10.1097/bsd.0000000000001384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 06/29/2022] [Indexed: 11/26/2022]
Abstract
The Arbeitsgemeinschaft fur Osteosynthese fragen Spine Sacral Injury Classification hierarchically separates fractures based on their injury severity with A-type fractures representing less severe injuries and C-type fractures representing the most severe fracture types. C0 fractures represent moderately severe injuries and have historically been referred to as nondisplaced "U-type" fractures. Injury management of these fractures can be controversial. Therefore, the purpose of this narrative review is to first discuss the Arbeitsgemeinschaft fur Osteosynthese fragen Spine Sacral Injury Classification System and describe the different fracture types and classification modifiers, with particular emphasis on C0 fracture types. The narrative review will then focus on the epidemiology and etiology of C0 fractures with subsequent discussion focused on the clinical presentation for patients with these injuries. Next, we will describe the imaging findings associated with these injuries and discuss the injury management of these injuries with particular emphasis on operative management. Finally, we will outline the outcomes and complications that can be expected during the treatment of these injuries.
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Affiliation(s)
- Mark J. Lambrechts
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
| | | | - William Conaway
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
| | - Parth Kothari
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
| | - Taylor Paziuk
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
| | - Brian A. Karamian
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
| | - Jose A. Canseco
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA
| | - Cumhur Oner
- Department of Orthopedic Surgery, University Medical Center, University of Utrecht, Utrecht, Netherlands
| | | | - Richard Bransford
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA
| | - Emiliano Vialle
- Spine Surgery Group, Department of Orthopaedics, Cajuru University Hospital, Catholic University of Parana, Curitaba, Brazil
| | | | - Klaus Schnake
- Center for Spinal Surgery, Schön Klinik Nürnberg Fürth, Fürth, Germany
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Hutchings L, Roffey DM, Lefaivre KA. Fragility Fractures of the Pelvis: Current Practices and Future Directions. Curr Osteoporos Rep 2022; 20:469-477. [PMID: 36342642 DOI: 10.1007/s11914-022-00760-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE OF REVIEW To summarise the current evidence and clinical practices for patients with fragility fractures of the pelvis (FFP). RECENT FINDINGS FFPs are an increasingly prevalent and recognised problem in the elderly population. Recent evidence indicates they have a significant impact on function, morbidity and mortality. While traditional management of FFPs was predominantly non-surgical, surgical options have been increasingly used, with a range of surgical methods available. To date, limited consensus exists on the optimal strategy for suitable patient selection, and clinical trials in this population have proved problematic. The management of FFPs requires a multi-faceted approach to enhance patient care, including adequate pain control, minimisation of complications and optimisation of medical management. Early return to mobilisation should be a key treatment goal to maintain functional independence. The selection of patients who will maximally benefit from surgical treatment, and the most appropriate surgical strategy to employ, remains contentious.
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Affiliation(s)
- Lynn Hutchings
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Darren M Roffey
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Kelly A Lefaivre
- Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada.
- Division of Orthopaedic Trauma, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, British Columbia, Canada.
- Division of Orthopaedic Trauma, Department of Orthopaedics, Faculty of Medicine, The University of British Columbia, 3rd Floor, DHCC, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada.
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Rickert MM, Windmueller RA, Ortega CA, Devarasetty VVNM, Volkmar AJ, Waddell WH, Mitchell PM. Sacral Insufficiency Fractures. JBJS Rev 2022; 10:01874474-202207000-00001. [PMID: 35849657 DOI: 10.2106/jbjs.rvw.22.00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Primary osteoporosis is the most common cause of sacral insufficiency fractures (SIFs). Therefore, a multidisciplinary team approach is necessary for treatment of the fracture and the underlying biologic pathology, as well as prevention of future fragility fractures. » The presentation of SIFs typically includes lower back or buttock pain after a ground-level fall or without an identified trauma. Symptoms often have an insidious onset and are nonspecific; consequently, a delay in diagnosis and treatment is common. Clinicians need to have a high index of suspicion, particularly in high-risk patients. » Postmenopausal women who are >55 years of age are the most common demographic affected by SIFs. Other risk factors include osteoporosis, history of a prior fragility fracture, local irradiation, long-term corticosteroid use, rheumatoid arthritis, metabolic bone disorders, vitamin D deficiency, pregnancy, history of prior multilevel spinal fusion, and malignancy. » Typical imaging on computed tomography (CT) shows sclerosis of cancellous bone in the sacral ala, with or without a discrete fracture line or displacement. Magnetic resonance imaging is more sensitive than CT and shows hypointense signal on T1-weighted sequences and hyperintensity on T2-weighted or short tau inversion recovery sequences. » The treatment of SIFs is dependent on the severity of symptoms, fracture displacement, and instability of the pelvis. Accepted treatments include nonoperative rehabilitation, sacroplasty, iliosacral screw fixation, transsacral bar or screw fixation, transiliac internal fixation, and lumbopelvic fixation.
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Affiliation(s)
- Mariel M Rickert
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Jäckle K, Meier MP, Seitz MT, Höller S, Spering C, Acharya MR, Lehmann W. A retrospective study about functional outcome and quality of life after surgical fixation of insufficiency pelvic ring injuries. BMC Musculoskelet Disord 2021; 22:1035. [PMID: 34903216 PMCID: PMC8670246 DOI: 10.1186/s12891-021-04925-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fragility fractures without significant trauma of the pelvic ring in older patients were often treated conservatively. An alternative treatment is surgery involving percutaneous screw fixation to stabilize the posterior pelvic ring. This surgical treatment enables patients to be mobilized quickly and complications associated with bedrest and temporary immobility are reduced. However, the functional outcome following surgery and quality of life of the patients have not yet been investigated. Here, we present a comprehensive study addressing the long-term well-being and the quality of life of patients with fragility pelvic ring fractures after surgical treatment. METHODS Between 2011-2019, 215 geriatric patients with pelvic ring fractures were surgically treated at the university hospital in Göttingen (Germany). Of these, 94 patients had fragility fractures for which complete sets of computer tomography (CT) and radiological images were available. Fractures were classified according to Tile and according to the FFP classification of Rommens and Hofmann. The functional outcome of surgical treatment was evaluated using the Majeed pelvic score and the Short Form Health Survey-36 (SF-36). RESULTS Thirty five tile type C and 48 type B classified patients were included in the study. After surgery eighty-three patients scored in average 85.92 points (± 23.39) of a maximum of 100 points using the Majeed score questionnaire and a mean of 1.60 points on the numerical rating scale ranging between 0 and 10 points where 0 points refers to "no pain" and 10 means "strongest pain". Also, the SF-36 survey shows that surgical treatment positively effects patients with respect to their general health status and by restoring vitality, reducing bodily pain and an increase of their general mental health. CONCLUSIONS Patients who received a percutaneous screw fixation of fragility fractures of the posterior pelvic ring reported an overall positive outcome concerning their long-term well-being. In particular, older patients appear to benefit from surgical treatment. TRIAL REGISTRATION Functional outcome and quality of life after surgical treatment of fragility fractures of the posterior pelvic ring, DRKS00024768. Registered 8th March 2021 - Retrospectively registered. Trial registration number DRKS00024768 .
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Affiliation(s)
- Katharina Jäckle
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany.
| | - Marc-Pascal Meier
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Mark-Tilmann Seitz
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Sebastian Höller
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Christopher Spering
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
| | - Mehool R Acharya
- Pelvic and Acetabular Reconstruction Unit, Department of Trauma & Orthopaedics, North Bristol NHS Trust, Southmead Hospital, Southmead Rd, Bristol, BS10 5NB, UK
| | - Wolfgang Lehmann
- Department for Trauma Surgery, Orthopaedics and Plastic Surgery, University Medical Center Göttingen, Robert-Koch Str. 40, 37075, Göttingen, Germany
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Wheatley BM, Amin A, Miller MC, Warner SJ, Altman DT, Routt MLC. Does operative treatment of geriatric pelvic ring injuries lead to a high risk of one-year mortality? Injury 2021; 52:2973-2977. [PMID: 34246482 DOI: 10.1016/j.injury.2021.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/26/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Non-operative management of pelvic ring injuries in the elderly is associated with a high risk of one-year mortality. The majority of these injuries are the result of a low-energy mechanism, however, due to the multiple medical comorbidities in this patient population the injuries are associated with a high degree of morbidity. The purpose of this study was to determine the one-year mortality risk after operative treatment of pelvic ring injuries in a geriatric patient population and the effect of patient and injury characteristics on the risk of mortality. PATIENTS AND METHODS We performed a retrospective review of patients over the age of 70 who underwent operative fixation of a pelvic ring injury at two Level 1 trauma centers between January 2016 and June 2019. Medical records were reviewed for patient and injury characteristics including: Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA) physical status score or Injury Severity Score (ISS), hospital and intensive care unit (ICU) length of stay (LOS). The primary outcome of interest was the one-year mortality risk following operative treatment. Secondary outcomes included the effect of patient and injury characteristics on the one-year mortality risk and the hospital LOS. RESULTS Ninety patients were included with an average age of 79.8 ± 6.5 years. The overall mortality was 8.9% (n = 8) and was significantly associated with the CCI. There was no significant effect related to the ASA physical status score or ISS. The average hospital LOS was 9.2 ± 7.3 days and was associated with the CCI, ASA physical status score, and ISS. DISCUSSION Non-operative management of pelvic ring injuries in geriatric patients is associated with a high risk of one-year mortality. Our findings suggest operative treatment of these fractures is associated with an acceptable risk of one-year mortality that falls below the commonly reported range for non-operatively managed injuries. Furthermore, the risk of mortality was significantly associated with the patient's pre-injury state as determined by the CCI.
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Affiliation(s)
- Benjamin M Wheatley
- Department of Orthopedic Surgery, Allegheny Health Network, Pittsburgh, PA, United States.
| | - Adeet Amin
- Department of Orthopedic Surgery, University of Texas Health Sciences Center, Houston, TX, United States
| | - Mark C Miller
- Department of Orthopedic Surgery, Allegheny Health Network, Pittsburgh, PA, United States; Department of Mechanical Engineering and Materials Science, University of Pittsburgh, Pittsburgh, PA, United States
| | - Stephen J Warner
- Department of Orthopedic Surgery, University of Texas Health Sciences Center, Houston, TX, United States
| | - Daniel T Altman
- Department of Orthopedic Surgery, Allegheny Health Network, Pittsburgh, PA, United States
| | - Milton Lee Chip Routt
- Department of Orthopedic Surgery, University of Texas Health Sciences Center, Houston, TX, United States
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12
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Richter PH, Blidon A, Eickhoff A, Gebhard F, Schuetze K. Accuracy of screw stabilization of the dorsal pelvic ring using a hybrid operating room: 5 Year experience in a level 1 trauma center. Injury 2021; 52:2968-2972. [PMID: 34275645 DOI: 10.1016/j.injury.2021.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/26/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Accuracy for screw placement in the dorsal pelvic ring can be enhanced using intraoperative 3D navigation. Advances in intraoperative imaging lead to benefits for pelvic surgery. New c-arms are equipped with flat panel detectors, which have a larger detector and assure higher image quality with accompanying dose reduction. A hybrid OR is defined by a fixed imaging system in an operating room providing the benefit of the surgical environment in combination with advanced intraoperative imaging. Aim of our investigation was to analyze the accuracy of navigated sacroiliac (SI) and transsacral transiliac (TSTI) screws in the dorsal pelvic ring, which were implanted with a hybrid OR in the first five years of use. MATERIAL AND METHODS All percutaneous SI or TSTI screws implanted in the hybrid OR using intraoperative navigation in the first 5 years of utilization (between June 2012 to June 2017) were included. Intraoperative 3D-scans and postoperative computed tomography were examined for screw perforation. RESULTS 210 SI and TSTI screws were implanted in 187 patients using intraoperative navigation in the hybrid-OR. 90.6 % of SI screws showed no cortical perforation. 6,3 % had a grade 1, 2.4 % a grade 2 and 0.8 % a grade 3 perforation. In 80.7 % of TSTI screws no perforation and in 13.3 % a grade 1 perforation was detected. 3.6 % showed a grade 2 and 2.4 % a grade 3 perforation. No significant difference between both screw types regarding the grade of cortical perforation could be seen. No significant relation between perforation rate and year of operation could be detected. CONCLUSION Intraoperative navigation in a hybrid OR ensures a high accuracy for SI screws. Due to the large field of view and high image quality TSTI screws can be safely implanted in S1 and S2. Utilization of a hybrid-OR is accompanied with a steep learning curve.
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Affiliation(s)
- P H Richter
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany.
| | - A Blidon
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
| | - A Eickhoff
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
| | - F Gebhard
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
| | - K Schuetze
- Department of Orthopaedic Trauma, University Hospital of Ulm, Albert-Einstein-Alle 23, Ulm 89081, Germany
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Short-term outcome of fragility fractures of the pelvis in the elderly treated with screw osteosynthesis and external fixator. Eur J Trauma Emerg Surg 2021; 48:2413-2420. [PMID: 34545420 PMCID: PMC9192446 DOI: 10.1007/s00068-021-01780-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 09/01/2021] [Indexed: 11/20/2022]
Abstract
Background The treatment of fragility fractures of the pelvis is rising challenge for orthopedic trauma surgeons. Operative treatment should allow immediate full weight bearing and early mobilisation but should also be as minimal invasive as possible. Sacroiliac (SI) or transsacral transiliac screws (TSTI) alone or depending on the fracture in combination with an external fixator meets both of these criteria. Material and methods The outcome of 121 operatively treated patients with fragility fractures of the pelvis were evaluated in this retrospective study. Depending on the type of fracture the patients were treated with navigated SI screw or TSTI screw alone or in combination with an external fixator. All patients were operated in supine position in a hybrid-OR, which consists of a fixed robotic 3D flatpanel detector (Artis zeego, Siemens Healthineers, Germany) and a navigation system (BrainLab Curve, BrainLab, Germany). Results 37 patients were treated with either one or two SI screws and 57 with one TSTI screw. An additional external fixator was combined with SI screws in 17 patients and with TSTI screws in 10 patients. The preoperative pain score was significantly higher compared to the postoperative score (5.1 ± 2.5 vs 2.2 ± 1.9, p < 0.05). Follow-up at 6 month was possible for 106 patients which showed screw loosening in 16.3% of the SI Screws (n = 49) compared to only 5.2% of TSTI screws (n = 57). No screw loosening was seen in the combination of TSTI-screw and external fixator (n = 10). There were two septic and three aseptic pin loosenings of the external fixator. Overall only one patient needed revision surgery due to screw loosening and local irritation. Overall 75.2% (n = 91) of the patients could be released in their home or in a rehabilitation unit and only 14% (n = 17) were released to a nursing home due to immobility despite the operation. Non-surgical complications rate was 21.5%. Conclusion SI or TSTI screws with possible combination with an external fixator show early pain relief and allows most of the patients to keep their former level of independence. With an also low surgical complication rate, it proved to be a safe and reliable treatment for fragility fractures of the pelvis. Due the effective pain relief and the minimal invasive approach, early mobilisation is possible and might prevent typical non-surgical complications which are very common during conservative treatment.
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Wilson DGG, Kelly J, Rickman M. Operative management of fragility fractures of the pelvis - a systematic review. BMC Musculoskelet Disord 2021; 22:717. [PMID: 34419037 PMCID: PMC8380328 DOI: 10.1186/s12891-021-04579-w] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/02/2021] [Indexed: 02/07/2023] Open
Abstract
Background The incidence of osteoporotic pelvic fractures in elderly patient is rising. This brings an increasing burden on health and social care systems as these injuries often lead to prolonged hospital admissions, loss of independence, morbidity and mortality. Some centres now advocate stabilisation of these injuries to reduce pain, facilitate early mobilisation, decrease hospital stay and restore independence. A systematic review of the literature was planned to establish the evidence for this intervention. Methods A systematic review was performed according to PRISMA guidelines. A clinical librarian performed a search of the following databases: NHS Evidence, TRIP, the Cochrane Database of Systematic Reviews, MEDLINE and EMBASE. Seventeen eligible studies were identified with 766 patients. Results The quality of evidence was poor with no good quality randomised trials. The majority of injuries were minimally displaced. Posterior ring injuries were most often stabilised with percutaneous screws which were sometimes augmented with void filler. A number of techniques were described for stabilisation of the anterior ring although fixation of the anterior ring was frequently not performed. There was consistent evidence from the included studies that operative intervention significantly improved pain. Complications were minimal but there were increased failure rates when a single unaugmented sacroiliac joint screw was used. The limited availability of non-operative comparators made it difficult to draw firm conclusions about the efficacy of surgical over non-surgical management in these patients. Conclusions Operative management of fragility fractures of the pelvis should be considered for patients failing a brief period of non-operative management, however prospective randomised trials need to be performed to provide improved evidence for this intervention. Surgeons should consider which fixation techniques for fragility fractures of the pelvis are robust enough to allow immediate weightbearing, whilst minimising operative morbidity and post-operative complications. PROSPERO Systematic Review ID: CRD42020171237. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04579-w.
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Affiliation(s)
- Daniel G G Wilson
- Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia. .,, Present address: Brighton, UK.
| | - Joshua Kelly
- Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia
| | - Mark Rickman
- Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia.,Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, SA, 5005, Australia
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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: 18] [Impact Index Per Article: 4.5] [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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Kim YW, Jang JH, Jung GH. Assessment of osseous corridor for transiliac-transsacral screws and clinical applications: Computational simulation study. Orthop Traumatol Surg Res 2020; 106:863-867. [PMID: 32565120 DOI: 10.1016/j.otsr.2020.03.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 03/01/2020] [Accepted: 03/20/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Transiliac-transsacral (TITS) screw fixation might be necessary in some cases involving the vertical shearing injuries with transforaminal fracture and bilateral posterior ring injuries. However, the possibility of S1 TITS screw should be preoperatively assessed because the pelvic ring injuries with sacral dysmorphism had the insufficient osseous corridors. HYPOTHESIS AxWS2 may predict the possibility of TITS screw fixation and be used as the new indicator to discriminate the sacral dysmorphism. MATERIALS & METHODS The conventional CT images of eighty-two cadaveric pelvis imported into Mimics® software to reconstruct three-dimensional (3D) models. A 7.0 mm-sized screw was processed into a 3D model using a 3D-sensor at actual size and virtually implanted as S1 and S2 TITS screw using Mimics® software. The cortical violation around screw path was evaluated using 3D biplanar and conventional CT images. The osseous corridor widths around TITS screws were measured in the axial plane images and defined as AxWS1 and AxWS2, respectively. RESULTS Despite no cortical violation in S2 of all models, cortical violation of S1 TITS screw was found in 20 models. Of them, 14 models (impossible models) were identified in the 3D biplanar images, and all 20 models (CT-violation models) were identified only in CT axial plane images. AxWS1 was<7mm in the impossible models and<9.0mm in the CT-violation models. AxWS2 negatively correlated with AxWS1 (R -0.450, p<0.01). By receiver operating characteristic curve analysis to identify the CT-violation model using AxWS2, the cut-off value of AxWS2 was 13.32mm (sensitivity 0.70, specificity 0.70). DISCUSSION By using AxWS2, the possibility of S1 TITS screw fixation could be predicted and safely placed without cortical violation, if AxWS2 was less than 13mm. Considering the negative relationship with AxWS1, AxWS2 should be used as a new indicator to predict safe S1 TITS screw fixation. LEVEL OF EVIDENCE III, controlled laboratory study.
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Affiliation(s)
- Young-Woo Kim
- Department of Orthopaedic Surgery, Catholic University, Uijeongbu St. Mary's Hospital, Uijeongbu, Republic of Korea
| | - Jae-Hoon Jang
- Department of Orthopaedic Surgery, Trauma Centre, Pusan National University Hospital, 179, Gudeok-ro, Seo-gu, Busan, 49241, Republic of Korea
| | - Gu-Hee Jung
- Department of Orthopaedic surgery, Gyeongsang National University, College of Medicine and Gyeongsang National University Changwon hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea; Institute of Health Sciences (Medical ICT Convergence Research Centre), Gyeongsang National University, College of Medicine, 816, Beongil 15, Jinju-daero, Jinju-si, 52727, Republic of Korea.
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Urits I, Orhurhu V, Callan J, Maganty NV, Pousti S, Simopoulos T, Yazdi C, Kaye RJ, Eng LK, Kaye AD, Manchikanti L, Viswanath O. Sacral Insufficiency Fractures: a Review of Risk Factors, Clinical Presentation, and Management. Curr Pain Headache Rep 2020; 24:10. [PMID: 32067155 DOI: 10.1007/s11916-020-0848-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF THE REVIEW Sacral insufficiency fractures (SIF) are a common and often underdiagnosed source of low back pain. In patients with SIF, there is both a compromised sacroiliac joint and weakened sacrum, resulting in decreased resistance to torsional stress, leading to fracture. While conservative medical management is a safe option, minimally invasive intervention may provide improved short and long-term relief of low back pain in patients presenting with SIF. This comprehensive review is undertaken to provide an update to the current understanding of SIF with description of risk factors, clinical presentation, and management. RECENT FINDINGS Sacroplasty is a minimally invasive procedure in which polymethylmethacrylate (PMMA) cement is inserted into bone to improve its structural integrity and alleviate symptoms. Balloon sacroplasty (BSP) has also been successful in alleviating pain with minimal cement leakage in SIF patients. Various other interventional techniques, including navigation-assisted screw fixation have been used to address SIF and have shown improvement in pain with minimal side effects. This review included various modalities of treatments available to manage SIF. This review shows that in comparison with nonsurgical management, sacroplasty has been shown to have greater pain reduction and improved mobility.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Vwaire Orhurhu
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Jessica Callan
- Department of Anesthesia, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Nishita V Maganty
- Department of Anesthesia, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Sara Pousti
- Department of Anesthesia, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Thomas Simopoulos
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Cyrus Yazdi
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Rachel J Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | | | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | | | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants, Phoenix, AZ, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
- Department of Anesthesiology, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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Chung HJ, Park J, Sohn HS, Jung GH. The usefulness of reformatting CT scanning plane to distinguish sacral dysmorphism and introducing the variable of elevated height for predicting the possibility of trans-sacral screw fixation. Orthop Traumatol Surg Res 2020; 106:109-115. [PMID: 31948877 DOI: 10.1016/j.otsr.2019.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 10/15/2019] [Accepted: 11/05/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Ilio-sacral screw fixation has been used for sacral fractures and sacroiliac joint dislocations. However, it is associated with significant complications including screw loosening with backing-out and loss of reduction. Trans-sacral screw fixation is indicated for rigid fixation in specific circumstances including bilateral posterior ring injuries, osteoporotic bone, or to supplement other types of posterior ring fixation. HYPOTHESIS The reformatting the CT scanning plane may distinguish sacral dysmorphism and predict the possibility of trans-sacral screw fixation by introducing the new indicator. MATERIAL AND METHODS The CT data of 112 adult cadavers (61 males and 51 females) were imported into Mimics® software and a 7.0 mm-sized trans-sacral screw was virtually placed in the ideal position of S1. The osseous widths around screw in the axial images (AxWS1) were measured. By reformatting the CT scanning plane parallel to the superior endplate of S1, the AxWRS1 was measured and the height of elevated segment in the upper sacrum (elevated height) was assessed as a new preoperative indicator. RESULTS Cortical violation around screw was detected in 26 models and was considered as sacral dysmorphism. The average AxWS1 was measured as 13.70±2.76mm in the non-dysmorphism group, and 5.81±2.19mm in the dysmorphism group, with statistical difference (p<0.001). By reformatting the CT scanning plane, the average AxWRS1 increased to 16.61±2.79mm in the non-dysmorphism group, and 8.04±2.62 in the dysmorphism group, and the difference was statistically significant (p<0.001). The elevated height was 3.29±4.19mm in the non-dysmorphism group, and 17.52±3.09mm in the dysmorphism group, and the differences were statistically significant (p<0.001). Based on the ROC curve analysis, the cut-off value of elevated height was 12.90mm (sensitivity 1.0 and specificity 1.0). DISCUSSION By reformatting the CT scanning plane, the osseous width around screw was widened, and the new preoperative indicator of elevated height could be introduced to predict the possibility of trans-sacral screw fixation into S1. If the elevated height exceeded 13mm, the pelvis was assigned to sacral dysmorphism and thus, could not apply the trans-sacral screw fixation into S1. LEVEL OF EVIDENCE III, controlled laboratory study.
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Affiliation(s)
- Hoe Jeong Chung
- Department of Orthopaedic Surgery, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, 20, Ilsan-ro, Wonju-si, Gangwon-do, 26436, Republic of Korea
| | - Jisu Park
- Department of Orthopaedic Surgery, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, 20, Ilsan-ro, Wonju-si, Gangwon-do, 26436, Republic of Korea
| | - Hoon-Sang Sohn
- Department of Orthopaedic Surgery, Wonju College of Medicine, Yonsei University, Wonju Severance Christian Hospital, 20, Ilsan-ro, Wonju-si, Gangwon-do, 26436, Republic of Korea
| | - Gu-Hee Jung
- Department of Orthopaedic surgery, Gyeongsang national university, college of medicine, Gyeongsang national university Changwon hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, 51472, Korea; Medical ICT Convergence research center, Institute of Health Sciences, college of Medicine, Gyeongsang National University, 816 Beongil 15, Jinju-daero, Jinju-si, 52727, Korea.
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Becker CA, Kussmaul AC, Suero EM, Regauer M, Woiczinski M, Braun C, Flatz W, Pieske O, Kammerlander C, Boecker W, Greiner A. Tape suture for stabilization of incomplete posterior pelvic ring fractures-biomechanical analysis of a new minimally invasive treatment for incomplete lateral compression pelvic ring fractures. J Orthop Surg Res 2019; 14:465. [PMID: 31881914 PMCID: PMC6935107 DOI: 10.1186/s13018-019-1509-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 12/05/2019] [Indexed: 12/13/2022] Open
Abstract
Background Incomplete lateral compression fractures (including AO Type B2.1) are among the most common pelvic ring injuries. Although the treatment of choice remains controversial, sacroiliac (SI) screws are commonly used for the operative treatment of incomplete lateral compression fractures of the pelvic ring. However, the disadvantages of SI screws include the risk of nerve root or blood vessel injury. Recently, tape sutures have been found useful as stabilizing material for the treatment of injuries of the syndesmosis, the rotator cuff and knee ligaments. In this current study, we aimed to test the biomechanical feasibility of tape sutures to stabilize the pelvis in the setting of AO Type B2.1 injury. Methods Six human cadaveric pelvises underwent cyclic loading to compare the biomechanical stability of different osteosynthesis methods in a B2.1 fracture model. The methods tested in this experiment were a FiberTape® suture and the currently established SI screw. A 3D ultrasound tracking system was used to measure fracture fragment motion. Linear regression was used to model displacement and stiffness at the posterior and anterior pelvic ring. Results At the posterior fracture site, the FiberTape® demonstrated similar displacement (2.2 ± 0.8 mm) and stiffness (52.2 ± 18.0 N/mm) compared to the sacroiliac screw (displacement 2.1 ± 0.6 mm, P > 0.999; stiffness 50.8 ± 13.0 N/mm, P > 0.999). Considering the anterior fracture site, the FiberTape® again demonstrated similar displacement (3.8 ± 1.3 mm) and stiffness (29.5 ± 9.0 N/mm) compared to the sacroiliac screw (displacement 2.9 ± 0.8 mm, P = 0.2196; stiffness 37.5 ± 11.5 N/mm, P = 0.0711). Conclusion The newly presented osteosynthesis, the FiberTape®, shows promising results for the stabilization of the posterior pelvic ring in AO Type B2.1 lateral compression fractures compared to a sacroiliac screw osteosynthesis based on its minimal-invasiveness and the statistically similar biomechanical properties.
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Affiliation(s)
| | - Adrian Cavalcanti Kussmaul
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Eduardo Manuel Suero
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Markus Regauer
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Matthias Woiczinski
- Department of Orthopedic Surgery, Physical Medicine and Rehabilitation, University Hospital, LMU Munich, Munich, Germany
| | - Christian Braun
- Department of Legal and Forensic Medicine, University Hospital, LMU Munich, Munich, Germany
| | - Wilhelm Flatz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Oliver Pieske
- Department of Trauma Surgery, Evangelic Hospital Oldenburg, Oldenburg, Germany
| | - Christian Kammerlander
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang Boecker
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Axel Greiner
- Department of General, Trauma and Reconstructive Surgery, University Hospital, LMU Munich, Munich, Germany.
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Bagheri H, Govsa F. Anatomical considerations of safe drilling corridor upper sacral segment screw insertion. J Orthop 2019; 16:543-551. [PMID: 31660021 PMCID: PMC6806658 DOI: 10.1016/j.jor.2019.04.010] [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: 01/12/2019] [Accepted: 04/15/2019] [Indexed: 10/26/2022] Open
Abstract
The upper segment of sacrum is an important for screw insertions of unstable lumbosacral spine. Measurements of the S1-S2 as sacral wings, pedicles, sacral foraminas and sacral canal were taken from 87 sacrums. The mean depths of S1 pedicle and sacral wing were estimated as 25.8 ± 2.3 mm and 50.1 ± 1.7 mm, respectively. Angles screw trajectory of sacral pedicle anteromedial and sacral wing were measured as 29.6 ± 0.9° and 29.7 ± 2.1°, respectively. To avoid injury to the vascular structures anteriorly and nerve roots medially, depth and angle of screw trajectory is important for the entrance off pedicular screw placement to the S1.
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Affiliation(s)
| | - Figen Govsa
- Department of Anatomy Digital Imaging and 3D Modelling Laboratory, Faculty of Medicine, Ege University, Izmir, Turkey
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Prolonged pain in patients with fragility fractures of the pelvis may be due to fracture progression. Eur J Trauma Emerg Surg 2019; 47:507-513. [PMID: 31111165 DOI: 10.1007/s00068-019-01150-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 05/13/2019] [Indexed: 12/20/2022]
Abstract
PURPOSE Most fragility fractures of the pelvis (FFPs) are conservatively treated in the early phase. However, the definition of conservative treatment failure and the subsequent treatment protocol is controversial. Fracture progression (FP) sometimes occurs during conservative treatment of FFPs. This study aimed to assess the association between FP and prolonged pain in patients with FFPs receiving conservative treatment. METHODS Retrospective case series in a single institution in Japan. A total of 192 consecutive FFP patients were identified during study period. Seventy-nine patients met the inclusion and exclusion criteria. FFPs were diagnosed using both CT and MRI and FP was diagnosed with CT. Patients met criteria for prolonged pain if they had persisting pain after 2 weeks of conservative treatment and had lack of improvement in mobility. The relationship between FP and prolonged pain was analyzed using Fisher's exact test. RESULTS Of the 79 patients, 18 developed FP. Four of the 18 patients with FP met criteria for prolonged pain. Two of 61 patients without FP had prolonged pain (p = 0.022; odds ratio 8.12). In the entire study cohort, six patients (7.6%) met criteria prolonged pain and underwent elective surgery. CONCLUSION In patients with FFPs, prolonged pain was associated with FP (p = 0.022, OR 8.12). The presence of prolonged pain might help identify FP. If FP is identified, surgical treatment may be required with cautious follow-up particularly in cases, where FFP progresses to type III or IV fracture.
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Pulley BR, Cotman SB, Fowler TT. Surgical Fixation of Geriatric Sacral U-Type Insufficiency Fractures: A Retrospective Analysis. J Orthop Trauma 2018; 32:617-622. [PMID: 30211791 DOI: 10.1097/bot.0000000000001308] [Citation(s) in RCA: 17] [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 define the incidence of sacral U-type insufficiency fracture and describe management of a consecutive series of patients with this injury. DESIGN Retrospective analysis. SETTING Single Level II trauma center. PATIENTS/PARTICIPANTS Sixteen adult patients with sacral U-type insufficiency fractures treated over a 36-month period. INTERVENTION Patients were indicated for percutaneous screw fixation of the posterior pelvis if they had posterior pelvic pain that prohibited mobilization. MAIN OUTCOME MEASUREMENTS Visual analog scale for pain, distance ambulated on postoperative day 1, and change in sacral kyphosis. RESULTS The sacral U-type insufficiency fracture incidence was 16.7% (19/114); average patient age was 75 years. Delayed surgery was performed after primary nonoperative treatment had failed in 62.5% (10/16) at an average 83 days postinjury. Acute surgery was performed in 37.5% (6/16) at an average 5 days postinjury. Distance ambulated on postoperative day 1 was 114.4 feet [95% confidence interval (CI) (50.6, 178.2)] and 88.7 feet [95% CI (2.8, 174.6)] in the delayed and acute surgery groups, respectively, P = 0.18. Change in visual analog scale for pain was -3.2 [95% CI (-5.0, -1.4)] and -3.7 [95% CI (-7.0, -0.4)] in the delayed and acute surgery groups, respectively, P = 0.15. Change in sacral kyphosis from presentation to surgery was 12.3 degrees [95% CI (6.7, 17.9)] and 0.3 degrees [95% CI (-0.2, 0.9)] in the delayed and acute surgery groups, respectively, P < 0.01. Minimum follow-up was 12 months. CONCLUSIONS Treatment of sacral U-type insufficiency fractures by percutaneous screw fixation permits early mobilization, provides rapid pain relief, and prevents progressive deformity. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Benjamin R Pulley
- Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, CA
| | - Steven B Cotman
- Department of Orthopaedic Surgery, Mount Carmel Health System, Columbus, OH
| | - T Ty Fowler
- Department of Orthopaedic Surgery, Mount Carmel Health System, Columbus, OH.,Orthopedic ONE, Columbus, OH
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Percutaneous Transiliac-Transsacral Screw Fixation of Sacral Fragility Fractures Improves Pain, Ambulation, and Rate of Disposition to Home. J Orthop Trauma 2018; 32:452-456. [PMID: 29916895 DOI: 10.1097/bot.0000000000001243] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether percutaneous transiliac-transsacral screw fixation improves pain, ambulation, length of stay, and the rate of disposition to home in patients with sacral fragility fractures. DESIGN Retrospective cohort study. SETTING Single academic Level 1 trauma center. PATIENTS/PARTICIPANTS Elderly patients who presented with an isolated sacral fragility fracture between August 2015 and August 2017. Of the 41 patients included in the study, 16 were treated operatively and 25 were treated nonoperatively. INTERVENTION Percutaneous transiliac-transsacral screw fixation. MAIN OUTCOME MEASUREMENTS Pain, ambulation, length of stay, complications, and disposition. RESULTS Patients treated operatively reported a greater improvement in pain as measured by the visual analog scale (3.9 vs. 0.6 points, P < 0.001). At the time of discharge, 100% of surgically treated patients were able to ambulate compared with 72% in the nonoperative group (P = 0.03). Average distance ambulating at the time of discharge was higher in the operative group (95 vs. 35 ft, P < 0.01). Length of stay was similar between the 2 groups (3.6 days in operative group vs. 4.2 days in nonoperative group, P = 0.5). Of the patients treated operatively, 75% were discharged to home compared with only 20% in the nonoperative group (P < 0.001). There were no complications related to surgery. CONCLUSIONS Percutaneous transiliac-transsacral screw fixation of sacral fragility fractures lessens pain, improves ambulation, and increases the rate of disposition to home. Further investigation is needed to determine if surgical fixation provides benefit regarding medium- and long-term outcome variables. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Eckardt H, Egger A, Hasler RM, Zech CJ, Vach W, Suhm N, Morgenstern M, Saxer F. Good functional outcome in patients suffering fragility fractures of the pelvis treated with percutaneous screw stabilisation: Assessment of complications and factors influencing failure. Injury 2017; 48:2717-2723. [PMID: 29122281 DOI: 10.1016/j.injury.2017.11.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 10/03/2017] [Accepted: 11/03/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Low energy pelvic ring fractures in the elderly have traditionally been treated conservatively, a treatment with potential long-term complications and loss of self-independence. Percutaneous screw stabilisation of the posterior pelvic ring is a new treatment modality that enables immediate mobilisation. The aim of this study was to assess the functional outcome after sacroiliac stabilisation in the elderly. METHODS All elderly patients with a surgically stabilised low energy pelvic fracture between 2010 and 2015 were included. In 2016 a radiographic follow up and functional test was performed at least one year postoperative. RESULTS The 50 operated patients had a mean age of 79 years and a one-year mortality of 10% (5/50). Only six patients lost independency after the pelvic fracture and moved to nursing home. The mean Timed Up and Go test was 16s at follow-up. The operation of the posterior pelvic ring averaged 63min with a radiation equal to a diagnostic pelvic CT. One intra-foraminally placed screw was immediately removed and 9 patients were later re-operated on due to symptomatic loosening of one or more screws. No loosening of screws was seen in 11 patients where both S1 and S2 were stabilised and out of 23 trans-sacral screws (crossing both sacroiliac joints) only two loosened. DISCUSSION CT guided stabilisation of the posterior pelvis is safe and most patients resumed good function and independent living. The risk of a revision operation was 20%, but trans-sacral screw stabilisation in both S1 and S2 could reduce the risk of implant loosening.
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Affiliation(s)
- Henrik Eckardt
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland.
| | - Alexander Egger
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Rebecca Maria Hasler
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Christoph J Zech
- Department of Interventional Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Werner Vach
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Norbert Suhm
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Mario Morgenstern
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - Franziska Saxer
- Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
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Jeong JH, Jin JW, Kang BY, Jung GH. Can the possibility of transverse iliosacral screw fixation for first sacral segment be predicted preoperatively? Results of a computational cadaveric study. Injury 2017; 48:2074-2079. [PMID: 28764917 DOI: 10.1016/j.injury.2017.07.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 07/17/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to predict the possibility of transverse iliosacral (TIS) screw fixation into the first sacral segment (S1) and introduce practical anatomical variables using conventional computed tomography (CT) scans. MATERIALS AND METHODS A total of 82 cadaveric sacra (42 males and 40 females) were used for continuous 1.0-mm slice CT scans, which were imported into Mimics® software to produce a three-dimensional pelvis model. The anterior height (BH) and superior width (BW) of the elevated sacral segment was measured, followed by verification of the safe zone (SZS1 and SZS2) in a true lateral view. Their vertical (VDS1 and VDS2) and horizontal (HDS1 and HDS2) distances were measured. VDS1 less than 7mm was classified as impossible sacrum, since the transverse fixation of 7.0 mm-sized IS screw could not be done safely. RESULTS Fourteen models (16.7%; six females, eight males) were assigned as the impossible sacrum. There was no statistical significance regarding gender (p=0.626) and height (p=0.419). The average values were as follows: BW, 31.4mm (SD 2.9); BH, 16.7mm (SD 6.8); VDS1, 13.4mm (SD 6.1); HDS1, 22.5mm (SD 4.5); SZS1, 239.5mm2 (SD 137.1); VDS2, 15.5mm (SD 3.0); HDS2, 18.3mm (SD 2.9); and SZS2, 221.1mm2 (SD 68.5). Logistic regression analysis identified BH (p=0.001) and HDS1 (p=0.02) as the only statistically significant variables to predict the possibility. Receiver operating characteristic curve analysis established a cut-off value for BH and HDS1 of impossible sacrum of 20.6mm and 18.6mm, respectively. CONCLUSION BH and HDS1 could be used to predict the possibility of TIS screw fixation. If the BH exceeds 20.6mm or HDS1 is less than 18.6mm, TIS screw fixation for S1 should not be undertaken because of narrowed SZ.
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Affiliation(s)
- Jin-Hoon Jeong
- Department of Orthopaedic Surgery, Gyeongsang National University, College of Medicine, Gyeongsang National University Changwon Hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea
| | - Jin Woo Jin
- Department of Orthopedic Surgey, Samsung Changwon hospital, Sungkyunkwan University, school of medicine, 158, Paryong-ro, Masanhoewon-gu, Changwon-si, Gyeongsangnam-do, 51353, Republic of Korea
| | - Byoung Youl Kang
- Department of Orthopedic Surgey, Samsung Changwon hospital, Sungkyunkwan University, school of medicine, 158, Paryong-ro, Masanhoewon-gu, Changwon-si, Gyeongsangnam-do, 51353, Republic of Korea
| | - Gu-Hee Jung
- Department of Orthopaedic Surgery, Gyeongsang National University, College of Medicine, Gyeongsang National University Changwon Hospital, 11, Samjeongja-ro, Seongsan-gu, Changwon-si, Gyeongsangnam-do, 51472, Republic of Korea.
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Osterhoff G, Dodd AE, Unno F, Wong A, Amiri S, Lefaivre KA, Guy P. Cement Augmentation in Sacroiliac Screw Fixation Offers Modest Biomechanical Advantages in a Cadaver Model. Clin Orthop Relat Res 2016; 474:2522-2530. [PMID: 27334321 PMCID: PMC5052190 DOI: 10.1007/s11999-016-4934-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 06/07/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Sacroiliac screw fixation in elderly patients with pelvic fractures is prone to failure owing to impaired bone quality. Cement augmentation has been proposed as a possible solution, because in other anatomic areas this has been shown to reduce screw loosening. However, to our knowledge, this has not been evaluated for sacroiliac screws. QUESTIONS/PURPOSES We investigated the potential biomechanical benefit of cement augmentation of sacroiliac screw fixation in a cadaver model of osteoporotic bone, specifically with respect to screw loosening, construct survival, and fracture-site motion. METHODS Standardized complete sacral ala fractures with intact posterior ligaments in combination with ipsilateral upper and lower pubic rami fractures were created in osteoporotic cadaver pelves and stabilized by three fixation techniques: sacroiliac (n = 5) with sacroiliac screws in S1 and S2, cemented (n = 5) with addition of cement augmentation, and transsacral (n = 5) with a single transsacral screw in S1. A cyclic loading protocol was applied with torque (1.5 Nm) and increasing axial force (250-750 N). Screw loosening, construct survival, and sacral fracture-site motion were measured by optoelectric motion tracking. A sample-size calculation revealed five samples per group to be required to achieve a power of 0.80 to detect 50% reduction in screw loosening. RESULTS Screw motion in relation to the sacrum during loading with 250 N/1.5 Nm was not different among the three groups (sacroiliac: 1.2 mm, range, 0.6-1.9; cemented: 0.7 mm, range, 0.5-1.3; transsacral: 1.1 mm, range, 0.6-2.3) (p = 0.940). Screw subsidence was less in the cemented group (3.0 mm, range, 1.2-3.7) compared with the sacroiliac (5.7 mm, range, 4.7-10.4) or transsacral group (5.6 mm, range, 3.8-10.5) (p = 0.031). There was no difference with the numbers available in the median number of cycles needed until failure; this was 2921 cycles (range, 2586-5450) in the cemented group, 2570 cycles (range, 2500-5107) for the sacroiliac specimens, and 2578 cycles (range, 2540-2623) in the transsacral group (p = 0.153). The cemented group absorbed more energy before failure (8.2 × 105 N*cycles; range, 6.6 × 105-22.6 × 105) compared with the transsacral group (6.5 × 105 N*cycles; range, 6.4 × 105-6.7 × 105) (p = 0.016). There was no difference with the numbers available in terms of fracture site motion (sacroiliac: 2.9 mm, range, 0.7-5.4; cemented: 1.2 mm, range, 0.6-1.9; transsacral: 2.1 mm, range, 1.2-4.8). Probability values for all between-group comparisons were greater than 0.05. CONCLUSIONS The addition of cement to standard sacroiliac screw fixation seemed to change the mode and dynamics of failure in this cadaveric mechanical model. Although no advantages to cement were observed in terms of screw motion or cycles to failure among the different constructs, a cemented, two-screw sacroiliac screw construct resulted in less screw subsidence and greater energy absorbed to failure than an uncemented single transsacral screw. CLINICAL RELEVANCE In osteoporotic bone, the addition of cement to sacroiliac screw fixation might improve screw anchorage. However, larger mechanical studies using these findings as pilot data should be performed before applying these preliminary findings clinically.
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Affiliation(s)
- Georg Osterhoff
- Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, 3114–910 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Andrew E. Dodd
- Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, 3114–910 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Florence Unno
- Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, 3114–910 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Angus Wong
- Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, 3114–910 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Shahram Amiri
- Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, 3114–910 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Kelly A. Lefaivre
- Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, 3114–910 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Pierre Guy
- Division of Orthopaedic Trauma, Department of Orthopaedics, University of British Columbia, 3114–910 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
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