Useful Intraoperative Technique for Percutaneous Stabilization of Bilateral Posterior Pelvic Ring Injuries

Minimally Invasive Treatment of Pelvic Fractures with Titanium Elastic Nailing: An Innovative Technology

BACKGROUND

Minimally invasive treatment has become the most popular and effective treatment for pelvic fractures. This study aimed to evaluate the safety and efficacy of a new technique, titanium elastic nailing (TEN), for the minimally invasive treatment of pelvic fractures.

METHOD

Twenty-four patients with pelvic fractures were referred to us between January 2020 to January 2022, including sixteen males and 8 females. Pelvic fractures were temporarily fixed by pelvic fixation belt accompanied by traction from the lower limb bone. Anterior pelvic ring injuries (superior ramus of pubis) and ilium fractures were treated with closed reduction and intramedullary fixation with minimally invasive TEN. Intraoperative C-arm, including pelvic anteroposterior, pelvic outlet, inlet and ilium oblique views, and O-arm fluoroscopy (intraoperative CT) were employed to assess fractures reduction and determine the location of the elastic titanium nail within the bone channel.

RESULTS

By adopting closed reduction and minimally invasive incision techniques, pelvic fractures could be safely fixed by placing an elastic titanium nail in the osseous medullary cavity channels of the pelvis. Postoperative investigation indicated that the wounds of all patients were healed in the first stage without any occurrence of complications, such as injuries to the nerves, blood vessels, and important tissue structures. Patients are essential quickly after the operation and could perform the functional exercise in the early stages of the recovery.

CONCLUSION

TEN can be used for minimally invasive treatment of pelvic fractures. This novel technique has no obvious complications and is worthwhile in clinical practice.

Quantification of the Safe Zone of the First to Third Sacral Segments for Transiliac-Transsacral Screw Fixation in Normal and Dysmorphic Sacra

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.].

Pelvic ring injuries: recent advances in diagnosis and treatment

Pelvic ring injuries typically occur from high-energy trauma and are often associated with multisystem injuries. Prompt diagnosis of pelvic ring injuries is essential, and timely initial management is critical in the early resuscitation of polytraumatized patients. Definitive management of pelvic ring injuries continues to be a topic of much debate in the trauma community. Recent studies continue to inform our understanding of static and dynamic pelvic ring stability. Furthermore, literature investigating radiographic and clinical outcomes after nonoperative and operative management will help guide trauma surgeons select the most appropriate treatment of patients with these injuries.

Modified Lumbopelvic Technique Using S1 Pedicle Screws for Spinopelvic Dissociation U-Type and H-Type Sacral Fractures With Kyphotic Deformity

Spinopelvic dissociation injuries are complex injuries defined as discontinuity between the appendicular and axial skeleton. Fracture patterns are variable, but U-type and H-type fractures are common and often present with kyphotic deformity along with translational displacement and impaction. The ideal method of fixation has not been established for these injuries. The goals of treatment include restoration of alignment, stability, and neural decompression as needed. Traditional methods of lumbopelvic fixation have spanned the upper sacral fracture site. Our novel modified method of lumbopelvic fixation directly instruments the S1 body. This allows for direct manipulation of the fracture which we theorize improves reduction and increases stability across the fracture. This article characterizes the injury patterns, outlines the modified technique, and reports the clinical and radiographic outcomes of our modified lumbopelvic fixation technique and construct.

A useful intraoperative technique for transiliac-transsacral screws: a point-to-point coaxial guide apparatus

Background

The transiliac-transsacral screw placement is a clinical challenge for surgeons. This study explored a point-to-point coaxial guide apparatus assisting the transiliac-transsacral screw insertion and aimed to investigate the feasibility and accuracy of the guide apparatus in the treatment of posterior ring unstable pelvic fracture compared with a free-hand technique.

Methods

A retrospective study was performed to evaluate patients treated with transiliac-transsacral screws assisted by the point-to-point coaxial guide apparatus or free-hand technique. The intraoperative data of operative time and radiation exposure times were recorded. Postoperative radiographs and CT scans were performed to scrutinize the accuracy of screws position. The quality of the postoperative fracture reduction was assessed according to Matta radiology criteria. The pelvic function was assessed according to the Majeed scoring criteria at 6 months postoperatively.

Results

From July 2017 to December 2019, a total of 38 patients were included in this study, 20 from the point-to-point guide apparatus group and 18 from the free-hand group. There were no significant differences between the two groups in gender, age, injury causes, pelvic fracture type, screws level, and follow-up time (P > 0.05). The average operative time of the guide apparatus group for each screw was significantly less than that in the free-hand group (25.8 ± 4.7 min vs 40.5 ± 5.1, P < 0.001). The radiation exposure times were significantly lower in the guide apparatus group than that in the free-hand group (24.4 ± 6.0 vs 51.6 ± 8.4, P < 0.001). The intraosseous and juxtacortical rate of screw placement (100%) higher than in the free-hand group (94.4%).

Conclusion

The point-to-point coaxial guide apparatus is feasible for assisting the transiliac-transsacral screw in the treatment of posterior unstable pelvic fractures. It has the advantages of simple operation, reasonable design and no need for expensive equipment, and provides an additional surgical strategy for the insertion of the transiliac-transsacral screw.

Multidimensional Pelvic Fluoroscopy: A New and Novel Technique for Assessing Safety and Accuracy of Percutaneous Iliosacral Screw Fixation

OBJECTIVES

Multidimensional fluoroscopy is new imaging technology that generates intraoperative cross sectional imaging. Can this technology be used to assess accuracy and safety of percutaneously placed iliosacral screws intraoperatively?

DESIGN

Retrospective study.

SETTING

Level 1 academic trauma center.

PATIENTS/PARTICIPANTS

Fifty-two consecutive patients during a 7-month period with unstable posterior pelvic ring disruptions.

INTERVENTION

All patients were treated with percutaneous iliosacral and/or transsacral screw fixation by a single experienced surgeon. Traditional triplanar fluoroscopy was performed during guidepin insertion. Intraoperative multidimensional fluoroscopy was used for all patients after iliosacral screw fixation.

MAIN OUTCOME MEASUREMENTS

Intraoperative multidimensional fluoroscopy and postoperative computed tomography (CT) scans for each patient were retrospectively reviewed by the treating surgeon and another trauma surgeon. Screw position in relation to the sacral neuroforamen was assessed using multidimensional fluoroscopy and compared to postoperative CT scan. Screws were classified as extraforaminal, juxtaforaminal, or intraforaminal.

RESULTS

No screws were intraforaminally seen on intraoperative multidimensional fluoroscopy or postoperative CT scan. All iliosacral and transsacral screws were considered safe. Intraobserver and interobserver variability existed between reviewers when grading screws as extraforaminal versus juxtaforaminal. This was not clinically significant because both agreed that extraforaminal and juxtaforaminal screw positions are safe. Multidimensional fluoroscopy was used in 3 patients to assess guidepin placement before definitive screw fixation. Two patients underwent a change of fixation after reviewing multidimensional fluoroscopy. No postoperative neurological examination changes occurred.

CONCLUSIONS

Multidimensional fluoroscopy is a novel imaging technology that can safely be used intraoperatively to accurately determine iliosacral and transsacral screw placement.

LEVELS OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Minimally Invasive Screw Fixation of Unstable Pelvic Fractures Using the "Blunt End" Kirschner Wire Technique Assisted by 3D Printed External Template

Objective

This study aimed to determine the accuracy and safety of the “blunt end” Kirschner wire (KW) technique for the minimally invasive treatment of unstable pelvic fractures with the assistance of a 3D printed external template.

Methods

Clinical data of 28 patients with unstable pelvic fractures between January 2016 and January 2018 were retrospectively analyzed. There were 6 cases of B1, 10 of B2, 8 of C1, and 4 of C2 fractures, all of which received surgical treatment. The “blunt end” KW technique with a 3D template was adopted for the minimally invasive placement of the iliosacral (IS) or superior ramus screws. The number of intraoperative fluoroscopies, surgical time, and complications were recorded. Postoperative reduction was assessed using the Matta criteria, and the Majeed score system was used to evaluate postoperative functional recovery.

Results

The average number of fluoroscopies was 35 per patient, and the average surgical time was 85.2 min. A total of 19 S1 and 28 S2 IS screws were inserted. Eleven antegrade superior ramus screws and 4 retrograde screws were placed in 11 patients, and anterior subcutaneous internal fixation (INFIX) was used to fix the anterior pelvic ring in 17 patients. All patients were followed up for an average of 18 months. Postoperative reduction was evaluated by Matta's criteria: excellent in 16 cases, good in 9 cases, and fair in 3 cases. The Majeed score was used in the last follow-up to evaluate functional recovery: excellent in 13 cases, good in 10 cases, fair in 4 cases, and poor in 1 case. There were no cases of operative vascular injury.

Conclusion

The “blunt end” KW technique with a 3D printed external template is a safe and effective method for the placement of IS and superior ramus screws in unstable pelvic fractures with minimized surgical duration and radiation exposure.