Minimally Invasive Percutaneous Spinopelvic Fixation for Unstable Pelvic Ring Fracture Performed With the Patient in a Lateral Position

Robotic guidance for percutaneous placement of triangular osteosynthesis in vertically unstable sacrum fractures: a single-center retrospective study

BACKGROUND

To evaluate the effectiveness and safety of robot-aided percutaneous triangular osteosynthesis combined with close reduction for vertically unstable sacrum fractures (VUSFs).

METHODS

The data on 21 patients of the VUSF were retrospectively analyzed from November 2016 to January 2021. According to Denis classification, there were 3 cases in zone I, 11 cases in zone II, and 7 case in zone III. The main perioperative indicators were recorded. The maximal angulation and displacement deviations of the screws were analyzed by comparing the planned trajectory with the actual position. Postoperative X-ray radiographs and CT scans were obtained for evaluating the reduction quality. Functional outcome was scored with Majeed criterion.

RESULTS

Fourteen patients of the unilateral VUSF and 7 patients of the bilateral VUSF underwent unilateral and bilateral triangular osteosynthesis with robotic assistance, respectively. No intraoperative neurovascular injuries and postoperative infection occurred. All patients were followed up for at least 12 months. The average operation time of posterior pelvic ring was 111.4 min, with the mean intraoperative bleeding of 110.5 ml. A total of 58 pedicle and iliosacral screws were implanted with robotic assistance. Of those, 52 screws were in the cancellous bone except 4 pedicle and 2 iliosacral screws cutting the cortical bone. The angulation and displacement deviations of the screws were 4.2° ± 2.5° and 1.7 ± 0.9 mm, respectively. The average displacement of the sacral fracture was reduced from 19.7 mm preoperatively to 3.1 mm postoperatively. According to Matta's criterion, the reduction quality was graded as "excellent" in 13 patients and "good" in 8. All sacral fractures healed within 6 months except one fracture with nonunion. The mean Majeed score at the last follow-up was 89.6.

CONCLUSIONS

Robot-aided triangular osteosynthesis combined with close reduction provide a safe and reliable option for percutaneous treatment of the fresh VUSF, with a high accuracy of iliosacral and pedicle screw implantation except insertion of iliac screws. Meanwhile, the technique may help to reduce incision-related complications.

The combination of intraoperative CT navigation and C-arm fluoroscopy for INFIX and percutaneous TITS screw placement in the treatment of pelvic ring injury: technical note

Background

The subcutaneous screw rod system, commonly known as the internal pelvic fixator (INFIX), is useful in managing unstable pelvic ring fractures. Conventional INFIX and transiliac–transsacral (TITS) screw techniques are performed using C-arm fluoroscopy. There have been problems with medical exposure and screw insertion accuracy with these techniques. This work describes new INFIX and TITS techniques using intraoperative computed tomography (CT) navigation and C-arm fluoroscopy for pelvic ring fracture.

Methods

A typical case is presented in this study. An 86-year-old woman suffered from an unstable pelvic ring fracture due to a fall from a height. INFIX and TITS screw fixation with intraoperative CT navigation were selected to optimize surgical invasiveness and proper implant placement.

Results

The patient was placed in a supine position on a Jackson table. An intraoperative CT navigation was imaged, and screws were inserted under the navigation. Postoperative X-rays and CT confirmed that the screw was inserted correctly. This technique was less invasive to the patient and had little radiation exposure to the surgeon. Rehabilitation of walking practice was started early after the surgery, and she was able to walk with the assistance of a walker by the time of transfer.

Conclusions

The technique employed in our case study has the cumulative advantages of safety, accuracy, and reduced radiation exposure, together with the inherent advantages of functional outcomes of previously reported INFIX and TITS screw techniques. Further experience with this approach will refine this technique to overcome its limitations and facilitate its wider use.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-02920-0.

Spinopelvic fixation with retention of external fixation in a lateral position for unstable pelvic fracture

Anterior external fixation (EF), as the primary treatment for unstable pelvic fractures, is performed with patients in the supine position. In most cases, however, definitive surgery for posterior fixation is performed first in the prone position without EF. We report the case of a patient with unilateral and vertically unstable pelvic fracture whom we had treated with minimally invasive spinopelvic fixation, with retention of the anterior EF in a lateral position. Reduction of the residual displacement was performed with percutaneous spinal instrumentation, and acceptable reduction was achieved. At the 13-month follow-up, the functional outcome, calculated using the Majeed Score, was 87 points. The plain radiograph showed good bone union, except for the right superior pubic ramus. The radiological outcome, measured using the Matta rating, was excellent. Thus, retaining the EF facilitates safe and accurate reduction without major surgical complications and may offer surgeons an additional management option for such fractures.

S3 Sacral-Alar Iliac Screw: A Salvage Technique for Pelvic Fixation in Complex Deformity Surgery

Sacral-alar iliac (SAI) screws constitute a relatively new technique for pelvic fixation. Since their initial description in 2007, SAI screws have gained wide popularity among the spine surgery community. In 2013, we first described the possibility of using both S1 and S2 SAI screws for pelvic fixation in revision surgeries for adult degenerative scoliosis. Although a previous radiological study has suggested the feasibility of S3 and S4 SAI screws, to the best of our knowledge, there has been no report in the literature on the clinical use of such techniques. In this brief technical note, we present the first clinical report of the use of S3 SAI screws as a salvage method for pelvic fixation in a patient with suboptimal anatomy that prevented proper placement of S1 and S2 SAI screws. We also discuss the recommended anatomical entry points and trajectory of such screws.

Evaluation of a Three-Dimensional Printed Guide and a Polyoxymethylene Thermoplastic Regulator for Percutaneous Pedicle Screw Fixation in Patients with Thoracolumbar Fracture

BACKGROUND This study aimed to evaluate the efficacy of a porous polyoxymethylene thermoplastic regulator combined with a three-dimensional (3D) printed template to guide pedicle needle insertion in patients undergoing percutaneous pedicle screw fixation (PPSF) for thoracolumbar fracture. MATERIAL AND METHODS Forty patients were randomly divided into group A, treated using a porous polyoxymethylene thermoplastic regulator combined with a 3D printed template, and group B, who underwent conventional PPSF. Data recorded included the number of pedicle screws successfully inserted on the first attempt, the number of attempts, the time to successful needle insertion, the total time of fluoroscopy, and the duration of surgery. The Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) scores one day before surgery, and at day 1, day 7, month 1, and month 3 after surgery were recorded. The postoperative vertebral posterior kyphotic angle (KA) and the rate of change of KA were recorded. RESULTS Group A had a significantly increased total number of successful first insertions compared with group BV (P<0.05). Postoperative VAS and ODI scores of patients in both groups were significantly lower than before surgery (P<0.05), with no significant difference between the two groups at postoperative month 1 and month 3 (P>0.05). The postoperative vertebral posterior KA decreased significantly in both groups after surgery, with no significant difference between the two groups (P>0.05). CONCLUSIONS The use of a porous polyoxymethylene thermoplastic regulator combined with a 3D printed template may improve the success of pedicle insertion in patients undergoing PPSF.