Comparison of lumbopelvic fixation and iliosacral screw fixation for the treatment of bilateral sacral fractures

Transiliac-Transsacral Screw Fixation is Superior to Lumbopelvic Stabilization in the Treatment of Minimally Displaced Sacral H-/U-Type Fragility Fractures

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

To compare the outcomes and complications of transiliac-transsacral screw fixation (TIS) and lumbopelvic fixation (LPS), the 2 most common fixation methods for nondisplaced and minimally displaced H-/U- type sacral fragility fractures.

METHODS

Medical records of patients treated with TIS or LPS for nondisplaced and minimally displaced H-/U-type sacral fragility fractures at 2 level A trauma centers between 2012 and 2022 were analyzed. Postoperative low back pain and mobility levels were assessed as primary outcomes before discharge and at 6 weeks and 6 months postoperatively. Surgery time, blood loss, and surgical complication rates were assessed as secondary outcomes. Statistical analyses consisted of Fisher's exact tests for frequency distributions and Mann-Whitney-U tests and t-tests for group comparisons.

RESULTS

52 patients undergoing TIS (mean age: 78 ± 9 years) and 36 patients undergoing LPS (74 ± 10 years) with no discrepancy in demographic parameters were identified. There were no differences in low back pain levels between the 2 groups before surgery, before discharge, at 6 weeks postoperatively, and at 6 months postoperatively (P > 0.05). There were no differences in mobility levels before surgery, before discharge, at 6 weeks postoperatively, and at 6 months postoperatively (P > 0.05). Duration of surgery was shorter after TIS (36 ± 13 min) compared to LPS (113 ± 31 min) (P < 0.0001). Intraoperative blood loss was lower for TIS (median <20 mL) compared to LPS (median 125 mL) (P < 0.0001). Postoperative radiculopathy was less frequent after TIS (n = 1) compared to LPS (n = 3) (P > 0.05). Median length of stay was shorter after TIS (11 days) compared to LPS (14 days) (P < 0.05). Rates of reoperations directly related to the index surgery were lower after TIS (n = 2) compared to LPS (n = 10) (P < 0.01). Implant failures were observed only after LPS (n = 1).

CONCLUSION

Patients with nondisplaced and minimally displaced H-/U- type sacral fragility fractures may preferably be treated using TIS, as it is equivalent to LPS in terms of low back pain reduction and restoration of mobility, but allows for shorter operative time, less blood loss and lower reoperation rates. Prospective randomized studies should be conducted to substantiate our findings and develop distinct treatment recommendations.

Treatment Outcomes in Vertical Shear Pelvic Fractures: A Comparative Study

Background Vertical shear (VS) pelvic ring injuries present a unique challenge due to their inherent vertical and rotational instability and the risk of massive bleeding. VS injuries may result from either bony or ligamentous injury. The goal in the treatment of VS fractures of the pelvis is to achieve and maintain an accurate reduction of the displaced hemipelvis. Aim of the study This study aimed to compare the results of the treatment of VS fractures pelvis by using iliosacral (IS) screws versus lumbopelvic fixation (LPF). Methodology This retrospective study was carried out on 40 patients with VS fracture pelvis injuries at El Hadara University Hospital, Alexandria, Egypt, from January 2020 to December 2020. Twenty of them were treated by an IS screw, and the other 20 were treated by LPF. Then, both groups were followed up for six months with regard to union rate, metal failure, and clinical outcomes. Results The EQ-5D showed a significant improvement in LPF more than the IS screw group in the five items of the score. Moreover, the total EQ-5D index showed a significant increase in the LPF group more than the IS screw group (p < 0.05). The incidence of neurological complication was found in four cases in the IS screw group, while no cases were found in the LPF group. The infection was found in six patients in the IS screw group and only three cases in the LPF group. The malunion was found in two cases in the IS screw group and no cases in the LPF group. The neurological change and the incidence of infection were significantly higher in the IS screw group than in the LPF group (p < 0.05). Conclusion Our results demonstrate reliable maintenance of reduction and acceptable complication rates with a minimally invasive LPF for VS fractured pelvis. The benefits of minimally invasive LPF may be offset by increased elective reoperations for the removal of instrumentation.

Pelvic Ring Fractures: A Biomechanical Comparison of Sacral and Lumbopelvic Fixation Techniques

BACKGROUND CONTEXT

Pelvic ring fractures are becoming more common in the aging population and can prove to be fatal, having mortality rates between 10% and 16%. Stabilization of these fractures is challenging and often require immediate internal fixation. Therefore, it is necessary to have a biomechanical understanding of the different fixation techniques for pelvic ring fractures.

METHODS

A previously validated three-dimensional finite element model of the lumbar spine, pelvis, and femur was used for this study. A unilateral pelvic ring fracture was simulated by resecting the left side of the sacrum and pelvis. Five different fixation techniques were used to stabilize the fracture. A compressive follower load and pure moment was applied to compare different biomechanical parameters including range of motion (contralateral sacroiliac joint, L1-S1 segment, L5-S1 segment), and stresses (L5-S1 nucleus stresses, instrument stresses) between different fixation techniques.

RESULTS

Trans-iliac-trans-sacral screw fixation at S1 and S2 showed the highest stabilization for horizontal and vertical displacement at the sacral fracture site and reduction of contralateral sacroiliac joint for bending and flexion range of motion by 165% and 121%, respectively. DTSF (Double transiliac rod and screw fixation) model showed highest stabilization in horizontal displacement at the pubic rami fracture site, while the L5_PF_W_CC (L5-Ilium posterior screw fixation with cross connectors) and L5_PF_WO_CC (L5-Ilium posterior screw fixation without cross connectors) showed higher rod stresses, reduced L1-S1 (approximately 28%), and L5-S1 (approximately 90%) range of motion.

CONCLUSIONS

Longer sacral screw fixations were superior in stabilizing sacral and contralateral sacroiliac joint range of motion. Lumbopelvic fixations displayed a higher degree of stabilization in the horizontal displacement compared to vertical displacement of pubic rami fracture, while also indicating the highest rod stresses. When determining the surgical approach for pelvic ring fractures, patient-specific factors should be accounted for to weigh the advantages and disadvantages for each technique.

Treatment of Unstable Sacral Fractures with Robotically-aided Minimally Invasive Triangular Fixation

OBJECTIVE

The treatment of unstable sacral fractures is huge challenge to surgeons. Robotically-aided minimally invasive triangular fixation (RoboTFX) is the most advanced technique up to now. This study is to evaluate the clinical outcomes of unstable sacral fractures treated with RoboTFX.

METHODS

From March 2017 to October 2021, 48 consecutive patients with unstable sacral fractures were included in the study. All patients received surgical treatment with triangular fixation (TFX). Patients were divided into four groups according to the number of fractures (uni- or bilateral) and surgical method employed (RoboTFX or traditional open TFX). Between these four groups, clinical data on operation time, intraoperative bleeding, intraoperative fluoroscopy time, infection rate, fracture healing rates, insertion accuracy, Majeed pelvic outcome score, Mears' criterion, and Gibbons score were compared. Quantitative data were expressed as mean ± standard deviation and compared using Student's t-test. Categorical variable were compared using the Pearson's χ2 test.

RESULTS

Comparing unilateral RoboTFX versus open TFX, neither fracture healing rate, infection rate, Majeed pelvic outcome score, Mears' radiological evaluation criterion, nor Gibbons score of the two groups were statistically significantly different (p > 0.05). However, operation time, intraoperative bleeding, intraoperative fluoroscopy time, and insertion accuracy in the RoboTFX group were all significantly better than those of the traditional open group (p < 0.05). Likewise, operation time, intraoperative bleeding, intraoperative fluoroscopy time, and accuracy of fixation insertion of the bilateral RoboTFX group were significantly better than those of the bilateral open group (p < 0.05). Meanwhile infection rate, fracture healing rate, Majeed score, Mears' criterion, and Gibbons score of two groups were not significantly different (p > 0.05).

CONCLUSION

RoboTFX has the advantages of less operation time, less intraoperative bleeding and fluoroscopy, more accurate fixation insertion, and a higher healing rate compared to traditional open methods in the treatment of unstable sacral fractures. However, RoboTFX requires a few critical considerations, and the indications of its operation should be strictly evaluated.

Biomechanical comparison of four triangular osteosynthesis fixations for unilateral vertical sacral fractures

To compare the stability and biomechanical characteristics of four commonly used triangular osteosynthesis techniques to treat unilateral vertical sacral fractures and provide a clinical application reference. Finite element models of Tile C-type pelvic ring injury (unilateral Denis II sacral fracture) were produced. In four models, sacral fractures were fixed with a combination of unilateral L5, unilateral L4, and L5 iliac lumbar fixation with lengthened or normal sacroiliac screws. The biomechanical properties of the four fixation models were measured and compared under bipedal stance and lumbar rotation. The fixation stability of the model with the lengthened sacroiliac screw was excellent, and the fracture end was stable. The stability of fixation using unilateral L4 and L5 segments was close to that of unilateral L5 segment fixation. Triangular osteosynthesis transverse stabilization devices using lengthened sacroiliac screws can increase the vertical stability of the sacrum after internal fixation and increase the stability of the fracture. When triangular osteosynthesis lumbar fixation segments were selected, simultaneous fixation of L4 and L5 segments versus only L5 segments did not significantly enhance the vertical stability of the sacrum or the stability of the fracture end.

Effective treatment of highest instability in a subacute fragility fracture of the pelvis (FFP IV) using a cement augmented transsacral screw only

The highest instability in fragility fractures of the pelvis (FFP) is noted in presence of H-, U-type sacral fractures. Suggested surgical treatment options include uni- or bilateral sacroiliac or transsacral screw fixation at different levels or in combination, as well as lumbopelvic and bilateral triangular lumbopelvic stabilization. However, distinct treatment recommendations for this subset of injuries are scarce. We present a case sustaining rapid FFP crescendo instability following initial conservative treatment of a FFP type II injury resulting in a U-type spinopelvic dissociation. Fixation using one percutaneous cement augmented transsacral S1 screw resulted in perpetual clinical improvements in pain and mobility in presence of radiologic fracture consolidation.

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.

Recent Progress in the Classification and Operation of Sacral Fractures

Most sacral fractures are caused by high-energy, violent injuries, often accompanied by lumbosacral plexus injuries, which can cause instability of the posterior pelvic ring or lumbosacral junction in severe cases. Currently, the most commonly used clinical classification methods are Denis classification, Tile classification, Isler classification, and Denis II classification. In recent years, lumbosacral vertebral injury classification and injury degree scoring systems have often been applied clinically as the choice of treatment methods. At present, the internal fixation and implantation methods of sacral fracture are developing in the direction of positive, efficient, safe, and minimally invasive. But different fixation methods have their own indications, which should be strictly followed. This article reviews the classification of sacral fractures and the latest progress in surgical treatment.

The relation between surgical approaches for pelvic ring and acetabular fractures and postoperative complications: a systematic review

Introduction

Although many articles report complications after pelvic ring and acetabular fracture surgery, a general overview of complication rates and potential risk factors is lacking. The current review provides a comprehensive summary of the complications after pelvic ring and acetabular fracture surgery in relation to the surgical approach.

Material and Methods

Pubmed and Embase databases were systematically searched using the key words: pelvic fracture, acetabular fracture, fixation, surgical approaches, complications, and their synonyms. Extracted data included patient and fracture characteristics, surgical approaches, and post-operative complications; surgical site infections (SSI), implant-related complications, malunion and non-union. Study data were summarized using descriptive statistics.

Results

Twenty-two studies (twenty-one retrospective cohort studies, of which three comparative, and one randomized controlled trial) were included in this review. The overall complication rates reported for the included surgical approaches were: 17% for the (Modified) Stoppa approach, 11% for percutaneous fixation, 5% for the Kocher–Langenbeck approach, 7% for the ilioinguinal approach and 31% for external fixation. The most frequent complications were SSI (22%) and neurological (31%) complications, which were most often reported in patients treated with an external fixator. Re-operation rates were comparable for the surgical approaches (4–8%). Two studies reported on risk factors and identified concomitant traumatic injuries, prolonged ICU stay and high body mass index as risk factors for SSI.

Conclusion

External fixation of pelvic fractures is associated with highest complications rates including SSI’s and neurological complications. Although post-operative complications are frequently reported after pelvic fracture surgery, more studies are needed that identify potential risk factors. These will assist the surgeon in (pre)operative decision making and development of preventive strategies.

Reconstruction of Tumor-Induced Pelvic Defects With Customized, Three-Dimensional Printed Prostheses

Background

Reconstruction of pelvis girdle stability after tumor-induced hemipelvectomy remains challenging. We surgically treated 13 patients with custom-made, three-dimensional printed hemipelvic prostheses. We aim to identify the preliminary outcomes for patients who have been managed with more mixed regions of prosthetic pelvic reconstruction and the feasibility of two reconstructive systems.

Methods

Seven male patients and 6 female patients treated at our center between January 2019 and May 2021 were included. There were 11 primary sarcomas and 2 solitary bone metastases. After en bloc tumor resection, two types of personalized, three-dimensional printed prostheses were fixed to restore the stability and rebuild the load transfer. The position of the reconstructed hemipelvis was evaluated on an anteroposterior plain radiograph. The complications and outcomes were traced. One amputation specimen was discovered through histological analysis of the porous structure.

Results

The operative duration was 467 ± 144 min, and the blood loss was 3,119 ± 662 ml. During a follow-up of 22.4 ± 8.5 months, two patients had delayed wound healing and one had a second-stage flap transfer. One patient with osteosarcoma died of pulmonary metastasis 27 months after surgery. Two patients with marginal resection suffered from local recurrence and had extra surgeries. One patient had traumatic hip dislocation 2 months after surgery and manipulative reduction was performed. The acetabular inclination of the affected side was 42.2 ± 4.3°, compared with 42.1 ± 3.9° on the contralateral side. The horizontal distance between the center of the femoral head and the middle vertical line was 10.4 ± 0.6 cm, while the reconstructed side was 9.8 ± 0.8 cm. No significant difference in acetabular position after surgery was found (p > 0.05). The amputation specimen harvested from one patient with local recurrence demonstrated bone and soft tissue ingrowth within the three-dimensional printed trabecular structure. Walking ability was preserved in all patients who are still alive and no prosthesis-related complications occurred. The MSTS score was 22.0 ± 3.7.

Conclusions

Both types of custom-made, three-dimensional printed prostheses manifested excellent precision, mechanical stability, and promising functional rehabilitation. The porous structure exhibited favorable histocompatibility to facilitate the ingrowth of bone and soft tissue.

Differences in Accuracy and Radiation Dose in Placement of Iliosacral Screws: Comparison between 3D and 2D Fluoroscopy

Percutaneous iliosacral screw fixation is a widely accepted method of stabilizing the posterior pelvic ring. Recently developed tools such as 3D-navigated fluoroscopy and computed navigation seem to prevent a surgeon from conducting screw misplacement. The study aimed to comparatively assess the introduction of sacroiliac screw placement using 2D and 3D fluoroscopy in terms of accuracy and radiation exposure. Iliosacral screws were introduced in 37 patients using 2D (group N1) and in 36 patients using 3D fluoroscopy (group N2) techniques. Overall, 61 and 56 screws were introduced in groups N1 and N2, respectively. Screw placement accuracy was assessed using postoperative computed tomography and Smith’s scale. Intraoperative radiation exposure was also assessed. No differences were noted between groups in terms of screw positioning accuracy and radiation dose. Both 2D and 3D fluoroscopy provide good visualization for safely placing percutaneous iliosacral joint screws. Using 3D fluoroscopy-based navigation in comparison with 2D fluoroscopy is not advantageous.