Anterior Pelvic Internal Fixation Research Articles

Pedicle screw internal fixation versus subcutaneous anterior pelvic internal fixation in treatment of pelvic anterior ring fractures

Objective To compare pedicle screw internal fixation (PSIF) and subcutaneous anterior pelvic internal fixation (APIF) in the treatment of pelvic anterior ring fractures. Methods A retrospective study was conducted of a consecutive series of 46 patients who had undergone surgery for anterior ring pelvic fractures at Department of Orthopaedic Surgery, The People’s Hospital of Henan Province from January 2014 to September 2018. Of them, 20 were treated by PSIF and 26 by APIF. In the PSIF group, there were 12 males and 8 females with an age of 47.8±2.4 years, and 6 cases of B1, 9 cases of type B2, 4 cases of type B3 and one case of type C1 by the Tile’s classification; in the APIF group, there were 16 males and 10 females with an age of 49.6±1.2 years, and 9 cases of B1, 8 cases of type B2, 5 cases of type B3, 2 cases of type C1 and 2 cases of type C2 by the Tile’s classification. The 2 groups were compared in terms of surgical or postoperative complications (including iatrogenic nerve injury, infection, implant failure and fracture nonunion), fracture reduction and therapeutic efficacy at the final follow-up. Results There were no significant differences between the 2 groups of patients in their preoperative general data, indicating they were compatible(P>0.05). The 46 patients were followed up for 9 to 18 months (mean, 13.5 months). In the PSIF and APIF groups, the incidences of injury to the lateral femoral cutaneous nerve were 5.0%(1/20) and 7.7%(2/26), those of infection 5.0%(1/20) and 3.8%(1/26), and those of skin discomfort 5.0% (1/20) and 7.7%(2/26), respectively. According to the Matta criteria, the fracture reduction at the last follow-up was evaluated as excellent in 7, as good in 11 and as fair in 2 in the PSIF group, giving an excellent and good rate of 90.0%, and as excellent in 9, as good in 13 and as fair in 4 in the APIF group, giving an excellent and good rate of 84.6%. According to the Majeed criteria, the pelvic function at the final follow-up was evaluated as excellent in 10, as good in 7, as fair in 2 and as poor in one in the PSIF group, giving an excellent and good rate of 85.0%, and as excellent in 13, as good in 10, and as fair in 3 in the APIF group, giving an excellent and good rate of 88.5%. There were no significant differences between the 2 groups in all the comparisons above (P>0.05). The incidence of femoral nerve parasthesia was 0(0/20) for the PSIF group, significantly lower than that for the APIF groups (3.8%, 1/26) (P<0.05). Conclusion As both PSIF and APIF lead to similar clinical efficacy in the treatment of pelvic anterior ring fracture, either of them can be selected as an appropriate surgical procedure depending on the patient’s situation and surgeon’s experience. Key words: Pelvis; Fractures, bone; Fracture fixation, internal; Bone plates; Surgical procedures, minimally invasive

Minimally invasive anterior pelvic internal fixation: An anatomic study comparing Pelvic Bridge to INFIX

ObjectivesAnterior external fixation for pelvic ring fractures has shown to effectively improve stability and reduce mortality. However, these fixators can be associated with substantial morbidity such as pin tract infection, premature loss of fixation, and decreased quality of life in patients. Recently, two new methods of subcutaneous anterior pelvic internal fixation have been developed; the INFIX and the Pelvic Bridge. These methods have the purported advantages of lower wound complications, less surgical site pain, and improved quality of life.We sought to investigate the measured distances to critical anatomic structures, as well as the qualitative and topographic differences notable during implantation of both devices in the same cadaveric specimen. Materials and methodsThe Pelvic Bridge and INFIX were implanted in eleven fresh cadavers. Distances were then measured to: the superficial inguinal ring, round ligament, spermatic cord, lateral femoral cutaneous nerve (LFCN), femoral nerve, femoral artery, and femoral vein. Observations regarding implantation and topography were also recorded. ResultsThe INFIX had greater measured distances from all structures except for the LFCN, in which its proximity placed this structure at risk. Neither device appears to put other critical structures at risk in the supine position. Significant implantation and topographic differences exist between the devices. The INFIX application lacked “safety margins” concerning the LFCN in 10/11 (90.9%) specimens, while Pelvic Bridge placement lacked “safety margins” with regard to the right superficial ring (1/11, 9%) and the right spermatic cord (1/11, 9%). ConclusionsBoth the Pelvic Bridge and INFIX lie at safe distances from most critical pelvic structures in the supine position, though INFIX application places the LFCN at risk.

The use of an anterior pelvic internal fixator to treat disruptions of the anterior pelvic ring: a report of technique, indications and complications.

The anterior pelvic internal fixator is increasingly used for the treatment of unstable, or displaced, injuries of the anterior pelvic ring. The evidence for its use, however, is limited. The aim of this paper is to describe the indications for its use, how it is applied and its complications. We reviewed the case notes and radiographs of 50 patients treated with an anterior pelvic internal fixator between April 2010 and December 2015 at a major trauma centre in the United Kingdom. The median follow-up time was 38 months (interquartile range 24 to 51). Three patients were excluded from the analysis leaving 47 patients with complete follow-up data. Of the 47 patients, 46 achieved radiological union and one progressed to an asymptomatic nonunion. Of the remaining patients, 45 required supplementary posterior fixation with percutaneous iliosacral screws, 2 of which required sacral plating. The incidence of injury to the lateral femoral cutaneous nerve (LFCN) was 34%. The rate of infection was 2%. There were no other significant complications. Without this treatment, 44 patients (94%) would have needed unilateral or bilateral open reduction and plate fixation extending laterally to the hip joint. The anterior pelvic internal fixator reduces the need for extensive open surgery and is a useful addition to the armamentarium for the treatment of anterior pelvic injuries. It is associated with injury to the LFCN in a third of patients. Cite this article: Bone Joint J 2017;99-B.1232-6.

The Pelvic Bridge: A Subcutaneous Approach for Anterior Pelvic Fixation.

An alternative method to external fixation for the treatment of unstable anterior pelvic ring injuries, termed the pelvic bridge technique, provides equivalent results with fewer complications and is performed using occipital cervical rods subcutaneously, with fixation into the iliac wings and parasymphyseal bone. For preoperative planning, review the appropriate imaging, including radiographs and computed tomography (CT) scans, to mesh the findings on imaging to the clinical picture of the patient and ensure that the patient meets operative criteria and that none of the contraindications are present. Position the patient to facilitate anterior and posterior fixation. Make the incisions necessary to expose the osseous contour where fixation will be utilized. Carefully contour the plate-rod construct, which is necessary to minimize postoperative complications. Use care when inserting the rod as doing so will help to avoid neurovascular complications. To recreate pelvic stability, the pelvic ring needs to heal in as close to anatomic position as possible and there are multiple methods that help to obtain an adequate reduction. Multiple constructs may be used to stabilize the anterior pelvic ring, but the fundamental principle is to attach the 2 hemipelves to achieve stability, and the location where fixation can be achieved depends on the fracture pattern. Ensure meticulous closure to reduce the chance of infection and achieve appropriate soft-tissue coverage over hardware. Early mobilization is a fundamental goal of this procedure, but the time to full weight-bearing is dependent on fracture characteristics and healing. Anterior pelvic internal fixation (APIF) using the pelvic bridge technique has been demonstrated to have significantly fewer complications than APEF2.

Anterior Pelvic Subcutaneous Internal Fixator Application

To determine what anatomic structures are at risk after the application of a subcutaneous anterior pelvic internal fixator (APIF), from an incision over the anterior iliac crest to an incision centered over the pubic symphysis (Pfannenstiel). A laboratory investigation was performed using 5 fresh, frozen, nonpreserved cadaveric specimens (3 male specimens, 2 female specimens). Dissections were carried out to identify the relationships and proximity between the fixator screw constructs and various anatomic structures, including the (1) lateral femoral cutaneous nerve (LFCN), (2) ilioinguinal nerve (IIN), (3) iliohypogastric nerve (IHN), (4) femoral nerve, (5) femoral artery, (6) femoral vein, (7) genitofemoral nerve; and (8) spermatic cord or round ligament. The mean and range of distance from each of these structures to the implant were measured with calipers. Despite variations in pelvic anatomy and width of pelvic brims, precontoured fixators (3.5 locking reconstruction plates) did not violate any pelvic neurovascular structures using this recommended application of an APIF. The spermatic cord was easily avoided as they were directly visualized using our application technique (mean, 0.4 cm, range, 0-2 cm). Abdominal musculature protected the IHN and IIN for most of their course, with the precontoured plates remaining inferior to their course and resting superficial to their branches (IHN mean, 1.5 cm, range, 1.2-1.8 cm and IIN mean, 2.1 cm, range, 0.9-4 cm). The LFCN traveled safely posterior to the inguinal ligament, thus being bridged by the internal spanning fixation without visualized disruption, impingement, or violation (mean, 1.5 cm, range, 0.6-4 cm). Finally, the femoral nerve, artery, and vein collectively demonstrated safe distance from the risk of compression (mean, 2.2 cm, range, 0.8-3.7 cm). The anatomic structures hypothesized to be potentially endangered because of the lack of direct visualization during APIF placement, include the LFCN, IIN, IHN, femoral nerve, femoral artery, and femoral vein. Based upon our anatomic study, APIF, which may be used for treatment augmentation of anterior pelvic ring disruptions, does not place these structures at significant risk. In addition, the reproductive structures (round ligament and spermatic cord) are in direct visualization and can easily be avoided during implant placement.

Anterior Pelvic External Fixator Versus Subcutaneous Internal Fixator in the Treatment of Anterior Ring Pelvic Fractures

To compare the short-term results of anterior pelvic external fixation (APEF) versus anterior pelvic internal fixation (APIF) applied subcutaneously in the context of surgical treatment of pelvic ring injuries. A single center retrospective chart review. A level 1 trauma center. A consecutive series of 48 patients who underwent surgical stabilization of their anterior pelvic ring (24 utilizing APIF and 24 utilizing APEF) by 2 surgeons at a single hospital were studied. The choice to use either APEF or APIF was left up to each surgeon, the indications for use are the same. Data collected included surgical or postoperative complications including infection, implant failure, reoperation, documented surgical site pain persisting to clinical follow-up visits, and radiographic union. Measurements on inlet and outlet pelvic radiographs were made immediately postoperation and at all follow-up clinic visits to determine whether there were differences in maintaining pelvic fracture reduction. Statistical analysis was performed to evaluate significant differences between the 2 groups with regard to each of these variables. The APIF group was found to have a significantly lower incidence of wound complication (P < 0.05) and a lower occurrence of associated morbidity events as compared with the APEF group. In addition, the APIF group was found to have a significantly lower rate of surgical site pain persisting through all clinical follow-up intervals (P = 0.05). There was no difference between the 2 groups in terms of maintenance of pelvic reduction in the early postoperative phase or at final follow-up. No other significant differences were observed between the 2 groups. The present study, which was based on our initial experience with the subcutaneous anterior pelvic fixator, demonstrated encouraging clinical outcomes in terms of a lower wound complication rate and associated morbidity, and surgical site symptoms, although maintaining equivalent reduction. These findings suggest that further analysis of this technique is warranted to determine if it can be definitively recommended for general use. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Technique: A Percutaneous Method of Subcutaneous Fixation for the Anterior Pelvic Ring: The Pelvic Bridge

Management of pelvic ring injuries using minimally invasive techniques may be desirable if reduction and stability can be achieved. We present a new technique, the anterior pelvic bridge, which is a percutaneous method of fixing the anterior pelvis through limited incisions over the iliac crest(s) and pubic symphysis. An incision is made over each anterior iliac crest and a 6- to 8-cm incision is centered over the symphysis. Either a locking reconstruction plate or a spinal rod is placed through a subcutaneous tunnel overlying the external oblique fascia in the subcutaneous tissue, and fixation into the iliac crest and pubis is achieved to effect stability. A randomized controlled trial comparing anterior pelvic external fixation (APEF) versus anterior pelvic internal fixation (APIF) for unstable pelvic ring injuries was begun in October 2010. Patients with unstable pelvic ring injuries were enrolled and followed with respect to fracture reduction, surgical pain, complications, and functional outcome scores. As of January 2012, 23 patients met inclusion; however, 12 patients refused participation because of the possibility of external fixation, leaving 11 patients (four male, seven female) enrolled. At 6-month followup, there was a single pin tract infection in the APEF cohort and no complications or pain in the APIF cohort. This clinical experience lends support to the use of a new minimally invasive technique to stabilize the anterior pelvis, particularly given the resistance on the part of patients to consider external fixation. Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Internal fixation in pelvic fractures and primary repairs of associated genitourinary disruptions: a team approach.

Associated urological and orthopedic injuries of the pelvic ring are complex with numerous potential complications. These patients are treated optimally using a team approach. The combined expertise is not only helpful initially when managing these difficult patients, but also later as problems develop. This study describes a treatment protocol and reports the early results of 23 patients with unstable pelvic fractures and associated bladder or urethral disruptions, or both, treated surgically with open reduction and internal fixation of the anterior pelvic ring injuries at the same anesthetic and using the same surgical exposure as the urethral realignments or bladder repairs or both. Early complications occurred in four patients (17%): one patient sustained a fifth lumbar nerve injury caused by the pelvic reduction procedure, and three patients had anterior pelvic internal fixation failures. Late complications occurred in eight patients (35%). There was one deep wound infection (4.3%) that presented 6 weeks after injury. Late urological complications occurred in seven patients (30%). Four of the nine male patients with urethral disruptions had urethral stricture after their primary urethral realignments (44%). Three of the 18 male patients admitted to impotence (16.7%). One of the three had a residual thoracic paraplegia caused by a burst fracture. One of the five female patients had urinary incontinence and required a bladder suspension operation to restore normal function (20%). A low infection rate can be expected despite the use of internal fixation. Early urethral "indirect" realignments avoid more difficult delayed open repairs; however, late urological complication rates are still high. Early "direct" bladder repairs are easily performed at the time of anterior pelvic open reduction and internal fixation. Suprapubic tubes are not necessary to adequately divert the urine when large diameter urethral catheters are used in these patients.