Pelvic Ring Fixation Research Articles

Do asymptomatic patients have normal function after percutaneous fixation of the posterior pelvic ring? A case-control pilot study.

BackgroundFollowing treatment of a posterior pelvic disruption, residual deformity or associated injuries can adversely affect functional recovery. No study has been performed on gait and functional outcome after closed reduction and percutaneous screw fixation (CRPSF) of posterior pelvic disruption in clinically asymptomatic patients. The purpose of this study was to determine if gait and functional outcome are different from normal in asymptomatic patients with a posterior pelvic injury after CRPSF, serving as a pilot study in this regard.MethodsSix asymptomatic patients with no grossly evident gait abnormality, treated by CRPSF for a posterior pelvic disruption, were included in the study (SG). A control group (CG) of six healthy volunteers was created. All participants completed the 12-Item Short Form Health Survey version 2 (SF-12v2), the Majeed Pelvic Score (MPS), and the Iowa Pelvic Score (IPS). In addition, the participants’ gait was analyzed.ResultsPelvic drop was significantly smaller on the uninjured side in the SG when compared to the injured side in the SG. There was no significant difference between the injured and uninjured side for other gait parameters within the SG. Knee angle at initial contact was significantly greater on the injured side when compared to the CG. The SG scored statistically worse than the CG on the Physical Component Summary part of the SF-12v2. However, when evaluated by age group using national mean scores, the SG differences were minimal. All six patients in our study scored “excellent” on both MPS and IPS.ConclusionsDespite having subclinical alterations in gait, asymptomatic pelvic ring injured patients show minimal, if any, evidence of impaired functional outcome following successful reduction of a posterior pelvic disruption treated by CRPSF.

Modified Stoppa approach for treatment of fracture of anterior pelvic ring

Objective To evaluate the modified Stoppa approach for treatment of fracture of anterior pelvic ring. Methods From March 2009 to June 2013, 40 patients with fracture of anterior pelvic ring (55 sides) were treated through the modified Stoppa approach at our department. They were 24 males (31 sides) and 16 females (24 sides), aged from 21 to 65 years (average, 34.4 years). According to the Tile classification, 2 cases were type A, 21 cases type B and 17 cases type C. The mean time from injury to surgery was 6.5 days (from 3 to 12 days). Simple plate fixation of the anterior pelvic ring was performed in 23 cases while 17 cases underwent plate fixation of the anterior pelvic ring plus additional fixation of the posterior pelvic ring. The incision length, operation time, blood loss, reduction quality and clinical rehabilitation were documented. Results On average, incision length was 8.2 cm, operation time 78.4 min and blood loss 420 mL for this cohort. According to Matta standard, all the 55 fractures obtained excellent reduction. Intraoperative vascular injury occurred in one case and delayed wound healing after plate removal in another. Of this group, 36 were followed up from 8 to 24 months (average, 18 months) and 4 lost. The fractures healed after 3 to 5.5 months (average, 3.8 months). The functional evaluation by the Majeed system scored an average of 84.4 points. Twenty-one cases were rated as excellent, 13 as good and 2 as fair, resulting in an excellent and good rate of 95.0%. No nonunion, delayed union, malunion or heterotopic ossification was found in the follow-ups. Conclusion In treatment of fracture of anterior pelvic ring, the modified Stoppa approach has advantages of small incision, fine visualization, quality reduction, a low rate of complications and rapid rehabilitation. Key words: Pelvis; Fractures, bone; Fracture fixation, internal; Bone plates; Surgical approach

Isolated pelvic ring injuries: functional outcomes following percutaneous, posterior fixation.

To characterize pelvic-specific functional outcomes in patients with isolated, partially unstable (AO/OTA 61-B), pelvic ring injuries treated with posterior only percutaneous screw fixation of the pelvic ring. Between September 2007 and October 2011, 16 subjects (mean age 42.4years; range 18-90years) with isolated, partially unstable pelvic ring injuries (AO/OTA 61-B) were treated with percutaneous, posterior pelvic ring fixation. Subjects underwent an evaluation of pelvic ring function with a modification of Majeed's pelvic functional outcome assessment tool. Subjects were excluded if they sustained a concomitant long-bone fracture, visceral injury requiring surgery, spinal cord injury, and an injury to the anterior pelvic ring or acetabulum requiring additional fixation. Mean follow-up was 30.8 (range 14-55) months. Eleven subjects sustained unilateral posterior ring injuries, and five subjects sustained bilateral posterior ring injuries. All fractures healed uneventfully, and no hardware failures were noted. Average pelvic functional outcome score at final follow-up was 85.3% (good). All but subjects required assistive walking devices and gait and sitting comfort scored "excellent." High rates of sexual dysfunction and persistent difficulty with daily activities were noted in this series. This series demonstrates that activity-specific dysfunction persists years after definitive percutaneous posterior fixation of isolated pelvic ring injuries. Radiographic outcomes were excellent as were subjects' ability to ambulate independently and sit comfortably without pain. Many complained of persistent discomfort with both daily activities and sexual activity, suggesting persistent pathology to the non-osseous structures about the pelvis.

Overlapping Dislocation of the Pubic Symphysis with an Open Reduction and Anterior and Posterior Pelvic Ring Fixation: A Case Report.

We present a case of a patient who sustained overlapping dislocation of the pubic symphysis (ODPS), which required an open reduction as well as anterior and posterior pelvic ring fixation. This case report is a valuable addition to the current literature on ODPS because we believe it to be the first report describing a patient who required both anterior and posterior fixation because of pelvic instability.

Pedicle axis view combined by sacral mapping can decrease fluoroscopic shot count in percutaneous iliosacral screw placement

BackgroundPercutaneous iliosacral screw fixation of the posterior pelvic ring is a demanding procedure with high exposure to radiation. The conventional technique includes the use of three classical projections with the C-arm: inlet, outlet, and true lateral views. A projection in the axis of the upper sacral alar pedicles with a 30° cephalad and 30° ventral oblique view would help in obtaining a more accurate visualization of the safe corridor. Two subcutaneously placed K-wires, one placed horizontally and one vertically, may facilitate the starting point and aim changes by offering the surgeon an option for exactly matching the position of the sacrum with the image. The purpose of this study was to detect if the radiation application could be decreased by our new methodology. MethodsSeventeen patients with pelvic posterior ring disruptions, in which percutaneous iliosacral screw placement was indicated, were included in the study. Group 1 comprised 7 patients in whom conventional projections and technique were used. Group 2 comprised 10 patients in whom 30°–30° projection and sacral mapping technique via two subcutaneous K-wires were applied. Radiation exposure time, total fluoroscopic shot count, fluoroscopic shot count needed for only guide wire and screw placement, radiation dose, and complications were compared between the two groups. ResultsThe median number of fluoroscopic images for guide and screw placement was 132 (56–220) and 29.5 (19–83) in Groups 1 and 2, respectively, and the difference was statistically significant (p<0.001). The median total fluoroscopic radiation time was 138 (68–234) and 52 (28–77)s in Groups 1 and 2, respectively, and the difference was significant (p<0.001). Group 1 had a significantly higher median radiation dose than Group 2 [3020 (1502–6032) vs. 1192 (426–2359); (p=0.001)]. ConclusionsIliosacral screw placement with the help of sacral mapping and a fourth view, “30°–30°”, helps the surgeon to markedly reduce the fluoroscopic shots, radiation time and dose during guide wire and screw placement. Level of evidenceTherapeutic, Level II.

Late fixation of vertically unstable type-C pelvic fractures: difficulties and surgical solutions

Delayed surgical stabilization of unstable pelvic ring disruptions is expected to have difficulties in achieving reduction and fixation with possible higher complications. The aim of this study is to report the difficulties and to evaluate the results of late surgical stabilization of vertically unstable type-C pelvic injuries. This study included 16 patients with 20 vertically unstable pelvic fractures who presented 4 weeks or more after the initial trauma during a period of 5 years. Time since injury averaged 7.6 weeks. Age of the patients averaged 28 years. There were 12 unilateral and four bilateral injuries. Seven patients had neurologic injuries. Combined posterior and anterior pelvic ring stabilization was carried out in nine patients, while posterior pelvic ring fixation alone was done in seven. The mean postoperative follow up was 31 months. All fractures healed with average 14 weeks. Complications included transient L5 palsy, ilio-femoral DVT, and early metal failure. Fracture reduction was considered excellent in 69 %, good in 25 %, and fair in 6 %. Functional outcome according to Majeed score was excellent in 75 %, good in 19 %, and fair in 6 %. There was a high significant positive correlation between time of treatment and fracture reduction (p = 0.009) and a significant correlation between preoperative neurological co-morbidity and functional outcome (p = 0.015). A significant negative correlation was found between functional outcome and fracture type (p = 0.039). Surgical management of delayed vertically unstable pelvic fractures is recommended to achieve anatomical reduction and rigid fixation and to avoid long-term morbidity.

Surgical resection and reconstruction after resection of tumors involving the sacropelvic region

Objectives:Surgical management of tumors in the sacropelvic region is a challenging field of spine surgery because of the region’s complex local anatomy and biomechanics. Recent developments in anesthesia and intensive care have allowed us to perform extended surgeries focused on the en bloc resection of sacropelvic tumors. Various techniques for the resection and for the reconstruction were published in the last decade.Methods:Sacropelvic tumor resection techniques and methods for the biomechanical and soft-tissue reconstruction are reviewed in this paper.Results:The literature data is based on case reports and case-series. Several different techniques were developed for the lumbopelvic stabilization after sacropelvic tumor resection according to three different reconstruction principles (spinopelvic fixation (SPF), posterior pelvic ring fixation (PRF), and anterior spinal column fixation (ACF)); however, long-term follow-up data and comparative studies of the different techniques are still missing. Soft-tissue reconstruction can be performed according to an algorithm depending on the surgical approach, but relatively high complication rates are reported with all reconstruction strategies. The clinical outcome of such surgeries should ideally be evaluated in three dimensions; surgical-, oncological-, and functional outcomes. The last and most important step of the presurgical planning procedure is a careful presentation of the surgical goals and risks to the patient, who must provide a fully informed consent before surgery can proceed.Discussion:Sacropelvic tumors are rare conditions. In the last decade, growing evidence was published on resection and reconstruction techniques for these tumors; however, experience at most medical centers is limited due to the low numbers of cases. The formation of international expert groups and the initiation of multicenter studies are strongly encouraged to produce a high level of evidence in this special field of spine surgery.

Emergent Stabilization of Pelvic Bones Fractures in Polytrauma

Principle aspects of the management of patients with concomitant pelvic injury and injuries of other localization from the standpoint of modern treatment concept Damage control are discussed. Special attention are paid to the techniques for pelvic ring fixation, arrest of intrapelvic hemorrhage, sequence of surgical interventions depending on the pattern of concomitant injuries. The necessity of emergent pelvic injuries fixation with external devices as well as the fractures of other localization in the acute period until stabilization of patient’s general condition is substantiated

Techniques for Final Pelvic Ring Fixation Based on the Method of Finite Element Modeling

Method of finite element modeling was used for mathematic modeling of pelvic fractures and various variants of anterior and posterior pelvic ring fixation with reconstructive plates, cannu- lated sacroiliac screws and pelvic screws. Four most common types of fracture were simulated. Stress-deformed conditions of metal constructions for every type of fracture and variant of its fixation were determined. Study results enabled to determine the optimum fixation techniques in various types of fractures, to confirm the significance of both anterior and posterior pelvic stabilization, as well as to substantiate the possibility of early rehabilitation with full weight bearing in such severe patients

Emergent Stabilization of Pelvic Bones Fractures in Polytrauma

Principle aspects of the management of patients with concomitant pelvic injury and injuries of other localization from the standpoint of modern treatment concept Damage control are discussed. Special attention are paid to the techniques for pelvic ring fixation, arrest of intrapelvic hemorrhage, sequence of surgical interventions depending on the pattern of concomitant injuries. The necessity of emergent pelvic injuries fixation with external devices as well as the fractures of other localization in the acute period until stabilization of patient’s general condition is substantiated

Techniques for Final Pelvic Ring Fixation Based on the Method of Finite Element Modeling

Method of finite element modeling was used for mathematic modeling of pelvic fractures and various variants of anterior and posterior pelvic ring fixation with reconstructive plates, cannu- lated sacroiliac screws and pelvic screws. Four most common types of fracture were simulated. Stress-deformed conditions of metal constructions for every type of fracture and variant of its fixation were determined. Study results enabled to determine the optimum fixation techniques in various types of fractures, to confirm the significance of both anterior and posterior pelvic stabilization, as well as to substantiate the possibility of early rehabilitation with full weight bearing in such severe patients

Biomechanical Comparison of Different External Fixation Configurations for Posttraumatic Pelvic Ring Instability

Background. External fixation is useful in the primary treatment of pelvic ring injuries. The present study compared the biomechanical stability of five different configurations of an external pelvic ring fixation system. Methods. Five configurations of an anterior external pelvic ring fixation system were tested using a universal testing machine. One single connecting rod was used in group “SINGLE,” two parallel connecting rods in group “DOUBLE,” two and four rods, respectively, in a tent-like configuration in groups “SINGLE TENT” and “DOUBLE TENT,” and a rhomboid-like configuration in group “RHOMBOID.” Each specimen was subjected to a total of 2000 consecutive cyclic loadings at 1 Hz lateral compression/distraction (±50 N) and torque (±0.5 Nm) loading alternating every 200 cycles. Translational and rotational stiffness were determined at 100, 300, 500, 700, and 900 cycles. Results. The “SINGLE TENT” and “RHOMBOID” configurations already failed with a preloading of 50 N compression force. The “DOUBLE” configuration had around twice the translational stability compared with the “SINGLE” and “DOUBLE TENT” configurations. Rotational stiffness observed for the “DOUBLE” and “DOUBLE TENT” configurations was about 50% higher compared to the SINGLE configuration. Conclusion. Using two parallel connecting rods provides the highest translational and rotational stability.

Surgical techniques for spinopelvic reconstruction following total sacrectomy: a systematic review

To identify all available reconstruction methods for a total sacrectomy. Secondarily, we aimed to evaluate outcomes based on different interventions. We searched PubMed to identify sacral resections for tumors requiring internal fixation for stabilization. Demographic information, fixation techniques and postoperative outcomes were abstracted. Twenty-three publications (43 patients) met inclusion criteria from an initial search of 856 (κ 0.93). Mean age was 37years and follow-up was 33months. Fixation methods included a combination of spinopelvic fixation (SPF), posterior pelvic ring fixation (PPRF), and/or anterior spinal column fixation (ASCF). For the purposes of analysis, patients were segregated based on whether they received ASCF. Postoperative complications including wound/instrument infections, GI or vascular complications were reported at a higher rate in the non-ASCF group (1.63 complications/patient vs. 0.7 complications/patient). Instrument failure was seen in 5 (16.1%) out of the 31 patients with reported outcomes. Specifically, 1 out of 8 patients (12.5%) with ASCF compared with 4 out of 23 patients (17.4%) without ASCF had hardware failure. At final follow-up, 35 of 39 patients were ambulating. While surgical treatment of primary sacral tumors remains a challenge, there have been advances in reconstruction techniques following total sacrectomy. SPF has shifted from intrapelvic rod and hook constructs to pedicle and iliac screw-rod systems for improved rigidity. PPRF and ASCF have adapted for deficiencies in the posterior ring and anterior column. A trend toward a lower rate of hardware failure emerged in the group utilizing anterior spinal column support. Despite a more involved reconstruction with ASCF, surgical complications such as infection rates and blood loss were lower compared to the group without ASCF. While we cannot definitively say one system is superior to the other, based on the data gleaned from this systematic review, it is our opinion that incorporation of ASCF in reconstructing the spinopelvic junction may lead to improved outcomes. However, most importantly, we recommend that the treating surgeon operate on patients requiring a total sacrectomy based on his or her level of comfort, as these cases can be extremely challenging even among experts.

Biomechanical Comparison of Standard Iliosacral Screw Fixation to Transsacral Locked Screw Fixation in a Type C Zone II Pelvic Fracture Model

Iliosacral screw fixation into the first sacral body is a common method for pelvic ring fixation. However, this construct has been shown to be clinically unreliable for the percutaneous fixation of unstable Type C zone II vertically oriented sacral fractures with residual fracture site separation. The objective of this study was to biomechanically compare a locked transsacral construct versus the standard iliosacral construct in a Type C zone II sacral fracture model. A Type C pelvic ring injury was created in ten embalmed cadaver pelves by performing vertical osteotomies through zone II of the sacrum and the ipsilateral pubic rami. The sacrum was then reduced maintaining a 2 mm fracture gap. Five specimens were fixed using two 7.0-mm iliosacral screws into the S1 body; the other 5 were fixed using one 7.0-mm iliosacral screw and one 7.0-mm transsacral screw exiting the contralateral ilium with a nut placed on its end, creating a locked construct. Each pelvis underwent 100,000 cycles at 250 N and was then loaded to failure using a unilateral stance testing model. Vertical displacements at 25,000; 50,000; 75,000 and 100,000 cycles and failure force were recorded for each pelvis. The locked transsacral construct performed significantly better than the iliosacral construct at all 4 measurement points (P = 0.009) and in force to failure (P value = 0.02). Fixation of unstable zone II sacral fractures using the combination of an iliosacral screw and a locked transsacral screw resists deformation and withstands a greater force to failure as compared to fixation with 2 standard iliosacral screws. This locked transsacral construct may prove advantageous, especially when a percutaneous technique is used for a Type C zone II vertically oriented sacral fracture injury pattern, which can result in residual fracture site separation.

Stoppa approach: clinical anatomy and application in pelvic anterior ring fracture

Objective To study the clinical anatomy and application of Stoppa approach in fixation of pelvic anterior ring fractures.Methods The frequency of Corona Mortis in pelvis were observed in 20 cadavers (40 sides).The safe areas for screw insertion into the medial sidewall of the pelvis were measured in anteroposterior X-ray films of the pelvis.A retrospective study was performed of a series of 22 patients (14 males and 8 females) with pelvic anterior ring fracture who had been treated by Stoppa approach.They were 17 to 56 years of age (mean,32.6 years).Simple anterior ring fractures occurred in 16 patients who were fixated with plate of pelvic anterior ring.The other 6 cases were complicated with fracture dislocation of the sacroiliac articulation and treated with plate of pelvic anterior ring and sacroiliac screws.According to the Tile classification,3 fractures were type A2,6 type B2,7 type B3,4 type C2 and 2 type C3.Results The presence rate of Corona Mortis was 85.0％ (34/40) in the 20 cadavers.Of the inner margin of a true pelvis,the pubic branch district was safe for screw insertion of a 4-hole plate and the supra-acetabular region was also safe for screw insertion of a 3-4-hole plate,but the acetabular region was unsuitable for screw insertion of a 3-4-hole plate.The blood vessel,Corona Mortis,was found in 18 of the patients (18/22) and ligated in the operation.According to the Matta criteria,14 cases obtained anatomic reduction,7 good reduction and one poor reduction (the pelvic anterior ring fracture).Nineteen patients obtained follow-ups for 6 to 12 months (average,10.4 months) and all achieved bony union at 2.8 months postoperatively on average(range,2 to 4 months).At the last follow-up,the pelvic function was rated as excellent in 12,good in 5 and fair in 2 cases according to the Majeed evaluation system.Conclusions The presence of Corona Mortis is high by the cadaveric and clinical observations.Consequently,Stoppa approach is appropriate for internal fixation of an unstable pelvic ring fracture because it allows an adequate exposure for visualization and managernent of the vessel to achieve good clinical outcomes. Key words: Pelvis; Fractures, bone; Anatomy; Stoppa approach

Fixation Techniques for Complex Traumatic Transverse Sacral Fractures

Systematic review. To identify and describe reconstruction methods for the treatment of transverse sacral fracture (TSF) and to evaluate outcomes based on treatment interventions. A variety of surgical interventions for stabilization of TSFs exist, yet the optimal management remains unclear. Although there are many individual case reports and series describing techniques to stabilize TSF, prior reviews fail to provide a comprehensive summary of current and past surgical techniques and their individual outcomes. Our systematic review searched the PubMed database using keywords identifying sacral fractures with a transverse component, requiring internal fixation for stabilization as well as a review of bibliographies and archives from meeting proceedings. Our search located 417 publications for abstract review, of which 27 (109 patients) with TSF were included. Average follow-up was 22 months (range, 0-82 mo). Thirty-eight patients (34%) underwent spinopelvic fixation (SPF), 53 (49%) underwent posterior pelvic ring fixation (PPRF), and 18 (17%) underwent both. PPRF included iliosacral screws (37 patients), transiliac screws (11 patients), transiliac screws with plating (3 patients), posterior plating (1 patient), and transiliac bar (1 patient). Additional injuries causing lumbosacral instability were seen in 8 patients (42%) who underwent SPF, 2 patients (18%) treated with PPRF, and 5 patients (45%) who were treated with both SPF and PPRF. Of those who presented with a neurological deficit, 5 patients (45%) with SPF, 9 (39%) with PPRF, and 3 (30%) with SPF and PPRF experienced full neurological recovery. Five patients (45%) with SPF, 7 (30%) with PPRF, and 5 (50%) with both regained partial neurological function. One patient (9%) with SPF, 7 (30%) with PPRF, and 2 (20%) with both experienced no neurological recovery. PPRF seems to be effective for stabilization of TSF. However, in the setting of further injuries causing additional lumbosacral instability, SPF should be used to ensure effective stabilization.

Disruptions of the Pelvic Ring: An Update: Editorial Comment

For more than three decades, since the publication of the first pelvic symposium in Clinical Orthopaedics and Related Research in 1980, much progress has been made in the evaluation and treatment of disruptions of the pelvic ring. Despite this progress, many questions remain unanswered and new ones have been raised. This symposium attempts to address a number of these unresolved issues. Its content should be of interest and value to all those involved in the management of patients sustaining an injury to the pelvic ring. An injury to the pelvic ring often results from a high-energy traumatic event, such as a motor vehicle accident. Therefore, these high-energy pelvic ring disruptions are frequently accompanied by additional musculoskeletal or other system injuries. With the advent of Advanced Trauma Life Support protocols and the stratification of medical centers based on their ability to evaluate and treat those who sustain high-energy trauma, patient survival has dramatically improved. However, patients continue to die from these injuries. What are the risk factors that predispose the demise of these patients and how can we better train surgeons to be competent in managing severely injured patients? After the patient has been evaluated and initially stabilized, the appropriate definitive management must be determined. Due to the importance of this topic and the recent introduction of alternative methods, a major portion of the symposium is devoted to definitive pelvic ring fixation. Is the anterior internal fixator a reasonable—or better—alternative to standard anterior fixation techniques? What happens when symphyseal plates fail? And does overconcern and misperception concerning the risk of infection cloud our decision-making process, favoring the use of closed techniques when open reduction might prove superior? These are some of the timely, focused topics of the papers in the middle section of this symposium. Fig. 1 Dr. Berton R. Moed is shown. This symposium includes new information regarding perhaps the most important aspect of pelvic ring injury care, namely the eventual function of the patient. No different from the care of any patient with an injury to the musculoskeletal system, the ultimate goal is to return patients with pelvic ring injuries to their preinjury level of function. Over the years, the pendulum of conventional wisdom has swung wildly between “they all do well” to “they all do poorly” and all points in between. It is of the utmost importance to avoid the dogma and focus on what is actually going on with our individual patients, thereby providing appropriate care and realistic expectations. Fig. 2 Dr. Mark S. Vrahas is shown. We would like to thank all of the authors for contributing their excellent work to this symposium. The topics are timely and add important information to the continually growing body of knowledge in the field of pelvic ring injury care. We would also like to thank all the reviewers who assisted us in the evaluation and vetting process. It is our sincere belief and expectation that the material presented will both inform and stimulate those involved in the care of the patient with a disruption of the pelvic ring.

A Simulator Model for Sacroiliac Screw Placement

Fixation with percutaneously placed sacroiliac screws has become a well-established technique for fixation of the posterior pelvic ring in the proper clinical setting. This technique, however, carries with it the risk of iatrogenic injury to neurovascular structures with aberrant screw placement. Given the potential risks involved with this technique, a model whereby the psychomotor skills involved could be refined before entering the operating room may be of benefit. The purpose of the current study is (1) to describe a simulator model for SI screw placement that can be assembled from readily available equipment and (2) to attempt to demonstrate the construct validity of such a simulator. A simulator was assembled using readily available equipment found in the hospital and at a hardware store, and the cost of set up is less than $50. Orthopedic surgeons and novice operators were then observed using the simulator and results were recorded. Tertiary referral teaching hospital. Orthopedic surgery residents, resident faculty, x-ray technicians. This simulator has been found to be a safe and effective model for teaching junior residents the technique of sacroiliac (SI) screw placement. An added benefit to this module is that it helps train new C-arm technicians to learn how to obtain the necessary views for this procedure. This model can be a valuable component of orthopedic training programs whereby technical and psychomotor skills necessary for percutaneous SI screw placement can be developed in a controlled setting.

Percutaneous iliosacral screw fixation in S1 and S2 for posterior pelvic ring injuries: technique and perioperative complications

Percutaneous iliosacral screw placement allows for minimally invasive fixation of posterior pelvic ring instabilities. The objective of this study was to describe the technique for screws in S1 and S2 using conventional C-arm and to evaluate perioperative complications. Thirty-eight consecutive patients after percutaneous pelvic ring fixation with cannulated screws in S1 and S2 using conventional C-arm fluoroscopy were analysed. Accuracy of screw placement, nerval lesions, need for second surgery, operation time, and time to full weight bearing were assessed postoperatively and during regular follow-up examinations. Twenty-one patients underwent unilateral screw fixation and 17 patients underwent bilateral screw fixation. In total, 83 screws were placed. Mean age of the patients was 52 ± 19 years. Mean operation time was 16 ± 7 min/screw. Mean follow-up was 5 ± 3 months. Time to full weight bearing in 28 patients was 9 ± 4 weeks. Eight patients were still not able to support full weight bearing, partially due to concomitant injuries. Patients without concomitant injuries that affected walking were able to bear full weight after 8 ± 4 weeks (n = 17). Two patients had persistent postoperative hypaesthesia. No motor weakness was apparent and no postoperative bleeding was observed. Secondary surgery due to screw malpositioning or loosening had to be performed in four patients. The presence of a screw in S2 was not indicated for perioperative complications. Percutaneous iliosacral screw fixation is a rapid and definitive treatment for posterior pelvic ring injuries with a low risk of secondary bleeding during posterior pelvic stabilization. The technique using standard C-arm fluoroscopy was also found to be safe for screws placed in S2.

Indirect Reduction of Bilateral Tilt Fractures Using a Supra-Acetabular Pelvic External Fixator

Tilt fractures are a variant of pelvic ring fractures that result when the anterior pelvic ring is fractured at the superior pubic root and through the ischial ramus.1 Most commonly, these injuries are associated with Young and Burgess Lateral Compression type injuries. Lateral compression drives the hemipelvis medially and the resultant force allows the fragment to “tilt” anteriorly and inferiorly into the perineum. The tilt fracture is more commonly seen in women, and displacement of the ramus fragment into the perineum may result in occult open fractures. Assessment of these injuries in women requires a careful manual and speculum pelvic examination. Even without penetration of the fragment into the perineum, if left untreated, these fragments may cause dyspareunia, and therefore operative treatment is recommended. Different operative techniques have been described for surgical treatment of pubic ramus fractures.2–4 Operative treatments for tilt fractures include attempted closed reduction or open reduction and internal fixation of the anterior pelvic ring.5 We present a simple technique using a two-pin supraacetabular external fixator to indirectly reduce and maintain the tilt fracture and the pelvic ring deformity. Specifically for the treatment of tilt fractures, the fixator may be used as both a reduction and definitive fixation tool. Alternatively, the supra-acetabular fixator may be used as an intraoperative reduction tool, maintaining the reduction while definitive internal fixation is applied.