Pelvic Ring Disruptions Research Articles

Pelvic Ring Disruption in a Patient with Bladder Exstrophy: A Case Report.

Bladder exstrophy is an uncommon urologic condition believed to be present in one in 10,000 to 50,000 live births1,2. Patients with this condition often require extensive treatment, including multiple surgeries early in life. Identification of pelvic ring disruption in this patient population is challenging and may be complicated by anterior pelvic deficiency, pubic diastasis, external rotation of innominate bones, and previous pelvic osteotomies1. Once identified, treatment of pelvic disruption in patients with bladder exstrophy may be complicated by comorbidities and osteotomy-related pelvic deformity. We present a patient with bladder exstrophy and an anterior-posterior compression type-III (APC-III) pelvic injury sustained from a high-energy trauma. To the best of our knowledge, this is the first case report of its kind in the English-language literature. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A thirty-year-old man with a history of bladder exstrophy, hypospadias, and bladder cancer presented to our institution after a motorcycle accident. The patient, who had been wearing a helmet, sustained loss of consciousness. The previous surgical history included neobladder creation at age three and multiple other unknown procedures to address the exstrophy, including a pelvic osteotomy. Medical records prior to this injury were not available. He had a left APC-III pelvic injury, a neobladder rupture, a perineal laceration, an open fracture of the right tibia, and a closed fracture of the right medial malleolus (Fig. 1 and Figs. 2-A through 2-D). Initially, he was hemodynamically unstable and required four units of packed red blood cells, two units of fresh-frozen plasma, ten units of platelets, and 4 L of crystalloid to maintain a systolic blood pressure of 90-100 mm Hg. The initial computed tomography (CT) scan of the abdomen and pelvis demonstrated contrast extravasation around …

Treatment of posterior pelvic ring disruptions using a minimally invasive adjustable plate

ObjectiveIliosacral (IS) screw fixation and posterior tension band plate (TBP) technique are two treatment alternatives for posterior pelvic ring injuries. However, IS screw fixation requires continuous fluoroscopic guidance for appropriate screw insertion and carries a risk of neurovascular injuries. TBP technique also has some disadvantages, including limited reduction potential, difficulty in precontouring the plate and a higher rate of symptomatic implants. To address these limitations, we introduced a minimally invasive adjustable plate (MIAP). This study aims to present the preliminary radiological and clinical results of posterior pelvic ring disruptions treated with MIAP. MethodsThe MIAP conforms to the irregular shape of posterior pelvic ring and can be used without prebending. This plate has a role in reducing compressed or separated fractures/dislocations. Sixteen patients, including seven males and nine females, were treated with MIAP through a minimally invasive approach. The fracture patterns consisted of six Type B and ten Type C fractures according to OTA classification of fracture. Preoperative and postoperative radiography was taken to assess the fracture displacement and reduction quality. Postoperative rehabilitation programme was individualised and early exercise was encouraged. Patients were followed up and the functional outcome was evaluated based upon the scoring system proposed by Lindahl and associates. ResultsAll posterior pelvic ring disruptions were reduced and fixed with MIAP. The average duration of surgery was 49min, the average radiation exposure was 6s, and the average blood loss was 80mL for the treatment of posterior pelvic ring injuries. Overall radiological results of the reduction were excellent in eleven patients and good in five. The patients were followed up for 30 months on average. All fractures healed. The functional outcome was excellent in ten patients, good in four and fair in two. There were no iatrogenic neurovascular injuries, implant failures, irritative symptoms or pressure sores due to subcutaneous implantation. ConclusionFavourable clinical and radiological outcomes can be achieved in treating posterior pelvic disruptions with MIAP. This plate is effective in view of its simplicity, less radiation exposure, safety, minimal invasion and stable fixation.

Combined Pelvic Ring Disruption and Acetabular Fracture

Combined pelvic ring disruptions and acetabular fractures are thought to be uncommon. Our objectives were to characterize concomitant injury patterns and to compare them with historically observed rates for each injury in isolation. Retrospective review comparing a study group with historical controls. Fracture patterns were compared with our institution's isolated injury patterns and with isolated injury patterns of other published series. Level I academic medical center. Between 1997 and 2001, 854 pelvic ring disruptions and 457 acetabular fractures were evaluated. Forty patients sustained combined injuries. None. Fracture patterns, Injury Severity Scores, and mortality rates. Our series of combined injuries included 5% posterior wall fractures. This was significantly different from the 30% incidence of posterior wall fractures among isolated acetabular fractures at our institution (P < 0.006). No posterior column or posterior column with associated posterior wall fractures occurred. Fifty-three percent of the patients sustained anterior-posterior compression pelvic ring injuries, exceeding our center's 19% norm for isolated pelvic ring injuries (P < 0.001). For combined injuries, the mean injury severity score was 27.9 and the overall mortality rate was 13%. Early death occurred in 19% of patients with combined anterior-posterior compression injuries and 6% with lateral compression injuries. Patients with combined pelvic and acetabular injuries have multiple system injuries and high Injury Severity Scores. Fracture patterns differ from those observed with isolated injuries. Posterior acetabular fractures are uncommon components. Anterior-posterior compression pelvic injuries seem much more frequent in cases of combined injuries than isolated injuries and are associated with high mortality rates. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Unstable pelvic ring injury with hemodynamic instability: What seems the best procedure choice and sequence in the initial management?

Most fatalities related to pelvic ring injuries occur early and are caused by massive retroperitoneal bleeding. The objective of our study is to determine the optimal sequence of surgical procedures to restore hemodynamic stability in patients with unstable pelvic ring injuries. This was a retrospective review of all patients with pelvic fractures and hemodynamic instability admitted to our level 1 trauma center between January 1998 and December 2008. We entered into our polytrauma database the following patient characteristics: age, sex, mechanism of injury, Injury Severity Score (ISS), classification of injury, timing of operative intervention, and type of operative procedures. Patients were divided into four groups (according to the sequence of surgical procedures performed within 24 hours following admission), as follows: group 1: patients treated with external fixation only; group 2: patients receiving external fixation followed by angiography; group 3: patients receiving external fixation followed by laparotomy ± angiography; and group 4: patients treated by immediate laparotomy or angiography before skeletal fixation. Eighty of 136 patients admitted with a pelvic fracture were classified, as unstable AO/OTA type B or C pelvic ring injury, and 70/80 were hemodynamically unstable. Eight patients died shortly after arrival and two remained stable without requiring any early procedure. Sixty patients went immediately to the operating room. Twenty-nine patients were placed in group 1 with 100% survival, 12 in group 2 with 91% survival, 11 in group 3 with 82% survival, and eight patients placed in group 4 with 0% survival (P<0.001). The management of hemorrhagic instability linked to pelvic ring disruption involves a sequence of therapeutic events, which is more important than the events themselves. Pelvic bone stabilization by pelvic clamp or external fixator followed by arteriography seems to be the more secure. Angiographic embolization is the method of choice whenever haemodynamic instability coexists with an unstable pelvic disruption. Laparotomy and packing are restricted to extreme severe cases in remote hospitals with skillful surgeons! Actually aortic balloon is a good solution to control uncontrollable bleeding. Level IV. Retrospective study.

Conservative treatment of Malgaigne fracture in young female - case report

Pelvic ring injuries usually result from high-energy trauma, and cranial and abdominal multiple injuries are frequently present. Malgaigne fracture is referred to pelvic ring disruption at two sites, and is often treated surgically for its instability. We present a case of nonoperative treatment of Malgaigne pelvic fracture. A 17-year-old girl sustained a Malgaigne fracture falling off a horse. After ruling out urgent multiple trauma in local hospital, she was then transferred to Pediatric Orthopedic and Trauma Service at the Institute of Orthopedic Surgery "Banjica" Belgrade, with provisional cutaneous traction of 2 kg applied to her right leg. After the status evaluation, the supracondylar femoral traction was applied for three months, combined with pelvic cradle for first 73 days. Weight of traction was gradually adjusted according to x-ray check-up, ranging from 1-16 kg (1/4 of body weight). Antibiotic prophylaxis was administered for 10 days, and thromboprophylaxis for two months. After the removal of traction, physical therapy was applied and the patient achieved full weight bearing four months after the injury. Treatment outcome was a symmetric and stable pelvic ring, equal leg length, full range of motion in both hip joints and normal walking. Traction therapy, combined with gravitational suspension in pelvic cradle, resulted in excellent clinical result. Although significantly longer and more loaded than usual, normal weight bearing and walking were promptly achieved using intensive physical therapy.

Assessing Radiographic Outcome of Pelvic Ring Disruptions

Assessing Radiographic Outcome of Pelvic Ring Disruptions

Vaginal mesh repair: is it appropriate for pelvic organ prolapse in a nulliparous female following pelvic ring fracture?

Pelvic organ prolapse (POP) in a nulliparous woman is a rare sequela of high-energy pelvic trauma. We report a case of a 26-year-old nulliparous woman who developed stage III pelvic organ prolapse two decades after pelvic ring disruption. Abdominal wall cervicopexy was performed as a primary procedure by her attending local gynecologist. Recurrence occurred in early postoperative period following which she was referred to our institute. Examination revealed 5-cm pubic symphysis widening and stage III pelvic organ prolapse with deficient perineal body. Widened levator hiatus with atrophic pelvic floor muscles were confirmed on MRI. The patient was successfully managed by sacrospinous hysteropexy using predesigned vaginal mesh kit along with anterior colporrhaphy and colpoperineorrhaphy. Mesh exposure detected at the 6th year of follow-up required partial excision of the exposed mesh.

Subcutaneous Stabilization of Anterior Pelvic Ring Disruption Is an Emerging Technique

Subcutaneous Stabilization of Anterior Pelvic Ring Disruption Is an Emerging Technique

Oblique Distraction External Pelvic Fixation

Simple anterior pelvic external fixation is a safe and effective strategy for reduction of pelvic ring deformity as well as the provisional or definitive stabilization of selected patterns of pelvic ring disruption. A two-pin oblique anterior pelvic deformity correction frame is a unique frame configuration designed to reduce and stabilize lateral compression pelvic ring disruptions associated with flexion/internal rotation hemipelvic deformities. In a small case series, we demonstrate that the oblique distraction external fixation frame alone or in combination with internal fixation is a simple and safe strategy for reduction and stabilization of unstable multiplanar hemipelvic deformities associated with partial posterior ring stability.

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.

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.

An overview of pelvic ring disruption

Pelvic ring disruption after trauma is uncommon, occurring in 20–37/100,000 people in the general population. However, in high velocity poly trauma up to 20% of cases have this injury contributing significantly to morbidity and mortality. The management of pelvic and acetabular trauma has become a subspecialty within the orthopaedic trauma care. The injury patterns are now better understood, there is agreement on a classification system and operative stabilisation has become a viable treatment option.

Biomechanical comparison of the stability of posterior pelvic ring disruptions fixed with three kinds of internal fixator

Objective To compare the stability of vertical fractures of posterior pelvic ring fixed with tension band plate (TBP),two sacroiliac(SI) screws and minimally invasive adjustable plate (MIAP) for posterior pelvic ring.Methods Eight adult male pelvic specimens without osteoporosis were selected.The sacroiliac complex was retained and other soft tissue was removed.The right sacral vertical fractures were made.The fractures were reduced anatomically and fixed in turn with TBP,two SI screws and MIAP.The pelvic specimens were fastened to the biomechanical testing machine in sitting position.Vertical load,ranging from 0 to 620 N,was applied on specimens at a speed of 20 N/s and the displacement was recorded.Then the specimens were exposed to torsional load at a speed of 0.1 degree/s.The rotation degree and corresponding torque were recorded.Analysis of variance was employed to analyze the data.Results Under vertical load,the displacement of the pelvis fixed with MIAP was similar to that fixed with two SI screws.The displacement of the pelvic fractures fixed with either MIAP or two SI screws was smaller than that fixed with TBP.Under torsional load,the torque measured on the pelvis fixed with MIAP was similar to that fixed with two SI screws.The torque measured on the pelvic fractures fixed with either MIAP or two SI screws was greater than that fixed with TBP.Conclusion The posterior pelvic ring disruptions fixed with MIAP is as stable as that fixed with two SI screws,both with better stability than that fixed with TBP,under both vertical load and torsional. Key words: Pelvis; Fractures, bone; Biomechanics; Internal fixators

Minimally invasive reduction of vertically displaced sacral fracture without use of traction table

BackgroundTreatment of vertically displaced sacral fracture can be difficult even for the expert traumatologist. Traditional reduction methods can show some limitations; we suggest a minimally invasive technique, which could be effective, tissue sparing and economic in terms of equipment needed.Materials and methodsOur retrospective study included 11 patients with average age of 40.2 years (range 24–59 years), with type C pelvic ring disruption with monolateral sacral fracture (C1.3), who underwent surgical treatment from April 2007 to March 2008 using the minimally invasive technique. Radiographic examination, using Matta’s criteria, was carried out pre-operatively, post-operatively and at least at 1 year after surgery. All patients were functionally evaluated using Majeed’s grading scale with mean follow-up time of 18.9 months (range 14–25 months).ResultsPre-operative displacements averaged 10.8 mm (range 7–21 mm); post-operative displacements averaged 5.4 mm (range 3–12 mm), with excellent or good reduction in 91% of cases. No major complications occurred. On functional evaluation, 82% of patients obtained good or excellent results.ConclusionThe minimally invasive reduction technique, requiring a limited surgical approach and a standard radiolucent table, is in our experience a satisfactory procedure for management of monolateral vertically displaced sacral fracture.

C-clamp and pelvic packing for control of hemorrhage in patients with pelvic ring disruption

Background:Exsanguinating hemorrhage is the major cause of death in patients with pelvic ring disruption.Aims:The aim of this study was to document outcomes after the stabilization of pelvic ring injuries by a C-clamp and control of hemorrhage by pelvic packing. Physiological parameters were tested as prognostic factors.Setting and Design:This was a retrospective study at a level I trauma center. The study period was from January 1996 to December 2007.Materials and Methods:Fifty patients with pelvic ring disruption and hemorrhagic shock were analyzed. The pelvic rings were fixed by a C-clamp, and patients with ongoing hemorrhage underwent laparotomy and extra- and/or intra-peritoneal pelvic packing. Clinical parameters (heart rate, mean arterial pressure) and physiological parameters (lactate levels, hemoglobin, hematocrit) were documented at admission and at different time points during the initial treatment (1, 2, 3, 4, 6, 8, and 12h after admission).Results:Within 12 h of admission, 16 patients died (nonsurvivors) due to hemorrhagic shock (n=13) or head injuries (n=3). In this group, 12 patients underwent laparotomy with pelvic packing. Thirty-four patients survived the first 12 h (early survivors) after fixation by a C-clamp and additional packing in 23 patients. Four of these patients died 12.3±7.1 days later due to multiple organ failure (n=3) or severe head injury (n=1). The blood lactate level at admission was significantly higher in the group of nonsurvivors (7.2±0.8 mmol/L) compared to the early survivors (4.3±0.5 mmol/L, P<0.05). While hemoglobin values improved within the first 2 h in nonsurvivors, lactate levels continued to increase.Conclusion:Pelvic packing in addition to the C-clamp fixation effectively controls severe hemorrhage in patients with pelvic ring disruption. Early sequential measurements of blood lactate levels can be used to estimate the severity of shock and the response to the shock treatment.

Open Reduction Internal Fixation of Displaced Sacral Fractures: Technique and Results

Pelvic ring disruption with an associated sacral fracture is typically a result of high-energy injury. Due to significant local soft tissue trauma and the complex neurovascular anatomy in the region, exposure and reduction of sacral fractures has proven to be difficult, hazardous, and fraught with complications. We describe a modified reduction technique to address displacement in sacral fractures to show that it can be safe and effective through evaluation of radiographic, clinical, and functional outcomes. We retrospectively reviewed the radiographic and clinical results of consecutive patients treated at a single institution by the senior surgeon (K.F.D.) with open reduction for displaced sacral fractures. Radiographic follow-up was available on all patients. Complete clinical follow-up was available on 19 of 20 patients. The average duration of follow-up was 3.7 years. All fractures united with no additional surgery. There were no infections or additional neurologic deficits or vascular injuries. There was 1 asymptomatic hardware failure 2 years postoperatively with no further displacement. Average preoperative displacement on the anteroposterior (AP) radiograph was 14.72 mm with a long-term follow-up displacement of 3.25 mm. Iowa Pelvic Score questionnaires demonstrated an average score of 92.2. Eighty-nine percent of patients returned to full time work or their previous activity level. The technique of open reduction and fixation of displaced sacral fractures described in this review is safe and effective with a low complication rate and clinical results comparable to or exceeding that of previously published series.

Radiographic Quantification and Analysis of Dysmorphic Upper Sacral Osseous Anatomy and Associated Iliosacral Screw Insertions

To quantify upper sacral dysmorphic osseous anatomy and assess its impact on second sacral segment iliosacral screw insertion. Retrospective evaluation of a prospective trauma database. Regional Level I trauma center. Twenty-four patients with unstable posterior pelvic ring disruptions and sacral dysmorphism were evaluated radiographically and second segment (S2) screws were placed using a standard technique. The sacral osseous pathway limits were measured using preoperative pelvic computed tomography at the upper and second sacral segments. The S2 screw location relative to the sacral nerve root tunnels and the maximum possible screw lengths for both S1 and S2 screws were evaluated with postoperative pelvic computed tomography. The S2 screw positions were graded as intraosseous, juxtaforaminal, or extruded. Preoperative and postoperative peripheral neurologic examinations were documented. The dysmorphic S1 width available for screw insertion averaged 13.2 mm. The S2 pathway width averaged 15.2 mm. The maximum potential screw length for the dysmorphic S1 averaged 100.8 mm and for S2 measured 151.9 mm. Twenty of 24 patients with S2 screws were intraosseous and in four patients were juxtaforaminal. There were no extruded screws. There were no neurologic injuries. Dysmorphic S1 segments are anatomically competent for routine screw fixation. The S2 segment provides a larger osseous site for screw insertion than S1 in dysmorphic sacrums. Significantly longer screws are possible in S2 compared with the dysmorphic S1 segment. S2 iliosacral screws can be safely and accurately accomplished using a standard technique in patients with unstable posterior pelvic ring disruptions and sacral dysmorphism. Safe screw insertions avoid iatrogenic nerve root injuries.

Surgeon Variability in the Treatment of Pelvic Ring Injuries

Pelvic ring injuries are associated with the potential for long-term disability and high mortality rates. No well-established, definitive treatment algorithms have been presented in the literature. We evaluated agreement among surgeons in selecting treatment of pelvic ring injuries and investigated the relationship between type of injury and treatment plan. We conducted a prospective agreement analysis of pelvic ring injury images at a level I regional trauma center. Eighty-nine isolated pelvic ring disruptions were selected; they were the only injuries present on the images and were thought to comprise a variety of pelvic fracture types from a database of 1600 pelvic fractures. Sets of injury images were randomly ordered and distributed to 5 orthopedic trauma surgeons blinded to patient name, attending surgeon, date of injury, and eventual treatment. Surgeons reviewed images, independently selected preferred treatments, and classified injuries with the Young-Burgess and Tile systems. Eight weeks later, images were again randomly ordered and distributed to the same 5 orthopedic surgeons, who again independently selected preferred treatments and classified injuries. Kappa analyses of agreement among surgeons and within each surgeon over time were conducted. Analysis among surgeons' treatment plans based on radiographic assessment alone revealed a mean kappa value of 0.47, indicating moderate level of agreement. Analysis of data collected 8 weeks later yielded a mean kappa value of 0.56, representing moderate agreement within each surgeon over time. Young-Burgess and Tile classifications yielded consistent treatment plans for certain fracture types and varied plans for other types. Our results question the usefulness of the 2 classification systems for predicting treatment decisions.

Pelvic Inlet and Outlet Radiographs Redefined

Musculoskeletal plain radiographic imaging protocols are typically predicated on orthogonal views of the bone or joint being evaluated. Pelvic injury has been evaluated with 45 degrees inlet and 45 degrees outlet radiographs. While these views are perpendicular to each other, they may not be in the best plane to evaluate pelvic injury because of variable lumbopelvic anatomy. We hypothesized that inlet and outlet radiographic views optimized to examine the clinically relevant osseous landmarks vary substantially from routine 45 degrees inlet and outlet views. Sixty-eight consecutive patients without pelvic ring disruption who had undergone routine axial pelvic computed tomography scans were retrospectively identified. The optimal inlet and outlet angles required to profile the clinically relevant pelvic anatomy were quantified for each patient with use of sagittal computed tomography reconstructions. The optimal inlet angle to profile the anterior body of S1 required an average caudal tilt of 21 degrees . The average outlet angle (cephalad tilt) perpendicular to the body of S1 was 63 degrees and perpendicular to S2 was 57 degrees . The optimal angles were the same for male and female patients and for patients with normal and dysmorphic pelves and were independent of patient age. Screening inlet and screening outlet radiographs made at 25 degrees and 60 degrees , respectively, are recommended to provide accurate profiles of the clinically relevant posterior osseous pelvic anatomy.

2D-fluoroscopic navigated percutaneous screw fixation of pelvic ring injuries - a case series

BackgroundScrew fixation of pelvic ring fractures is a common, but demanding procedure and navigation techniques were introduced to increase the precision of screw placement. The purpose of this case series was the evaluation of screw misplacement rate and functional outcome of percutaneous screw fixation of pelvic ring disruptions using a 2D navigation system.MethodsBetween August 2004 and December 2007, 44 of 442 patients with pelvic injuries were included for closed reduction and percutaneous screw fixation of disrupted pelvic ring lesions using an optoelectronic 2D-fluoroscopic based navigation system. Operating and fluoroscopy time were measured, as well as peri- and postoperative complications documented. Screw position was assessed by postoperative CT scans. Quality of live was evaluated by SF 36-questionnaire in 40 of 44 patients at mean follow up 15.5 ± 1.2 month.Results56 iliosacral- and 29 ramus pubic-screws were inserted (mean operation time per screw 62 ± 4 minutes, mean fluoroscopy time per screw 123 ± 12 seconds). In post-operative CT-scans the screw position was assessed and graded as follows: I. secure positioning, completely in the cancellous bone (80%); II. secure positioning, but contacting cortical bone structures (14%); III. malplaced positioning, penetrating the cortical bone (6%). The malplacements predominantly occurred in bilateral overlapping screw fixation. No wound infection or iatrogenic neurovascular damage were observed. Four re-operations were performed, two of them due to implant-misplacement and two of them due to implant-failure.Conclusion2D-fluoroscopic navigation is a safe tool providing high accuracy of percutaneous screw placement for pelvic ring fractures, but in cases of a bilateral iliosacral screw fixation an increased risk for screw misplacement was observed. If additional ramus pubic screw fixations are performed, the retrograde inserted screws have to pass the iliopubic eminence to prevent an axial screw loosening.