Percutaneous Iliosacral Screw Research Articles

Intra-operative multi-dimensional fluoroscopy of guidepin placement prior to iliosacral screw fixation for posterior pelvic ring injuries and sacroiliac dislocation: an early case series.

Traditional fluoroscopic techniques during percutaneous fixation of the posterior pelvic ring at times cannot adequately visualize errant or malpositioned iliosacral screws. Intra-operative fluoroscopic techniques have been advanced using multi-dimensional fluoroscopy to generate computed tomography-like images. This provides the surgeon not only the ability to assess iliosacral screw placement, but also the opportunity to assess reduction. We present a case series of four patients in which the Ziehm RFD multi-dimensional fluoroscopy was used to assess reduction and guidepin placement prior to definitive iliosacral screw fixation. Four patients at our university level 1 trauma center with posterior pelvic ring disruptions were treated with percutaneous iliosacral screw fixation. Traditional fluoroscopic techniques were used during guidepin placement. Multi-dimensional fluoroscopy was performed using the Ziehm RFD 3D to assess guidepin placement and reduction prior to definitive iliosacral screw fixation. Our case series highlights two patients in which multi-dimensional fluoroscopy was utilized to ensure safe placement of iliosacral screws. In one of these two patients, a change was made after reviewing the imaging as a guidepin was found to be intruded into bilateral S2 neural tunnels. We also present two patient examples in which multidimensional fluoroscopy was used to assess reduction achieved by less invasive methods, precluding the need for direct visualization using more extensive open approaches. This retrospective case series demonstrates the direct impact that the Ziehm RFD 3D technology provides in surgical management of patients with complex posterior pelvic ring injuries.

Clinical application of percutaneous iliosacral screws combined with pubic ramus screws in Tile B pelvic fracture

To investigate the application and effect of minimally invasive percutaneous anterior pelvic pubic ramus screw fixation in Tile B fractures. A retrospective review was conducted on 56 patients with posterior pelvic ring injury combined with fractures of anterior pubic and ischiadic ramus treated between May 2010 and August 2015, including 31 males and 25 females with an average age of 36.8 years old ranging from 35 to 65 years old. Based on the Tile classification, there were 13 cases of Tile B1 type, 28 cases of Tile B2 type and 15 cases of Tile B3 type. Among them, 26 patients were treated with sacroiliac screws combined with external fixation (external fixator group) and the other 30 patients underwent sacroiliac screw fixation combined with anterior screw fixation (pubic ramus screw group). Postoperative complications, postoperative ambulation time, fracture healing, blood loss, Majeed pelvic function score and visual analogue scale(VAS) were compared between two groups. Fifty-four patients were followed up from 3 to 24 months with a mean of 12 months. There were no significant difference in the peri-operative bleeding and operation time between two groups(P>0.05). The postoperative activity time and fracture healing time of pubic ramus screw group were shorter than those of the external fixator group, the differences were statistically significant(P<0.05). The Majeed score, VAS score of pubic ramus screw group were higher than those of the external fixator group, the differences were statistically significant(P<0.05). The incidence of postoperative complications of pubic ramus screw was lower than that of the external fixator group, the difference was statistically significant (P<0.05). Percutaneous iliosacral screws fixation combined with the pubic ramus screw is an effective and safty treatment method to the Tile B pelvic fracture. It has advantages of early ambulation, relief of the pain and few complications.

Open reduction internal fixation versus percutaneous iliosacral screw fixation for unstable posterior pelvic ring disruptions

BackgroundSurgical stabilization of posterior pelvic ring fractures can be achieved by either open or closed methods. They all provide a comparable biomechanical stability. The aim of the present study is to compare the clinical results of both techniques for treating posterior pelvic ring injuries. Material and methodsSeventy patients operated for unstable posterior pelvic ring disruptions were retrospectively reviewed. We compared 35 patients treated by open reduction internal fixation (ORIF group) versus 35 patients stabilized by using closed reduction and percutaneous iliosacral screw fixation (CRIF group) under fluoroscopic guidance. ResultsAccording to pelvic outcome scoring system of Pohlemann et al., 28 patients out of the ORIF group obtained good or excellent results (20 excellent and 8 good), five fair and two poor. In the CRIF group, 30 patients obtained good or excellent results (25 excellent and 5 good), four fair and one poor (P=0.64). The average intraoperative blood loss in the ORIF group was 500cc with average blood transfusion of 2units (1000cc) compared to blood loss 150cc in the CRIF group, with average blood transfusion of 1unit (500cc) (P=0.002). No intraoperative complications were reported in the ORIF group while operative guide wires were broken in two cases in the CRIF group (P=0.16). There were no neurological complications observed in the ORIF group, but one radiculopathy (L5 root palsy) occurred in the CRIF group (P=0.317). In the ORIF group, three patients had superficial wound infection and one patient had deep infection while in the CRIF group, we noted only one case of deep infection (P=0.083). ConclusionNo difference was noticed between ORIF and CRIF. The technical decision is variable according to time of surgery, fracture types, patient general condition, skin condition, presence of ipsilateral fractures of the acetabulum and feasibility of the closed reduction. More studies are needed to identify prognostic factors related to quality of the reduction. We need for creation of decisional algorithm for ORIF versus CRIF. Level of evidenceLevel 4.

Correct Positioning of Percutaneous Iliosacral Screws With Computer-Navigated Versus Fluoroscopically Guided Surgery in Traumatic Pelvic Ring Fractures

Correct Positioning of Percutaneous Iliosacral Screws With Computer-Navigated Versus Fluoroscopically Guided Surgery in Traumatic Pelvic Ring Fractures

Correct Positioning of Percutaneous Iliosacral Screws With Computer-Navigated Versus Fluoroscopically Guided Surgery in Traumatic Pelvic Ring Fractures

To assess the correct positioning of iliosacral screw in patients with unstable traumatic pelvic ring injury by comparing fluoroscopically guided computer-navigated surgery (CNS) with conventional fluoroscopy (CF) through reviewing postoperative computed tomography (CT) and clinical indicators. A comparative multicenter cohort study. Two level I Trauma Centers in the Netherlands. The computer-navigated group (n = 56) and the CF group (n = 24) were comparable regarding age (mean, 43 years), sex (58%, male), body mass index (25 kg/m), injury severity score (27), injury-to-surgery interval (7 days), and Orthopaedic Trauma Association classification (40% 61-B, 60% 61-C). The position of the iliosacral screws was evaluated on postoperative CT. In addition, clinical morbidity and reoperation were assessed. In the CNS group, a total of 111 screws were placed (2.0 per patient), of which 83% were placed correctly. In the CF group, 39 screws (1.6 per patient) were placed, 82% of them correctly.Inadequate fixation included neural foramina hit [12 screws (11%) in the CNS group versus 3 screws (8%) in the CF group, P = 0.76] and extraosseous dislocation [7 screws (6%) vs. 4 screws (10%), respectively, P = 0.47]. Five patients required reoperation, all in the CNS group, P = 0.32. We observed more adequate positioning with increased surgical experience, P = 0.12. In contrast to what has been suggested by previous studies, we found no benefit from computer-navigated iliosacral screw fixation compared with fluoroscopically guided surgery regarding the correct positioning of iliosacral screw on postoperative CT and related morbidity. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Ilio-Sacral (IS) Screw Fixation for Sacral and Sacroiliac Joint (SIJ) Injuries in Children.

Treatment of sacral fractures and sacroiliac joint (SIJ) disruption with percutaneous ilio-sacral (IS) screw fixation had become a more popular treatment option. There has been no study that specifically assessed IS fixation in children. The purpose of this study is present our results with fixation of the sacral fractures and SIJ disruption using IS screw in children 18 years old and younger. This is a retrospective review chart for children with sacral fracture or SIJ disruption who were treated by IS fixation in the period from 2000 to 2012. The patients were assessed for the following (age, sex, type of injury, associated injuries, surgery, complications, postoperative return of function, healing of the injury, and return to function). In the studied period (2000 to 2012), 11 patients who had either sacral fracture (4 patients) or SIJ (7 patients) disruption were treated by IS screws. The average age of these patients was 14 years (range, 6 to 17 y). Six patients had 1 screw and 5 patients had 2 screws. Eight patients had their entire fixation in S1, and 3 patients had 1 screw in S1 and 1 screw in S2. All screws were cannulated and were inserted over a guidewire with fluoroscopy and/or navigation guidance. Five patients had added anterior fixation of the pelvis. One patient was lost for follow-up. All patients (except 1) achieved healing of their injuries with no displacement or implant failure with return of function. One patient had failure of fixation and needed revision. One patient had neurological complication related to screw insertion. IS screws can be safely used to treat sacral fractures and SIJ injuries in children. This was feasible in children as young as 6 years old. The complications of the procedure were minimal with good stability obtained by IS screws.

Management of crescent fracture–dislocation of the sacroiliac joint: iliosacral screws versus plate fixation

Background Crescent fracture–dislocations are a well-recognized subset of pelvic ring injuries, which result from a lateral compression (LC) force. They are characterized by the disruption of the sacroiliac joint and extend proximally as a fracture of the posterior iliac wing. They are classically fixed using open reduction and internal fixation using plates and screws. We hypothesized that iliosacral screws (IS) can provide stable fixation in Day type II and Day type III. Patients and methods This clinical study was conducted with the aim of assessing the clinical results and functional scores of 43 patients (34 male and nine female patients). Their ages ranged from 16 to 64 years. The study included 43 patients who had sustained LC pelvic fractures (44 fractures) and had been operated upon between April 2000 and June 2010 (one patient had sustained bilateral fractures). Radiography and computed tomography of the pelvis were obtained for all patients. The classification by Day and colleague was used with three distinct types of crescents. Percutaneous IS alone were used in 20 fractures; a plate was used in 22 fractures, and two fractures were fixed with both plates and IS. LC II (LC screws) were added in two cases. The average follow-up period was 53 months (range: 4–126 months). Two patients died and one patient was lost to follow-up. The principal goal of surgical intervention was the accurate and stable reduction of the sacroiliac joint. Results Intraoperatively, there was no significant blood loss in cases treated with IS; the average blood loss in cases treated with open reduction and internal fixation using the plate was 600 ml (range: 200–1000 ml). The operative time was shorter for cases treated with IS (40 min; range: 30–60 min) than that for cases treated with plates (100 min; range: 60–150 min). The difference was statistically significant with a P-value of less than 0.001. The clinical results were good in all cases; there were no wound complications, neurological complications, or residual rotational deformity of the limb. The healing rate was 100%. The Majeed score was used for functional evaluation, and the mean score for the 40 patients was 86.2 points (range: 53–100 points); 26 (65%) patients scored greater than 85 points (excellent), 12 (30%) patients scored 66–84 points (good), and two (5%) patients scored 53 and 64 points (poor). The average Majeed score for the group fixed with plates was 84.56 points (range: 66–100 points), and it was lower than the Majeed score for IS, which was 87.2 points (range: 53–97 points). However, the difference was not statistically significant, with a P-value of 0.404. The average Majeed score for cases fixed with plates and IS was 91.5 points (range: 90–93 points). Discussion and conclusion Percutaneous IS fixation is a good option for types II and III crescent fractures, with lesser blood loss and shorter operative time compared with plate fixation. The functional outcome of the cases fixed with IS was better; however, the difference was not statistically significant. Level of evidence The level of evidence was IV (case series).

Measurement of Optimal Insertion Angle for Iliosacral Screw Fixation Using Three-Dimensional Computed Tomography Scans.

BackgroundPercutaneous iliosacral screw fixation can provide stable fixation with a minimally invasive surgical technique for unstable posterior pelvic ring injuries. This surgical technique is not limited by cases of difficult fracture patterns, sacral dysplasia, and small sacral pedicles that can occur in Asians. The purpose of this study was to investigate the incidence of the sacral dysplasia in the Korean population and determine the optimal direction of iliosacral screws by analyzing pelvic three-dimensional computed tomography (3D-CT) scans.MethodsOne hundred adult patients who had pelvic 3D-CT scans were evaluated. The upper sacral morphology was classified into three groups, i.e., normal, transitional, and dysplastic groups; the cross-sectional area of the safe zone was measured in each group. S1 pedicle with a short width of more than 11 mm was defined as safe pedicle. The incidences of safe pedicles at different angles ranging from 0° to 15° were investigated in order to determine optimal angle for screw direction.ResultsThe incidence of normal, transitional, and dysplastic group was 46%, 32%, and 22%, respectively. There were significant increases of the cross-sectional area of the safe zones by increasing the angles from 0° to 15° in all groups. The incidence of safe pedicles increased similar to the changes in cross-sectional area. The overall incidence of safe pedicles was highest at the 10° tilt angle.ConclusionsThe incidence of sacral dysplasia in Koreans was 54%, which is higher than previous studies for Western populations. The cross-sectional area of the safe zone can be increased by anteromedial direction of the iliosacral screw. Considering the diversity of sacral morphology present in the Korean population, a tilt angle of 10° may be the safest angle.

Computer Assisted Surgery for Iliosacral Screw Placement-How Far have we gone?

Unstable pelvic ring injuries require definite operative fixation. While the posterior ring can be fixed utilizing open approaches, percutaneous screw fixation has become the treatment of choice avoiding the complications of open approaches. As the pelvis is a complex three-dimensional (3D) shape with many neurovascular structures situated within it, a thorough knowledge and understanding of the anatomy and radiographic imaging is required to accomplish the task of percutaneous iliosacral screw placement, while avoiding potential complications. Recent advances in computer assisted surgery (CAS) has provided some powerful tools in overcoming the obstacles associated with this procedure. This review examines the evolution of image guided surgery used for iliosacral screw placement, the current available options, and future perspectives.

Accuracy of computer-assisted iliosacral screw placement using a hybrid operating room

IntroductionIn recent years hybrid operating rooms were established all over the world. In our setting we combined a 3D flat-panel c-arm (Artis zeego, Siemens) with a navigation system (BrainLab curve, BrainLab). This worldwide unique combination enables the surgeon to visualise an entire pelvis in CT-like image quality with a single 3D-scan. The aim of our study was to investigate, if utilisation of a hybrid operating room increases the accuracy of SI-screws in comparison to standard 3D-navigation. Material and methodsRetrospective, not randomised single centre case series at a level I trauma centre. Inclusion criterion was insertion of a percutaneous iliosacral screw using image-guidance in the hybrid operating room. 61 patients (35 female, 26 male) were included from June 2012 till October 2014. 65 iliosacral screws were inserted. Intraoperative 3D-scans and postoperative scans were examined to investigate screw placement. The results were compared to a preceding study performed in 2012 using conventional 3D-navigation. Statistical calculations were performed with Microsoft Excel 2011 and SPSS. Results65 iliosacral screws were implanted. Two different types of screws were implanted: 1. “Standard” iliosacral screws stabilizing one joint/a unilateral fracture. 2. Single SI-screws stabilizing both SI-joints and if present a bilateral fracture. Forty one patients were included in group 1 (screws n=45). There was no perforation in 43 screws, grade 1 perforation in 2 screws. There was no grade 2 or 3 perforation in this group. Compared to the conventional 3D-navigated screws there was a highly significant difference (p<0.001). Twenty patients could be included in group 2. Eleven screws showed a complete intraosseous position. There was grade 1 perforation in 2 screws, grade 2 perforation in 5 screws and grade 3 perforation in 2 screws. ConclusionImprovements in image quality and enlargement of the display window lead to better intraoperative visualisation of the entire dorsal pelvis. Thereby the accuracy of computer-assisted iliosacral screws could be increased using a hybrid operating room. Furthermore difficult tasks like a single screw for both joints can be accomplished.

Functional Outcome With Percutaneous Ilio-sacral Screw Fixation For Posterior Pelvic Ring Injuries In Patients Involved In Heavy Manual Laboring.

Introduction: Unstable posterior pelvic ring injuries are best treated with operative methods due to better post-op functional score. Our patient cohort was involved in heavy manual laboring frequently required ground level work in their activities of daily living. There are very few outcome studies dealing exclusively with such patients.Materials & Methods: Forty one patients who were treated with percutaneous sacroiliac screw fixation under fluoroscopic guidance and were followed-up for at least one year were analyzed retrospectively for functional outcome using the Majeed score.Results: Twenty one (51.22%) and thirteen (31.70%) patients were found to be in excellent and good categories respectively and majority of the patients (thirty/73.17%) were able to return to their original occupation with or without minor adjustments.Conclusion: Percutaneous ilio-sacral screw fixation for posterior pelvic unstable injuries is an acceptable mode of treatment in patients involved in heavy manual laboring.

Percutaneous Ilio-Sacral Screw Fixation in Supine Position under Fluoroscopy Guidance.

Pelvic ring disruption when treated conservatively can be associated with prolonged hospital stay and immobilization, mal-union, chronic pain, limb length discrepancy if they are treated conservatively. Open reduction and fixation in an already compromised soft tissue and hemodynamically unstable patient causes more soft tissue injury, heamatoma, infection and neurovascular injury. Percutaneous iliosacral joint fixation can be an alternative technique for sacro-iliac joint injury and sacral fracture. To evaluate technique and safety of percutaneous ilio-sacral screw fixation in supine position under single fluoroscopy guidance for sacral fracture and sacro-iliac joint disruption. Twenty one patients either with sacral fracture or sacro-iliac joint disruption with percutaneous ilio-sacral screw fixation with cannulated cancellous screw fixation in between 2008 to 2014 were retrospectively evaluated including AP, inlet and outlet views of pelvis X rays and CT scan. Tile's classification and Dennis classification were used for pelvis and sacral injury. Thirty five percutaneous ilio-sacral screws were placed (Male: 6, Female: 15; range: 15 to 54) for sacral fracture involving zone 2 (8 with sacral fracture only and 5 with pelvis injury; Tile's type B in four and type C in one) and sacro-iliac joint injury (Tile's type B in three and type C in five). Commonest mode of injury was motor vehicle accidents (10) followed by fall related injury (6). Injury hospital interval and injury surgery interval was five hours to 13 days and 2 to 20 days respectively. Follow period was 3 months to 6 years. One patient developed post-operative deep vein thrombosis and another patient had post-operative haematoma. Two screws were juxtra-foramial. Good to excellent outcome were in 16 patients, fair in four and poor in one patient (Majeed Scoring). Percutaneous ilio-sacral screw fixation for sacro-iliac joint injury and sacral fracture with C arm guidance is safe and minimally invasive technique. Clear images and accurate interpretation of X-rays, CT scans and per operative C arm images are important to avoid malpositioning of screws and iatrogenic neurovascular injuries.

PMMA-augmented SI screw: a biomechanical analysis of stiffness and pull-out force in a matched paired human cadaveric model

IntroductionCurrent literature data and clinical experience show that the number of pelvic fractures continuously rises due to the increasing elderly population. In the elderly with suspected osteoporosis additional implant augmentation with bone cement seems to be an option to avoid secondary displacement. There are no reported biomechanical data in the literature comparing the fixation strength (and anchorage) of standard and augmented SI screws so far.The purpose of this study was to assess the biomechanical performance of cement-augmented versus non-augmented SI screws in a human cadaveric pelvis model. Material and MethodsSix human cadaveric pelvises preserved with the method of Thiel were used in this study. Each pelvis was split to a pair of 2 hemi-pelvises, assigned to 2 different groups for instrumentation with one non-augmented or one contralateral cement-augmented SI screw, placed in the body of S1 in a randomized fashion. The osteosynthesis followed a standard procedure with 3D controlled percutaneous iliosacral screw positioning. A biomechanical setup for a quasistatic pullout test of each SI screw was used. Construct stiffness and maximum pullout force were calculated from the load-displacement curve of the machine data. Statistical evaluation was performed at a level of significance p = .05 for all statistical tests. ResultsStiffness and pullout force in the augmented group (501.6 N/mm ± 123.7, 1336.8 N ± 221.1) were significantly higher than in the non-augmented one (289.7 N/mm ± 97.1, 597.7 N ± 115.5), p = .04 and p = .014, respectively. BMD influenced significantly the pullout force in all study groups. ConclusionCement augmentation significantly increased the fixation strength in iliosacral screw osteosynthesis of the sacrum in a biomechanical human cadaveric model.

Image-guided percutaneous internal fixation of sacral fracture

Percutaneous iliosacral screw placement is a technically challenging procedure with a significant complication profile for misplaced screws. The use of stereotactic image guidance has been shown to provide superior accuracy in the placement of spinal instrumentation. Here, the authors describe a novel application of O-arm technology (Medtronic Sofamor Danek, Memphis, TN, USA) to help safely place iliosacral screws for the treatment of a traumatic sacral fracture.

Assessment of pelvic injuries treated with ilio-sacral screws: injury severity and accuracy of screw positioning.

The aim of this study was to analyse possible indicative parameters for percutaneous ilio-sacral stabilisation and to identify parameters associated with screw misplacement. Cohort study, level I trauma centre. (1) unstable pelvic injury, (2) percutaneous ilio-sacral screws placement. (1) sacral dysmorphy, (2) failed closed reduction, (3) navigated techniques. Indicative parameters were age, gender, body mass index, number of screws, screw angulation, fracture type and injury severity. End points were ilio-sacral screw position and associated complications. Screw placement accuracy was graded as follows: grade 0, no perforation; grade 1, perforation <2mm; grade 2, perforation from 2 to 4mm; grade 3, ≥4mm perforation. Between March 2008 and March 2013, 102 (53 women) patients were included (mean age, 48.5 ± 21.4years). The Injury Severity Score (ISS) and New Injury Severity Score (NISS) were 18.9 ± 9.9 and 22.3 ± 22.3, respectively. The positions of 137 ilio-sacral screws were analysed. Of all screws, 87.6% (120) were placed satisfactory (<2mm perforation). The incidence of screw misplacement was significantly higher in the case of two unilateral S1 screws compared with a single screw (failure rate: two unilateral screws 23.1% vs single screw 7.0%; p < 0.05). Screw perforation anterior to the lateral mass (in-out-in) represented the most frequent malposition. Revision was necessary in three cases due to malpositioning. Furthermore, no major complication occurred. We conclude, that twofold ilio-sacral screw positioning from one side increases the risk for screw misplacement. In this case, alternative techniques like navigation should be considered. Anterior screw perforation represents a common problem with a high incidence and warrants particular attention.

Correlating preoperative imaging with intraoperative fluoroscopy in iliosacral screw placement

BackgroundPercutaneous iliosacral screw placement can successfully stabilize unstable posterior pelvic ring injuries. Intraoperative fluoroscopic imaging is a vital component needed in safely placing iliosacral screws. Obtaining and appropriately interpreting fluoroscopic views can be challenging in certain clinical scenarios. We report on a series of patients to demonstrate how preoperative computed tomography (CT) imaging can be used to anticipate the appropriate intraoperative inlet and outlet fluoroscopic views.Materials and methods24 patients were retrospectively identified with unstable pelvic ring injuries requiring operative fixation using percutaneous iliosacral screws. Utilizing the sagittal reconstructions of the preoperative CT scans, anticipated inlet and outlet angle measurements were calculated. The operative reports were reviewed to determine the angles used intraoperatively. Postoperative CT scans were reviewed for repeat measurements and to determine the location and safety of each screw.ResultsPreoperative CT scans showed an average inlet of 20.5° (7°–37°) and an average outlet of 42.8° (30°–59°). Intraoperative views showed an average inlet of 24.9° (12°–38°) and an average outlet of 42.4° (29°–52°). Postoperative CT scans showed an average inlet of 19.4° (8°–31°) and an average outlet of 43.2° (31°–56°). The average difference from preoperative to intraoperative was 4.4° (−21° to 5°) for the inlet and 0.45° (−9° to 7°) for the outlet. The average difference between the preoperative and postoperative CT was 2.04° (0°–6°) for the inlet and 2.54° (0°–7°) for the outlet.ConclusionThere is significant anatomic variation of the posterior pelvic ring. The preoperative CT sagittal reconstruction images allow for appropriate preoperative planning for anticipated intraoperative fluoroscopic inlet and outlet views within 5°. Having knowledge of the desired intraoperative views preoperatively prepares the surgeon, aids in efficiently obtaining correct intraoperative views, and ultimately assists in safe iliosacral screw placement.Level of evidenceIV, Retrospective case series.

Percutaneous iliosacral screw fixation after osteoporotic posterior ring fractures of the pelvis reduces pain significantly in elderly patients

IntroductionOsteoporotic posterior ring fractures of the pelvis are common injuries in the elderly, but the treatment of these fractures still remains controversial. Percutaneous iliosacral screw fixation is one surgical option if conservative treatment cannot provide sufficient pain reduction. The aim of this study is to provide short-term results of elderly patients with percutaneous screw fixation. Methods30 patients with posterior ring fractures were treated between 12/2009 and 01/2014 with percutaneous iliosacral screw fixation. Patients’ mean age was 78.4 years. Concerning short-term outcome, we focused on initial pain level and postoperative pain reduction together with intra- and postoperative complications. ResultsThe average hospital stay was 23.7 days, with surgical treatment performed after an average of 9.2 days. 90% of our patients were female. All 30 patients had a lower level of pain at discharge compared with admission or immediately prior to surgery. The difference in pain level at admission compared with the pain level upon discharge showed a mean reduction from 6.8 to 1.8 with a statistically significant change (P≤0.001). 24 of 30 patients had no registered complications, one screw malpositioning with postoperative nerve irritation occurred. DiscussionConventional percutaneous iliosacral screw fixation is a successful operative treatment for elderly patients with persistent lower back pain after unstable posterior ring fractures of the pelvis. Intra- and postoperative complications are rare, so this treatment can be regarded as a safe procedure. Level of evidenceIV (retrospective study).

Standalone percutaneous transiliac plating of vertically unstable sacral fractures: outcomes, complications, and recommendations

The aim of this study is to evaluate results of a standalone percutaneous posterior plating of the vertically unstable sacral fractures, to analyze the influencing factors, to discuss encountered complications, and to express the related recommendations. Forty two cases were included; all of them had type C vertical sacral fractures; and 16 cases had associated nerve roots injury. Subcutaneous 3.5-mm reconstruction plate was used in all cases, through vertical incisions in 28 cases and transverse incisions in 14 cases. Hannover pelvic outcome scoring system was implemented for results evaluation. The mean follow-up period was 22.1 ± 7.5 months; the mean operative time was 43.3 ± 7 min; the mean surgical incision length was 4.6 ± 1.1 cm. 14 cases had excellent scores, 16 cases had good scores, 6 cases had fair scores, and 6 cases had poor scores. Younger age groups had significantly better outcome (P = 0.015), whereas the comminuted sacrum had significantly worse score (P = 0.041). Final residual posterior displacements significantly improved (P = 0.001) in comparison to the initial displacement. The nerve roots injury had final significant recovery (P = 0.012). Transverse skin incisions had subjectively significant satisfaction (P = 0.017). Percutaneous 3.5-mm reconstruction plate is a good alternative to percutaneous iliosacral screws in vertically unstable sacral fractures; especially in the presence of contraindication to the latter. It is simple procedure with minimal incisions; short operative time; less radiological exposure; good mechanical stability; and less iatrogenic injuries.

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.

U-shaped Sacral Fracture With Iliac Crest Apophyseal Avulsion in a Young Child

U-shaped sacral fractures or Jumper's fractures are rare injuries in adults and are even rarer in the pediatric population. These fractures share a common pathoanatomy where the pelvis as a unit together with the bilateral alar parts and the lower part of the sacrum, loses its skeletal and soft tissue connections to the remaining axial skeleton and hence the term spinopelvic dissociation. This report describes an unusual pattern of spinopelvic dissociation in a young child where the transverse process of the fifth lumbar vertebra was avulsed on one side (spinal side avulsion), whereas on the other side, complete iliac crest apophyseal avulsion took place (pelvic sided avulsion). To our knowledge, this combination of injuries was not reported before. The available literature describing pediatric U-shaped sacral fractures were also reviewed to help explain the pathoanatomic basis of this association. An 8-year-old boy sustained a U-shaped sacral fracture with avulsion of the left iliac crest apophysis. A search in the English literature was performed for all reports of U-shaped sacral fractures in pediatric patients (≤ 18 y of age), as well as the relevant literature, which describes the pathoanatomy, possible radiologic findings, and current classification systems and treatment options. Fixation using a 7.3 mm percutaneous iliosacral screw was performed. At the latest follow-up, the child had no pain, was fully bearing weight on lower extremities, and was neurologically intact. The literature review yielded 6 other pediatric patients with U-shaped sacral fractures in 4 articles. In young children with immature pelvis, the iliac apophysis may be avulsed instead of the transverse process of the fifth lumbar vertebra by forces transmitted through the iliolumbar ligament. The apophysis will therefore keep its attachment to the abdominal and trunk muscles, whereas the bony iliac wing and the pelvis would be dissociated from the axial skeleton. Otherwise, the pathoanatomy of these injuries is the same as described in adults. Level IV.