Unstable Posterior Pelvic Ring Disruptions Research Articles

Multidimensional Pelvic Fluoroscopy: A New and Novel Technique for Assessing Safety and Accuracy of Percutaneous Iliosacral Screw Fixation

Multidimensional fluoroscopy is new imaging technology that generates intraoperative cross sectional imaging. Can this technology be used to assess accuracy and safety of percutaneously placed iliosacral screws intraoperatively? Retrospective study. Level 1 academic trauma center. Fifty-two consecutive patients during a 7-month period with unstable posterior pelvic ring disruptions. All patients were treated with percutaneous iliosacral and/or transsacral screw fixation by a single experienced surgeon. Traditional triplanar fluoroscopy was performed during guidepin insertion. Intraoperative multidimensional fluoroscopy was used for all patients after iliosacral screw fixation. Intraoperative multidimensional fluoroscopy and postoperative computed tomography (CT) scans for each patient were retrospectively reviewed by the treating surgeon and another trauma surgeon. Screw position in relation to the sacral neuroforamen was assessed using multidimensional fluoroscopy and compared to postoperative CT scan. Screws were classified as extraforaminal, juxtaforaminal, or intraforaminal. No screws were intraforaminally seen on intraoperative multidimensional fluoroscopy or postoperative CT scan. All iliosacral and transsacral screws were considered safe. Intraobserver and interobserver variability existed between reviewers when grading screws as extraforaminal versus juxtaforaminal. This was not clinically significant because both agreed that extraforaminal and juxtaforaminal screw positions are safe. Multidimensional fluoroscopy was used in 3 patients to assess guidepin placement before definitive screw fixation. Two patients underwent a change of fixation after reviewing multidimensional fluoroscopy. No postoperative neurological examination changes occurred. Multidimensional fluoroscopy is a novel imaging technology that can safely be used intraoperatively to accurately determine iliosacral and transsacral screw placement. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Réduction et fixation à foyer ouvert versus vissage ilio-sacré percutané des lésions postérieures instables de l’anneau pelvien

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), 5 fair and 2 poor. In the CRIF group, 30 patients obtained good or excellent results (25 excellent and 5 good), 4 fair and 1 poor, P=0.64). The average intraoperative blood loss in the ORIF group was 500cc with average blood transfusion of 2 units (1000cc) compared to blood loss 150cc in CRIF group, with average blood transfusion of 1 unit (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 1 radiculopathy (L5 root palsy) occurred in the CRIF group (P=0.317). In the ORIF group, 3 patients had superficial wound infection and 1 patient had deep infection while in the CRIF group, we noted only 1 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 that we need for the creation of decisional algorithm for ORIF versus CRIF. Level of evidenceLevel 4.

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.

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.

The Upper Sacral Nerve Root Tunnel: An Anatomic and Clinical Study

To radiographically demonstrate the upper sacral nerve root tunnel (USNRT) in both cadaveric specimens and a clinical cohort and to quantify its clinical relevance. Level 1 trauma center and anatomy laboratory. Eleven cadaveric pelves and 23 consecutive patients who underwent fluoroscopically assisted iliosacral screw insertions. Cadaveric pelves were fluoroscopically imaged using standard pelvic inlet, outlet, and true lateral sacral views. The course of the USNRT pathway was identified. Then, these tunnels were filled completely with a semisolid radio-opaque agent. The specimens were reimaged after the contrast injection. Clinically, 23 consecutive patients with unstable posterior pelvic ring disruptions were treated using fluoroscopically assisted percutaneous iliosacral screws based on these predictable radiographic landmarks. A total of 44 iliosacral screws were inserted. For the cadaveric portion, the images with contrast were used to identify the USNRTs. For the clinical study, tunnel visualization was determined on all views intraoperatively. Screw placement was documented by postoperative pelvic plain radiographs and computed tomography scan. In the cadaveric specimens, the contrast agent consistently demonstrated the USNRTs on all 3 pelvic radiographic views. In the clinical series, the USNRTs were well visualized on the pelvic outlet image in all 23 patients (100%). Using the inlet image, the USNRTs were visualized in only 5 of 23 patients (21%). On the true lateral sacral views, the USNRTs were seen in 21 of 23 patients (91%). Using these USNRT radiographic landmarks, no iliosacral screw was extraosseous. The USNRTs have a consistent radiographic appearance that is best seen on the pelvic outlet and true lateral sacral views, but their course is best understood when seen on all 3 views. Awareness and understanding of the USNRT, its course, and its radiographic landmarks allow the surgeon to avoid tunnel intrusion by an iliosacral screw.

Outcome of operatively treated unstable posterior pelvic ring disruptions.

Forty-six patients with 48 operatively fixed unstable posterior pelvic ring disruptions were observed for an average of 44 months. Two thirds of the patients returned to their original jobs and 16% changed jobs because of an associated injury. Sixty-three percent of the patients had no pain or pain only on strenuous activity and ambulated without limitation. However, 35% of the patients had significant neurologic injuries that compromised their final result. Properly performed open reduction and internal fixation of unstable posterior pelvic ring injuries may he expected to yield good functional results in the majority of patients. Associated injuries continue to be a major source of disability.

CT Guided Fixation of Unstable Posterior Pelvic Ring Disruptions

CT Guided Fixation of Unstable Posterior Pelvic Ring Disruptions

Computed tomography-guided fixation of unstable posterior pelvic ring disruptions.

Open reduction and internal fixation (ORIF), the current treatment of choice of posterior pelvic ring disruptions with instability, has significant disadvantages. These include relatively "blind" placement of the fixation screws, infection, exsanguinating hemorrhage, and high wound complication rates. We feel fluoroscopy does not offer significant clarity in defining the posterior structure. Advantages of computed tomography (CT)-guided sacral fixation are direct visualization of the course of the screws and absence of significant wound complications. This technique provides superior visualization of the nerve roots and sacral canal compared to fluoroscopic methods. Thirteen patients (10 unilateral and 3 bilateral) with unstable but reducible sacral fractures or sacroiliac joint (SIJ) disruptions underwent CT-guided posterior pelvic ring fixation using a cannulated screw system. Skeletal traction was required intraoperatively in one case by a traction-counteraction pulley system in the CT scanner. All other reductions were performed by preoperative skeletal traction or manually by the surgeons after anesthesia in the scanner or after push-pull films demonstrated instability. The guide pin, using depth and angulation measurements derived from the scout CT scans, was positioned across the fracture or SIJ. Following CT confirmation of the position of the pin, the screw tract was drilled and the cannulated screw was placed into position. Radiographic and clinical follow-up observation (7-24 months) showed healing with no significant complications in all 13 patients. Computed tomography-guided sacral fixation is a safe alternative to ORIF in selected patients with reducible unstable pelvic fractures.

The Antishock Pelvic Clamp

Unstable posterior pelvic ring disruptions are frequently accompanied by severe venous bleeding and hypotension. Mechanical stabilization has been shown to help reduce such blood loss. A new external fixator called an antishock clamp provides direct reduction and compression of such fracture-diastases about the sacroiliac joint. It is used acutely to rapidly stabilize the posterior pelvic ring in hypotensive patients. The simplicity of design allows the device to be applied in less than ten minutes in the emergency room. Most importantly, it does not interfere with the ability to carry out subsequent laparotomy or other required procedures. Although more clinical experience is needed, the clamp has provided hemodynamic stabilization accompanying fracture reduction. The device is not expected to be of benefit in the cases with significant bleeding of arterial origin.

Current oscillation in germanium containing radiation damage

Surgical 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.Seventy 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.According 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), 5 fair and 2 poor. In the CRIF group, 30 patients obtained good or excellent results (25 excellent and 5 good), 4 fair and 1 poor, P = 0.64). The average intraoperative blood loss in the ORIF group was 500 cc with average blood transfusion of 2 units (1000 cc) compared to blood loss 150 cc in CRIF group, with average blood transfusion of 1 unit (500 cc) (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 1 radiculopathy (L5 root palsy) occurred in the CRIF group (P = 0.317). In the ORIF group, 3 patients had superficial wound infection and 1 patient had deep infection while in the CRIF group, we noted only 1 case of deep infection, (P = 0.083).No 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 that we need for the creation of decisional algorithm for ORIF versus CRIF.Level 4.