Anterior subcutaneous internal fixation combined with posterior percutaneous iliosacral screw for treatment of unstable pelvic fractures / 中国修复重建外科杂志

Objective: To assess the effectiveness of anterior subcutaneous internal fixation (INFIX) combined with posterior percutaneous iliosacral screw for the treatment of unstable pelvic fractures. Methods: Between August 2016 and November 2017, 19 cases of unstable pelvic fractures were treated with anterior subcutaneous INFIX combined with posterior percutaneous iliosacral screw. There were 14 males and 5 females, with an average age of 40.6 years (range, 17-69 years). Causes of injury included traffic accident injury in 11 cases, falling from height in 5 cases, bruise injury by heavy object in 3 cases. According to Tile classification, there were 2 cases of type B1, 6 cases of type B2, and 11 cases of type C. Anterior ring injuries included bilateral pubic ischial ramus fractures in 12 cases, unilateral pubic ischial ramus fractures in 5 cases, and symphysis pubis separation in 2 cases. Posterior ring injuries included sacroiliac ligament injuries in 2 cases, unilateral iliac bone fractures in 3 cases, unilateral sacral fractures in 11 cases, unilateral sacroiliac joint dislocation in 2 cases, and bilateral sacral fracture in 1 case. The intraoperative blood loss and operation time were recorded, and the fracture healing and postoperative complications were observed. Matta score was used to evaluate the reduction of fracture, and Majeed score was used to evaluate the postoperative function of patients. Results: The operation time was 47-123 minutes (mean, 61.4 minutes) and the intraoperative blood loss was 50-115 mL (mean, 61.1 mL). One case had superficial infection at the site of screw implantation, and 1 case had unilateral cutaneous nerve stimulation, which were cured after corresponding treatment. There was no damage of urinary system, reproductive system, and intestine. All cases were followed up 12-25 months (mean, 18.1 months). All the fractures healed after operation, the average healing time was 9.5 weeks (range, 8-13 weeks); no nonunion, delayed healing, internal fixation loosening, fracture, and other situations occurred. Of the 2 patients with lumbosacral plexus injury before operation, 1 recovered completely and 1 had residual mild claudication. At last follow-up, the reduction of fracture was evaluated by Matta scoring standard, the results were excellent in 13 cases and good in 6 cases, with an excellent and good rate of 100%; the function was evaluated by Majeed scoring standard, the results were excellent in 15 cases and good in 4 cases, with an excellent and good rate of 100%. Conclusion: Minimally invasive pelvic stabilization by using anterior subcutaneous INFIX and posterior percutaneous iliosacral screw for treatment of unstable pelvic fractures, can achieve good fracture reduction and definitive stabilization with minimum complications and obtain excellent functional outcomes.

Spino-Pelvic Fixation in Unstable Sacral Fracture: A Case Report

A 22-year-old female patient visited the emergency room (ER) after a pedestrian traffic accident in a drunken state. An examination at the ER revealed fractures at the right side of the sacral ala, sacral foramina, left anterior acetabulum, right inferior ramus, and right superior articular process of S1. She underwent spino-pelvic fixation and iliosacral (IS) screw fixation. One year later, bone union was completed and implant removal was performed and the treatment was completed without complications. The authors recommend spino-pelvic fixation and IS screw fixation for unstable sacral fractures as one of the excellent methods for obtaining posterior stability of the pelvis among the various treatments of unstable sacral fractures.

Three-dimensional computed tomography analysis and clinical application of sacroiliac screw placement / 中华外科杂志

Objective@#To evaluate the possibility of transverse sacroiliac screw placement in different segments of the sacrum.@*Methods@#Data of 80 pelvic CT scans (slice thickness ≤1.0 mm) archived in CT department of the Third Hospital of Hebei Medical University from September 2016 to October 2017 were retrospectively collected. Mimics software was used to rebuild the pelvis three-dimensional model. According to whether the sacral 1(S1) segment could place the transverse sacroiliac screws or not, all the sacrums were divided into normal group (n=55) and dysmorphic group (n=25). Simulation the S1, sacral 2(S2) transverse sacroiliac screw placement in 3-Matic software. Analysis whether there was any difference in maximum diameter and length of S2 transverse sacroiliac screw between the normal group and the dysmorphic group. The pelvic CT data of the dysmorphic group were measured, and the optimal tilt angle and length of the oblique S1 screw were obtained. The feasibility of transverse sacroiliac screw insertion in sacral 3(S3) segment was evaluated.t-test, rank sum test, and χ2 test was used to analyze data, respectively.@*Results@#In the dysmorphic group, the largest diameter of the S1 transverse screw was (4.9±1.6)mm, and the normal group was (13.6±3.6)mm (t=-15.07, P=0.00). In the dysmorphic group, the largest diameter of S2 transverse screw was (13.8±3.0)mm, and was (12.4±2.2)mm in the normal group(t=2.11, P=0.04). There was no significant difference in the length of S2 transverse sacroiliac screw between the two groups (t=0.47, P=0.64). In the dysmorphic group, the anterior vertebral height of S1 was (23.1±4.0)mm, which was significantly higher than that of the normal group ((14.1±4.2)mm)(t=9.01, P=0.00). The angle of S1S2 in the dysmorphic group was 10.9°(3.8°, 17.6°), which was significantly larger than that of the normal group (2.0°(1.0°, 2.0°) (Z=-4.03, P=0.00). In the dysmorphic group, the incline angle of the oblique S1 sacroiliac screw was (35.6±6.2)°, the anteversion angle was (37.2±4.4)°, and the mean screw length was (90.2±4.7)mm. In the dysmorphic group, the placement rate of S3 transverse sacroiliac screw was 48.0%, and that of the normal sacral group was 9.1%.@*Conclusions@#There is often dysmorphic in the sacrum in patients with large S1 anterior vertebral height and S1S2 angle. Sacral dysmorphic patients with posterior pelvic ring injury may be treated with S1 pedicle oblique sacroiliac screws. S3 transverse sacroiliac screws should be carefully placed, especially for the absence of sacral dysmorphic in patients.

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. laboring

Superior Gluteal Artery Injury during Percutaneous Iliosacral Screw Fixation: A Case Report / 대한고관절학회지

Percutaneous iliosacral screw fixation is commonly practiced to treat unstable posterior pelvic ring injuries. The number of reported cases of iatrogenic complications is increasing. We present a case of superior gluteal artery injury during bilateral percutaneous iliosacral screw fixation in a patient with sacral fracture of spino-pelvic dissociation. This complication was managed by arterial embolization. We discussed the cause, prevention and treatment of arterial injury along with a review of literature.

Treatment of Unstable Sacral Fractures Related to Spino-Pelvic Dissociations

PURPOSE: To evaluate the outcomes of surgical treatment modality in unstable sacral fractures combined with spinal and pelvic ring injury depending on the presence of spino-pelvic dissociations. MATERIALS AND METHODS: The subjects were 16 patients, with unstable sacral fractures combined with spinal and pelvic ring injuries, were operated from July 2004 to January 2011. The patients were divided into 2 groups depending on the presence of spino-pelvic dissociations: those with dissociations were group 1, and those without dissociations were group 2. Group 1 was treated with spino-pelvic fixations using iliac screw, while group 2 was treated with percutaneous iliosacral screw fixations. The availability of the radiological bony union with its application periods, and clinical results using visual analogue scale (VAS) and oswestry disability index (ODI) were evaluated, retrospectively. RESULTS: Out of 16 patients, 8 patients in group 1 were treated with spino-pelvic fixation using iliac screw, and 8 patients in group 2 were treated with percutaneous iliosacral screw fixation. The mean bony union period was 17.4 weeks in group 1, and 19.6 weeks in group 2. The Mean VAS and ODI scores on the last follow-up were 2.5 points and 15.6 points in group 1, 2 points and 18.8 points in group 2, respectively. Both groups had favorable clinical results at the last follow-up. CONCLUSION: For surgical treatments of unstable sacral fractures, spino-pelvic fixation using iliac screws is advised for cases with combined spino-pelvic dissociation, while percutaneous iliosacral screw fixation is advised for cases without combined dissociation.

Operative Treatment of Unstable Pelvic Ring Injury

PURPOSE: To analyze the clinical and radiological results of the different fixation methods according to the type and displacement of unstable pelvic ring injuries. MATERIALS AND METHODS: Twenty-three patients with unstable pelvic ring injuries from January 2005 to December 2009 were classified according to the AO/OTA classification system. When patients had been diagnosed with unstable pelvic ring injuries with partial instability, they were treated by anterior fixation with a plate and posterior percutaneous iliosacral screw fixation. When patients had been diagnosed with unstable pelvic ring injuries with complete instability, they were treated by open reduction and anterior to posterior fixation with a plate through the ilioinguinal approach. The radiological results were evaluated using Matta and Saucedo's method, and the clinical results were evaluated using Rommens and Hessmann's method. RESULTS: The outcomes from the radiological evaluation were that the displacement of the posterior pelvic ring were improved by about 6.65 mm in unstable pelvic ring injuries with partial instability. The displacement of the posterior pelvic ring were improved by about 7.8 mm in unstable pelvic ring injuries with complete instability. The clinical results were excellent in 13 cases and good in 6 cases on latest follow-up. CONCLUSION: Good results can be achieved by selecting the treatment method according to the type of unstable pelvic ring injurie and displacement.

Técnica quirúrgica para facilitar lacolocación de tornillos sacroilíacospercutáneos / Percutaneous iliosacral screw fixation

Percutaneous iliosacral screw fixation is a useful technique for fixation of posterior pelvis ring injuries but it has potential complications. We describe a surgical technique modification of the original technique described by Routt etal. Using the surface of the C-arm as a guide in the inlet and outlet views, exact positioning of the guide wire is easier and surgical time as radiation exposure are decreased. We hope that this modification, in addition to a better understanding of sacral anatomical variations and risk factors for misplacement of iliosacral screws would reduce complications related to this procedure.

La fijación percutánea con tornillos sacroilíacos es una técnica de utilidad demostrada para la fijación de las fracturas de la pelvis posterior, sin embargo, no está exenta de riesgos. Describimos una modificación de la técnica quirúrgica original descrita por Routt et al. Utilizando las superficies del fluoroscopio como referencia en las vistas inlet y outlet, se facilita la orientación de la aguja guía disminuyendo el tiempo operatorio y el tiempo de radiación necesaria para la colocación de este tipo de osteosíntesis. Esperamos que esta modificación, asociado a un mejor conocimiento de la anatomía del sacro y los factores asociados a mal posición de los tornillos sacroilíacos permita disminuir los riesgos asociados a este procedimiento.

Comparison with Number and Position of Percutaneous Iliosacral Screws as Treatment of Unstable Pelvic Fracture / 대한정형외과학회잡지

PURPOSE: A closed reduction of the posterior arch and percutaneous fixation with S1 and S2 iliosacral (IS) screw was performed on an unstable pelvis fracture with a disruption of the sacroiliac complex. The radiological and clinical results were analyzed according the number of screws and their position. MATERIALS AND METHODS: Of 31 cases with an unstable pelvis fracture involving the sacral complex, classified as Tile type C (AO/OTA), 16 and 15 cases were treated with one S1 screw fixation and two screws fixation into S1 and S2, respectively, using a percutaneous fixation technique. The patients were followed up for a minimum of 12 months and the radiological and clinical outcomes were analyzed statistically using the Majeed score and SF-36. RESULTS: Five cases of screw displacement occurred in the one screw fixation group. On the other hand, there was no screw displacement in the two screws fixation group after a mean follow-up of 40.2 months. In the case of a narrow safe zone (iliac cortical density, ICD), it is impossible to fix with two S1 screws. However, in these patients, good clinical results were achieved with S1 and S2 were achieved with S1 and S2 screw without complications. CONCLUSION: The technique of two screws fixation is an efficient and reliable method for reducing and fixing the unstable pelvic ring disruptions. Additional S2 screw fixation is recommended for patients with a narrow ICD.

Anterior Plating and Ilio-sacral Screwing for Unstable Pelvic Injury / 대한정형외과학회잡지

PURPOSE: To evaluate the effectiveness of iliosacral screw fixation with anterior plating in the management of an unstable pelvic ring injury. MATERIALS AND METHODS: Nineteen patients with an unstable pelvic ring injury were enrolled in this retrospective study. All patients were followed up for at least 1 year. The mean age of the patients was 43 years. According to the AO-OTA classification, there were five B2 injuries, 11 C1 injuries, and 3 C2 injuries. After anterior fixation by plating, ilio-sacral screw fixation was performed percutaneously under the C-arm guide. RESULTS: All cases united except for 1 case of nonunion at the pubic ramus. The radiology results showed 9, 7, 2 and 1 case of anatomic, nearly anatomic, moderate and poor reduction, respectively. Sixteen out of 19 patients had a good or excellent functional result. Two moderate and one poor result were from an unsatisfactory reduction in a type C injury with the residual neurological signs. Screw misplacement with neurological compromise occurred in one patient but there were no adverse sequelae after its removal. Regarding the complications, there were two cases of screw loosening, two cases of anterior metal failures, and 1 case of a deep infection. CONCLUSION: Percutaneous ilio-sacral screwing with anterior plating may be a useful method for treating unstable pelvic ring injuries, and the reduction quality and neurological signs are important.

Upper Sacral Morphology Related to Iliosacral Screw Fixation in Korean

PURPOSE: To evaluate upper sacral morphology and anatomy of safe zone related to iliosacral screw fixation in Korean. MATERIALS AND METHODS: 100 patients performed pelvis 3D CT scan were evaluated. We used 16 channel CT and analyzed reconstructed image (shaded-surface display, transparent image and reformat image). RESULT: The angle between superior aspect of S1 body and iliac cortical density is 27.3°, between anterior cortical line of S1,2 body and horizontal plane 24.6°, and between superior aspect of S1 body and horizontal plane is 39.7°. The axis of S1, S2 pedicle is 32.5° and 15.6° toward anteromedial. The area of S1 pedicle according to sagittal plane and sagittal-oblique axis is 310.7 mm2 and 384.8 mm2. Also, S2 pedicle area is increased 163.1 mm2 to 188.4 mm2. The average depth of ala indentation is 5.1 mm and the maximal value is 9.5 mm. Distinct upper sacral dysplasia is 22%, transitional form is 32%. CONCLUSION: We measured Korean upper sacrum with 3D-CT, found out dysplasia come up to 54%. Considering the frequency of dysplasia, the investigation of anatomy and technique is essential to sacroiliac screw insertion.

Percutaneous Iliosacral Screw Fixation for Pelvic Ring Injury / 대한정형외과학회잡지

PURPOSE: This study evaluated the surgical outcomes of percutaneous iliosacral screw fixation for an unstable pelvic ring injury. MATERIALS AND METHODS: Twenty patients (20 cases) who were classified as having a Tile classification type B or C pelvic ring injury. Anterior fixation was added in 17 cases to maintain the stability of the anterior pelvic structre. The radiological results were compared using Slatis and Karaharju's method and the clinical results before and after surgery were compared using Moon's method between before and after surgery. RESULTS: The outcomes of the radiological evaluation were excellent in 19 cases, good in 1. The outcomes of the clinical evaluation were excellent in 7 cases, good in 12, and poor in 1. There were similar clinical and radiological results regardless of the number of screws. One patient complained of mild discomfort in the screw entry site. Nonunion developed in one case. However, there was no lloss of fixation observed. No neurological or vascular complications were encountered during the procedure. CONCLUSION: Satisfactory outcomes could be obtained without serious complications after percutaneous iliosacral screws in the unstable pelvic ring fractures. One iliosacral screw fixation provided for the stability in a pelvic ring injury in association with anterior fixation.

Iliosacral Screw Fixation of the Posterior Pelvic Ring Using Local Anesthesia and Computerized Tomography / 대한정형외과학회잡지

PURPOSE: To analyze the functional and radiological results after a CT-guided iliosacral screw fixation of the posterior pelvic ring using local anesthesia. MATERIALS AND METHODS: Nine patients with unstable pelvic ring injuries treated by CT-guided percutaneous iliosacral screw fixation under local anesthesia were enrolled in this study. Anterior lesion including 4 cases of symphysis pubis separation and 3 cases of displaced pubic ramus fracture was stabilized using a plate and screw before the posterior iliosacral screw fixation. The Iowa pelvic score was used for a functional evaluation. A reduction of the sacroiliac joint gap was analyzed using plain radiographs and CT. RESULTS: The mean follow-up period was 25 months (12-48) and the mean Iowa pelvic score was 84. The mean number of screws introduced was 1.55 and the mean time for the procedure was 24 minutes per screw. There were no neurovascular complications related to misplaced screws encroaching the spinal canal or neural foramen. The iliosacral joint separation was 8.2 mm preoperatively and 3.6 mm postoperatively. There was no screw loosening or breakage. CONCLUSION: Iliosacral screw fixation using local anesthesia and computerized tomography is an easyand safe procedure for the patients with unstable pelvic ring injuries.

Percutaneous Iliosacral Screw Fixation in Unstable Pelvic Ring Injury / 대한정형외과학회잡지

PURPOSE: To evaluate and analyse the operative results of percutaneous iliosacral screw fixation in displaced posterior pelvic ring injuries. MATERIALS AND METHODS: Fourteen consecutive patients with displaced posterior pelvic ring injuries (August 1995-June 1998) treated by percutaneous iliosacral screw fixation were reviewed. We analysed the pattern of fracture, associated injury and method of operation including patient's position, complication and functional result. RESULTS: Seventeen iliosacral screws under fluoroscopic guidance were applied in fourteen patients. During the operations various positions of patients were possible, and all cases were treated with closed reduction and percutaneous iliosacral screw fixation except in one case (open reduction and percutaneous screw fixation). Fixation of associated anterior pelvic ring injury was undertakes in eight cases. Screw-related neurovascular injury and other complications such as breakage, loosening, misplacement and redisplacement, nonunion and screw site infection during follow-up period were not found. Satisfactory clinical and radiologic results were achieved during follow-up period except in one case (limping due to leg length discrepancy, malreduction) in this study. CONCLUSION: Precise understanding of iliosacral anatomy and its variants, proper patient positioning and appropriate intraoperative interpretation of fluoroscopic iliosacral image are mandatory. We believe percutaneous iliosacral screw fixation is a useful addition to treatment options for unstable posterior pelvic ring injury.

Early Results of Percutaneous Ilioscral Screw Fixation in Unstable Posterior Pelvic Ring Injury / 대한정형외과학회잡지

In the past two decades, open reduction and internal fixation has been the preferred treatment of posterior pelvic ring disruption with instability. Despite of rigid fixation, it can induce bleeding, wound infection, wound necrosis and prolong operation time in the patient with combined injuries. To compensate for these disadvantages, we have implemented closed reduction and percutaneous iliosacral fixation under fluoroscopy in reducible posterior pelvic ring disruption. In spite of anatomical risk during screw insertion, the percutaneous iliosacral screw technique after closed reduction of the posterior pelvic ring disruption minimally violates the soft tissue envelope and reduces both the operative blood loss and infection rate. We are reporting the early results of our 6 patients treated between Aug. 1995 to Aug. 1996. The operation time was shorter than open reduction and internal fixation. There was no significant bleeding, wound infection and nerve injury by screws.