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

Pain perception, opioid consumption and mobility following lateral compression pelvic ring injuries: a two-year prospective cohort study

PURPOSE

A prospective longitudinal cohort study was performed to gain insight into the course of recovery in terms of pain, opioid consumption, and mobility in patients with a lateral compression (LC) pelvic injury.

METHODS

Adult patients with an LC injury, without any cognitive disorders or limited mobility and who could communicate in Dutch were asked to participate. Pain in terms of NRS (numeric rating scale, range 0-10), opioid use and mobility were recorded at eight time points: at hospital admission, and three days, one week, six weeks, three months, six months, one year and two years after the injury. A sub-analysis was performed for nonoperatively and operatively treated patients.

RESULTS

Ninety-seven patients were included, of which 23 (24%) were treated operatively and 74 (76%) conservatively. Pain at rest and exertion, were highest upon admission (mean NRS of 3.4 (SD = 2.6) and 4.4 (SD = 2.8), respectively) but decreased within six weeks (mean NRS of 0.8 (SD = 1.6) and 2.0 (2.0), respectively). After two years, the mean NRS was 0.5 (SD = 1.6) and 0.9 (SD = 2.1), respectively. Upon admission, 85% were given opioids, however only 11% used opioids after three months and 4% after two years. At three months, 35% were walking using walking aids and 58% were walking independently. After two years, 98% were walking independently.

CONCLUSIONS

Pain rapidly decreased within the first six weeks. Most patients did not need opioids after three months. Furthermore, most patients were walking with walking aids after six weeks. After two years, few patients experienced pain, used opioids or had difficulties walking.

The Italian version of the Majeed pelvic score: translation, cross-cultural adaptation and validation

PURPOSE

The assessment of functional outcomes after pelvic ring fracture remains a controversial topic. The Majeed pelvic score (MPS) is the most commonly used pelvic-specific questionnaire in the literature. The aim of this study is translation, cross-cultural adaptation and validation of the Italian version of MPS.

METHODS

The study was articulated in two phases. Phase 1 consisted in translation and cross-cultural adaptation of MPS, from English into Italian. The psychometric properties were tested on 52 Italian patients (Phase 2). Construct validity was assessed by correlation with Short-Form 12 (SF-12). 33 patients repeated the questionnaire after 14 days to assess its reproducibility. All data were subsequently analyzed (descriptive statistics, multitrait analysis, reliability and construct validity assessment).

RESULTS

The questionnaire was clear and easily understood (no missing data). A ceiling effect was detected for all items of the scale. Multitrait analysis showed good results for each outcome measure, except for the item "walking distance" that showed poor item discriminant validity. A significant correlation between the MPS and the physical component summary (PCS) of the SF-12 was found, while there was a weak correlation with the mental component summary (MCS). The questionnaire showed high internal consistency (Cronbach's alpha: 0.91-0.99) and very good test-retest reliability (intraclass correlation coefficients: 0.92-0.96).

CONCLUSIONS

The Italian version of the MPS has demonstrated to be reliable and valid in the evaluation of patients with pelvic ring fractures. There is still however a need for an instrument capable of evaluating the mental component in these types of injuries.

Identification of subtle residual sacroiliac joint flexion and extension malreductions in AO/OTA 61-C1.2 (APC3) pelvic injuries after provisional anterior ring reduction

PURPOSE

Hemipelvis reduction in the setting of AO/OTA 61-C1.2 (APC3) pelvic injuries can be challenging. A common strategy is to provisionally reduce or fix the anterior ring prior to definitive fixation of the posterior ring. In this scenario, it is difficult to assess whether residual sacroiliac joint (SIJ) widening is due to hemipelvis flexion/extension or lateral displacement. This simulation sought to identify a radiographic marker for posterior ilium flexion or extension malreduction in the setting of a reduced anterior ring.

METHODS

Symphyseal and both anterior and posterior SIJ ligaments were cut in 8 cadaveric pelvis. The symphysis was reduced and wired. One centimeter of posterior flexion or extension at the SIJ was created to mimic the clinical scenario of hemipelvis flexion or extension malreduction, and a lateral compressive force was applied. SIJ widening and the direction of anterior or posterior ileal displacement relative to the contralateral joint were assessed via inlet views. SIJ widening and the direction of cranial or caudal ileal displacement were assessed using outlet views. Comparisons between flexion and extension models used Fisher's exact test.

RESULTS

On outlet views, all flexed hemipelvis demonstrated caudal ileal translation at the superior SIJ, in contrast to all extended hemipelvis demonstrated cranial translation (p < 0.0005); the scenarios were easily distinguishable. Conversely, inlet imaging was unable to identify the direction of malreduction. Flexion/extension scenarios resulted in similar amounts of SIJ widening.

CONCLUSION

Residual flexion and extension hemipelvis malreductions in APC3 injuries after provisional anterior fixation can be differentiated by the direction of ileal displacement at the superior SIJ on the outlet view.

Incidence of Suboptimal Fluoroscopic Outlet Imaging of the Sacrum and Pelvic Retroversion Necessary for Optimal Views

OBJECTIVES

To estimate the prevalence of suboptimal fluoroscopy of sacral outlet images due to anatomic and equipment dimensions. Pelvic retroversion is hypothesized to mitigate this issue.

METHODS

DESIGN

In silico simulations using retrospectively collected computed tomography (CT) data from human patients.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Adults with OTA/AO 61 pelvic ring disruptions treated with posterior pelvic fixation between July and December 2021.

OUTCOME MEASURES AND COMPARISONS

C-arm tilt angles required to obtain 3 optimal fluoroscopic sacral outlet images, defined as vectors from pubic symphysis to S2 and parallel to the first and second sacral neural foramina, were calculated from sagittal CT images. A suboptimal view was defined as collision of the C-arm radiation source or image intensifier with the patient/operating table at the required tilt angle simulated using the dimensions of 5 commercial C-arm models and trigonometric calculations. Incidence of suboptimal outlet views and pelvic retroversion necessary to obtain optimal views without collision, which may be obtained by placement of a sacral bump, was determined for each view for all patients and C-arm models.

RESULTS

CT data from 72 adults were used. Collision between patient and C-arm would occur at the optimal tilt angle for 17% of simulations and at least 1 view in 68% of patients. Greater body mass index was associated with greater odds of suboptimal imaging (standard outlet: odds ratio [OR] 0.84, confidence interval [CI] 0.79-0.89, P < 0.001; S1: OR 0.91, CI 0.87-0.97, P = 0.002; S2: OR 0.85, CI 0.80-0.91, P < 0.001). S1 anterior sacral slope was associated with suboptimal S1 outlet views (OR 1.12, Cl 1.07-1.17, P < 0.001). S2 anterior sacral slope was associated with suboptimal standard outlet (OR 1.07, Cl 1.02-1.13, P = 0.004) and S2 outlet (OR 1.16, Cl 1.09-1.23, P < 0.001) views. Retroversion of the pelvis 15-20 degrees made optimal outlet views possible without collision in 95%-99% of all simulations, respectively.

CONCLUSIONS

Suboptimal outlet imaging of the sacrum is associated with greater body mass index and sacral slope at S1 and S2. Retroversion of the pelvis by 15-20 degrees with a bump under the distal sacrum may offer a low-tech solution to ensure optimal fluoroscopic imaging for percutaneous fixation of the posterior pelvic ring.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Complications of conventional percutaneous sacroiliac screw fixation of traumatic pelvic ring injuries: a systematic review and meta-analysis

OBJECTIVES

The objective of this review was to present a thorough overview of the complications associated with conventional percutaneous sacroiliac screw fixation to identify areas for improvement in surgical technique and patient selection.

METHODS

PubMed/Medline, Web of Science, Embase, Ovid, Cochrane library, and Google Scholar were systematically searched for original human studies reporting on complications of conventional percutaneous sacroiliac fixation in traumatic pelvic ring injuries from January 1, 2000, to April 30, 2022. The main meta-analysis was based on the random effect model to pool all complications reported in the included studies. The results were reported as weighted proportions with 95% confidence intervals. This review was conducted in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

A total of 56 studies with 3644 screws (2871 procedures) met the inclusion criteria, with a mean age of 40.5 years. The most frequently reported complications were screw malposition with a weighted proportion of 6% (95% CI: 5-9%) and involved 189 out of 3644 screws, persistent pain following the procedure with a weighted proportion of 3% (95% CI: 2-4%) and affected 98 out of 2871 patients, and nerve injury, which had a weighted proportion of 2% (95% CI: 1-3%) and was observed in 41 out of 2871 procedures. The L5 and S1 nerve roots were more frequently affected. Revision surgery was required for 184 out of 2871 patients with a weighted proportion of 5% (95% CI: 3-7%). The primary reason for the revision was persistent pain after the initial procedure, which affected 74 out of 184 patients, with a weighted proportion of 2.0% (95% CI: 1.2-2.8%).

CONCLUSIONS

This study showed that screw malposition, the need for revision surgery, persistent pain, and nerve injuries were the most frequent complications following conventional percutaneous sacroiliac screw fixation. However, these results must be interpreted in context due to confounding factors, including the lack of high-quality studies and the absence of uniformity in defining some complications across studies.

Erectile Dysfunction after Conservative Treatment of Sacral Fractures in Males without Injury to the Urinary System

BACKGROUND

This study aimed to determine the incidence of erectile dysfunction (ED) reported by patients, and to define the prognostic relationship between ED and conservatively treated sacral fracture without urethral injury.

METHODS

Patients aged between 20 - 50 years who were sexually active and had no known sexual dysfunction prior to the trauma were included in the study. Seventy-seven patients (47 married, 30 single) treated conservatively for sacral fracture between April 2012 and February 2017 were retrospectively screened. Patients were compared in terms of age, marital status, body mass index (BMI), trauma mechanism, additional system injury, functional outcomes, and complications. Functional outcomes were assessed using the International Index of Erectile Function (IIEF-5) and the Majeed pelvic fracture functional assessment scale (MPS).

RESULTS

No statistically significant difference was observed between fracture types with respect to age, BMI, follow-up, marital status, trauma mechanism, and accompanying injury. The incidence of ED was 27.3% for those that received conservative treatment after sacrum fracture. The mean score of IIEF-5 was 18.6 ± 6.6 and MPS was 77.2 ± 13.2. There was no significant relationship between the injury type of the patients and the IIEF-5 and MPS scores (p = 0.593 and p = 0.907, respectively). The lowest IIEF-5 score was found in Denis type 2 fractures (p = 0.020).

CONCLUSION

The frequency of ED was higher in Denis type 2 sacrum fractures. Sexual function should be questioned in the follow-up, especially in those fracture types.

Effect of Percutaneous Posterior Pelvic Ring Reduction and Fixation on Patient-Reported Outcomes

OBJECTIVES

The purpose of this study was to assess patient outcomes using Patient-Reported Outcomes Measurements Information System (PROMIS) scores after closed reduction and percutaneous fixation (CRPF) of the posterior pelvic ring and determine whether quality of reduction affects the outcomes.

DESIGN

This is a retrospective cohort study.

SETTING

The study involved a Level I trauma center.

PATIENTS

The study included 46 adult patients with operatively treated pelvic ring injuries (63% OTA/AO 61-B) who underwent CRPF between 2014 and 2018 at a single institution.

INTERVENTION

The intervention involved closed reduction and percutaneous posterior pelvic ring fixation.

MAIN OUTCOME MEASUREMENTS

The main outcome measurements were postoperative patient PROMIS scores, including physical function, pain interference, anxiety, and depression, and radiographic measurements of postoperative displacement and pelvic deformity.

RESULTS

After CRPF, PROMIS scores of physical function, pain interference, and anxiety were significantly improved at the time of final follow-up when compared with the first postoperative visit. The amount of malreduction or pelvic deformity did not significantly affect outcome scores; however, results were limited by small sample size.

CONCLUSIONS

CRPF of posterior pelvic ring injuries results in good functional and radiographic outcomes. Degree of malreduction may not affect outcomes as much as previously believed.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Unstable Posterior Pelvic Ring Injury with S2-Alar-Iliac Screw and S1 Pedicle Screw Fixation

OBJECTIVE

The S2-alar-iliac (S2AI) screws have been described as an alternative method for lumbosacropelvic fixation in place of iliac screws. However, the clinical effect of the short-segment S2AI screw fixation technique in the treatment of unstable posterior pelvic ring injuries remains unclear. In this study, we report the preliminary clinical results of the internal fixation connecting a S2-alar-iliac screw and a S1 pedicle screw (i.e., S2AI-S1 fixation) in the treatment of unstable pelvic posterior ring injuries.

METHODS

Twenty-five patients with unstable posterior pelvic ring injury were treated with S2AI-S1 fixation from February 2019 to June 2020. The incision length, surgical time, blood loss, frequency of intraoperative fluoroscopy, quality of reduction, complications, and functional outcome were analyzed.

RESULTS

A total of 29 groups of S2AI-S1 fixation were used in 25 patients. The mean incision length was 8.3 (6.2 - 10.3) cm, mean operative time was 86.4 (60 - 142) minutes, mean frequency of intraoperative fluoroscopy was 7.9 (4 - 12) times, and mean blood loss was 148 (50 - 500) mL. The mean postoperative follow-up time was 17.8 (10 - 26) months. The satisfaction rate of pelvic reduction quality was 25/29, and the satisfactory rate of functional outcome was 23/25. There were no obvious signs of screw prominence, screw loosening, or implant failure.

CONCLUSIONS

The case series presented in this study show the successful use of S2AI-S1 fixation to treat unstable posterior pelvic ring injuries. The S2AI-S1 fixation, not including the lumbar spine in the fixation range, is a simple, safe, and effective fixation method.

Superior gluteal artery injury risk from third sacral segment transsacral screw insertion

OBJECTIVES

Iliosacral (IS) and transsacral (TS) screws are commonly used to stabilize pelvic ring injuries. The course of the superior gluteal artery (SGA) can be close to implant insertion paths. The third sacral segment (S3) has been described as a viable osseous fixation pathway (OFP) but the proximity of the SGA to the S3 screw path is unknown.

METHODS

Fifty uninjured patients with contrasted pelvic computed tomograms (CTA) were identified with an S3 path large enough for a 7.0 mm TS screw. Starting sites for S1 IS or TS, S2 and S3 TS screws were located on the volume rendered lateral CTA image and transferred onto the surface rendered 3D CTA with the SGA clearly visible. The distance from screw start sites to the SGA was measured. A distance less than 3.5 mm was considered likely for injury.

RESULTS

The average distances from screw start sites to the SGA were 23.0 ± 7.9 mm for S1 IS screws, 14.3 ± 6.4 mm for S2 TS screws and 25.9 ± 6.5 mm for S3 TS screws. No S1 IS screws, 5 S2 TS screws (10%), and no S3 TS screws were projected to cause injury to the SGA.

CONCLUSIONS

The osseous start site and soft tissue path for an S3 TS screw is remote from the SGA. The S1 IS and S3 TS pathways are further away from the SGA while the S2 TS pathway is closer and may theoretically pose a higher injury risk in patients with an available S3 OFP.

Inaccuracies in the Use of the Majeed Pelvic Outcome Score: A Systematic Literature Review

OBJECTIVES

To evaluate the accuracy with which the Majeed Pelvic Score has been reported in the English literature.

DATA SOURCES

Databases used to search for literature were PubMed, Embase, and Ovid, restricted to English language from inception to October 2, 2018.

STUDY SELECTION

Search words used were: Majeed, pelvis, and outcome.

DATA EXTRACTION

Articles were assessed for descriptions of scoring and proper reporting of Majeed Pelvic Outcome Score.

DATA SYNTHESIS

Descriptive statistics were used to report the outcome of our findings.

CONCLUSIONS

Ninty-two English articles were identified. Twenty-four (26%) articles were identified as including methodology related to the use and scoring of the Majeed Pelvic score. The remaining 68 presented mean Majeed scores with no methodological information. None (0/92) discussed how the range of possible scores for the most severe function was applied. Six (7%) reported adjusted scores for patients not working. Three (3%) included a discussion of the scores as adjusted for patients working before injury compared with those not working. Ten (11%) addressed the categorization of scores by excellent to poor describing what raw scores defined those categories. We observed poor accuracy and notable inconsistency in the use and reporting of the Majeed Pelvic Outcome Score in the literature. These data demonstrate that interpretation and comparison of research reporting this score should be done cautiously. Future studies should include specific information as to how the Majeed instrument calculated to allow for verification of the presented scores and subsequent conclusions.

The Longitudinal Short-, Medium-, and Long-Term Functional Recovery After Unstable Pelvic Ring Injuries

OBJECTIVES

Describe the trajectory of functional recovery for patients with surgically treated unstable pelvic ring injuries from baseline to 5 years.

DESIGN

Prospective cohort study.

SETTING

Level I Trauma Center.

PATIENTS/PARTICIPANTS

One hundred eight adult patients with surgically treated pelvic fractures (72% OTA/AO 61 B1-B3 and 28% OTA/AO 61 C1-C3) were enrolled into the institutions orthopaedic trauma database between 2004 and 2015. The cohort was 78% men with a mean age of 44.9 years and injury severity score of 16.9.

INTERVENTION

Surgical pelvic stabilization.

MAIN OUTCOME MEASUREMENTS

Function was measured at baseline and prospectively at 6 months, 1, and 5 years postoperatively using the Short Form-36 Physical Component Score (SF-36 PCS). The trajectory was mapped, and the proportion of patients achieving a minimal clinically important difference (MCID) between time points was determined.

RESULTS

The mean SF-36 PCS improved for the entire group between 6 and 12 months (P = 0.001) and between 1 and 5 years (P = 0.02), but did not return to baseline at 5 years (P < 0.0001). The proportion of patients achieving a MCID between 6 and 12 months and 1 and 5 years was 75% and 60%, respectively. The functional level was similar between type B and C groups at baseline (P = 0.5) and 6 months (P = 0.2); however, the type B cohort reported higher scores at 1 year (P = 0.01) and 5 years (P = 0.01). Neither group regained their baseline function (P < 0.0001).

CONCLUSIONS

Functional recovery for patients with surgically treated pelvic fractures is characterized by an initial decline in function, followed by sharp improvement between 6 and 12 months, and continued steady improvement between 1 and 5 years. Type B injuries show better early recovery than type C and reach a higher level of function at the final follow-up. Despite the proportion of patients achieving MCID, patients do not regain the preinjury level of function.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Long-Term Patient-Reported Functional Outcome of Polytraumatized Patients With Operatively Treated Pelvic Fractures

OBJECTIVES

To report the long-term functional outcome of a cohort of patients with operatively treated unstable pelvic fractures using validated patient-reported outcome measures.

DESIGN

Long-term observational study using prospective and retrospective data.

SETTING

Tertiary referral pelvic trauma center, Bristol, United Kingdom.

PATIENTS

Seventy-four polytraumatized patients with operatively treated unstable pelvic ring injuries (50 OTA/AO type B and 24 OTA/AO type C, mean Injury Severity Score 17) treated between 1994 and 2005.

INTERVENTION

Sixty-four (86%) patients were treated with internal fixation. The remaining 10 patients (14%) were treated with either combined percutaneous posterior fixation and anterior external fixation or external fixation in isolation.

MAIN OUTCOME

Patient-reported functional outcome.

MEASUREMENTS

Short Form-36, with UK norm-based comparator scores and EQ-5D-3L.

RESULTS

Patients were between 11 and 22 years after injury (mean 15 years). We found no significant association between fracture classification and outcome score, but compared with age- and sex-matched scores for a UK population, differences were statistically significant in 3 of the 8 domains of health: physical function (P = 0.04), bodily pain (P = 0.001), and vitality (P = 0.001). The level of disability remained constant for these patients compared with their patient-reported outcome measure scores reported 8 years previously.

CONCLUSION

Patients who sustain an unstable pelvic fracture continue to have significant functional limitations compared with an uninjured population. These changes were not found to be related to age, injury pattern, genitourinary injury, or neurological injury. Functional outcome scores did not change over the 2 long-term time points.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The relationship between injury mechanism and sexual dysfunction in surgically treated pelvic fractures

PURPOSE

The aim of the study was to identify the incidence of new sexual dysfunction reported by the patient in surgical treatment of pelvic ring injuries, and to describe the relationship between new sexual dysfunction and type of fracture.

METHODS

Ninety-five patients who were operated for pelvic fracture were included in the study. Patients were evaluated according to age, gender, marital status, body mass index, trauma mechanism, fracture classification, genitourinary injury, accompanying injury, injury severity score, surgical technique, fixation material, duration of operation, functional outcomes, blood loss, complications, and sexual dysfunction. Functional outcomes were assessed with Female Sexual Functioning Index (FSFI), International Index of Erectile Function-5 (IIEF5), Arizona Sexual Experience Scale (ASEX), and Modified Majeed's pelvic outcomes grading scale (MPS).

RESULTS

Genitourinary symptoms were erectile dysfunction (ED) in 13 men, ejaculatory dysfunction in 9 men, and dyspareunia in 23 women. Urethral stricture developed in 4 males and 1 female with the urethral injury. FSFI score, ASEX score, and MPS score showed the statistically significant difference between the fracture types (p = 0.021, p = 0.032 and p = 0.020, respectively). There were no significant difference between fracture types in terms of the IIEF5 score, and no significant relationship between fracture type and ED development (p = 0.141).

CONCLUSION

Anteroposterior compression (APC) is the most common cause of sexual dysfunction in both sexes, independent of surgery. In addition, the most common cause of ED in men is vertical shear (VS). Especially patients with APC and VS injuries should be multidisciplinary evaluated with gynecology, urology, and psychiatry departments.

Patient Weight-bearing after Pelvic Fracture Surgery-A Systematic Review of the Literature: What is the Modern Evidence Base?

Background

Little attention in the literature appears to have been paid to the issue of postoperative weight-bearing protocols for different injury patterns after pelvic fracture surgery. The primary aim of this study is to review the currently available literature to define the level of available evidence used to inform surgical decisions on weight-bearing after pelvic fracture surgery. Secondary aims are to assess the published methods of fracture classification, surgical management, and assessment or reporting of patient outcomes.

Methods

A systematic review of the English language literature from 1990 to 2016 was undertaken. Eligible papers were all papers reporting minimum 6-month outcomes following surgery for pelvic fractures in adults. Exclusion criteria included pathological fractures or those resulting from penetrating injury, solely osteoporotic fractures, or series with less than 6 months of follow-up data.

Results

There is very little published scientific data to inform the treating surgeon on postoperative weight-bearing protocols after pelvic fracture surgery, with no randomized trials and only 1 paper out of 122 stating this as a primary aim. More than half of the papers published did not state what postoperative protocol was employed. There is no standardization of outcome measures, with less than 20% of papers using the most common validated outcome scoring system; in contrast, there is good agreement on the use of either the Tile (75%) or Burgess and Young (20%) classification.

Limitations

Due to the lack of published studies looking at the topic of postoperative weight-bearing after pelvic fractures, no specific recommendations are possible. As large numbers of papers were included, they were not individually assessed for bias.

Conclusion

A review of postoperative weight-bearing regimes reveals a nonexistent scientific evidence base from which to make recommendations, although a consensus strategy has been identified. Future research needs to be directed at this topic, as has already been the case in numerous other fracture areas, since the advantages of early mobility are potentially significant. The reported methodology for assessing and reporting patient outcomes after pelvic fracture surgery reveals no consistent standards, and the majority of papers use no specific outcome scoring system.

How to cite this article

Rickman M, Link B-C, Solomon LB. Patient Weight-bearing after Pelvic Fracture Surgery-A Systematic Review of the Literature: What is the Modern Evidence Base? Strategies Trauma Limb Reconstr 2019;14(1):45-52.

Reduction and temporary stabilization of Tile C pelvic ring injuries using a posteriorly based external fixation system

Tile C pelvic ring injuries are challenging to manage even in the most experienced hands. The majority of such injuries can be managed using percutaneous reduction techniques, and the posterior ring can be stabilized using percutaneous transiliac-transsacral screw fixation. However, a subgroup of patients present with inadequate bony corridors, significant sacral zone 2 comminution or significant lateral/vertical displacement of the hemipelvis through a complete sacral fracture. Percutaneous strategies in such circumstances can be dangerous. Those patients may benefit from prone positioning and open reduction of the sacral fracture with fixation through tension band plating or lumbo-pelvic fixation. Soft tissue handling is critical, and direct reduction techniques around the sacrum can be difficult due to the complex anatomy and the fragile nature of the sacrum making clamp placement and tightening a challenge. In this paper, we propose a mini-invasive technique of indirect reduction and temporary stabilization, which is soft tissue friendly and permits maintenance of reduction during definitive fixation surgical.

Risks to the Superior Gluteal Neurovascular Bundle During Iliosacral and Transsacral Screw Fixation: A Computed Tomogram Arteriography Study

OBJECTIVES

Iliosacral (IS) and transsacral (TS) screws are popular techniques to repair complicated injuries to the pelvis. The anatomy of the superior gluteal neurovasculature (SG NV bundle) is well described as running along the posterior ilium, providing innervation and perfusion to important abductor muscles. The method of pelvis fixation least likely to injure the SG NV bundle is unknown.

METHODS

Twenty uninjured patients with a contrasted computed tomogram of the pelvis and lower extremities (CTA) were evaluated. Starting points for an S1 IS screw and S1 and S2 TS screws were estimated on the "ghost" lateral CTA image for those pelvi with safe corridors (>9 mm diameter). The distance from the projected screw to the SG artery was measured. A distance of <3.65 mm (half of a 7.3-mm screw's diameter) was considered likely for NV bundle injury.

RESULTS

Of 40 pelvi CTAs (single sides), 10 pelvi (25%) were determined to be inappropriate for an S1 TS screw. The average distances from the screw starting point and the artery were 25.3 mm (±9.2) for S1 IS, 12.4 mm (±9.0) for S1 TS, and 23.5 mm (±10.7) for S2 TS screws, respectively. Ten S1 TS screws (25%) and no S1 IS or S2 TS screws were projected to have caused injury to the SG NV bundle (P < 0.001).

CONCLUSIONS

Inserting S1 IS and S2 TS screws put the SG NV anatomy at significantly less risk than S1 TS screws. This information may aid in choosing the "best" fixation option for patients with pelvic ring trauma requiring surgery.

The Retrograde-Antegrade-Retrograde Technique for Successful Placement of a Retrograde Superior Ramus Screw

Stabilization of pelvic ring injuries and certain acetabular fractures using percutaneous techniques is becoming increasingly more common. Intramedullary superior ramus screw fixation is beneficial in both injury types. While implants can be placed in an antegrade or retrograde direction, parasymphyseal ramus fractures benefit from retrograde implant insertion. In some patients, the parabolic osseous anatomy or obstructing soft tissues of the anterior pelvis or thigh can prevent appropriate hand and instrumentation positioning for appropriate retrograde ramus screw insertion through the entire osseous fixation pathway. Instead of abandoning medullary fixation, we propose a technique utilizing cannulated screws to successfully place retrograde screws in this distinct clinical scenario.

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.