Percutaneous sacroiliac screw versus anterior plating for sacroiliac joint disruption: A retrospective cohort study

A case report of S1-S3 sacroiliac screw fixation for posterior pelvic ring injury with S1 sacral dysmorphism

INTRODUCTION

There are few reports on the treatment of pelvic posterior ring injury with Sacral 1 - Sacral 3(S1-S3)sacroiliac screw fixation. This article reports a case of pelvic posterior ring injury with S1 sacral dysmorphism treated with S1-S3 sacroiliac screw fixation and reviews the relevant research progress.

PRESENTATION OF THE CASE

A 72-year-old man riding e-bike was struck by a car at a high speed and diagnosed with pelvic fracture. The patient successfully underwent treatment of 3 sacroiliac screws (S1-S3) fixation. Postoperative X-rays and CT scans confirmed that all screws were in good position and located in the bone corridors. Follow up pelvic Majeed score of 96 at 11th month after surgery.

DISCUSSION

Preoperative CT scans of this patient showed that S1 segment was a dysmorphic sacrum with narrow corridor while S2 and S3 segments were wide corridors. S1-S3 sacroiliac screw fixation can be attempted.

CONCLUSION

For patients with posterior pelvic ring injury with S1 sacral dysmorphism, S1-S3 sacroiliac screw fixation may be a better choice.

Functional outcome and analysis of factors affecting health-related quality of life of surgically managed pelvic ring fractures: a cross-sectional study

INTRODUCTION

Pelvic ring fractures, particularly those involving the posterior pelvis, pose significant challenges due to their inherent instability. The posterior pelvic ring is critical in providing structural support and stability to the pelvis. This study evaluates the functional outcomes and health-related Quality of life (HRQOL) of patients who underwent internal fixation for unstable pelvic fractures. Various factors influencing the outcomes are also investigated.

MATERIAL AND METHODS

A single-center cross-sectional study was conducted on patients with unstable sacral fractures treated with posterior tension band plate or sacroiliac plating with or without symphyseal plating between 2016 and 2020. Patient demographics, injury mechanisms, associated injuries, surgical details, complications, and return-to-work data were collected. HRQOL was assessed using specific pelvic fracture instruments and general HRQOL questionnaires. Logistic regression analysis was performed to identify factors associated with lower SF-12 and SF-36 scores RESULTS: The study included 54 patients, predominantly males (55.6%), aged 18-70 years, with high-energy trauma mechanisms, such as road traffic accidents and occupational injuries. The majority of patients had lateral compression pelvic fractures. Overall, the functional outcomes were favorable, with excellent or good outcomes observed in 86.1% of cases. Patients with associated injuries, such as abdominal, chest, or head injuries, were likelier to have lower SF-12 physical component scores. Sexual satisfaction scores remained stable for most patients post-surgery.

DISCUSSION

This study highlights the favorable functional outcomes and HRQOL for patients undergoing fixation for unstable pelvic ring fractures. Younger, working-age males were the most commonly affected demographic. Associated injuries significantly affected physical HRQOL scores. Despite high-energy trauma, patients generally reported satisfactory sexual function post-surgery.

Critical distance of the sacroiliac joint for open reduction using screw fixation for traumatic sacroiliac joint diastasis: a retrospective study

BACKGROUND

Osteosynthesis for sacroiliac joint (SIJ) diastasis using an iliosacral screw (ISS) and a trans-iliac-trans-sacral screw (TITSS) can be performed using a closed or an open method. However, no clear indication for open reduction has been established.

METHODS

Data on patients with unilateral traumatic SIJ diastasis who underwent ISS and TITSS fixation were retrospectively collected and separated into groups according to the reduction method: closed reduction group (C group) and open reduction group (O group). Demographic data and perioperative image assessments were compared between the groups. The critical distance of the SIJ was identified to elucidate the indication for open reduction of the diastatic SIJ.

RESULTS

Fifty-six patients met the inclusion criteria over a 3-year period. There was no significant difference in the reduction quality of pelvic ring injuries between the groups, according to Matta's and Lefaivre's criteria. The improvement in the SIJ distance was significantly greater in the O group than in the C group in the axial plane on multiplanar computed tomography (p = 0.021). This model predicted that a difference of > 3.71 mm between the injured and healthy SIJ was a recommended indication for open reduction, with an area under the curve of 0.791 (95% confidence interval 0.627-0.955, p = 0.004).

CONCLUSIONS

Open reduction for SIJ diastasis might achieve better reduction quality than does closed reduction in the axial plane in selected cases. When the difference between the injured and healthy SIJ was wider than 3.71 mm, open reduction was recommended for satisfactory radiological outcomes.

Open reduction and internal fixation of crescent fracture-dislocation: anterior or posterior approach?

INTRODUCTION

To date, the approach that prevails in the open reduction and internal fixation of crescent fracture-dislocations (CFD) remains unknown. This study aimed to compare the outcomes of CFD treated via the anterior or posterior approach.

MATERIALS AND METHODS

Data from 64 cases of CFDs openly reduced through an anterior (group A, n = 31) or a posterior (group B, n = 33) approach were retrospectively analyzed. Functional results, reduction quality, residual displacements in the axial and coronal planes, pelvic asymmetry deformity, and correlations between Day's classification were compared. Complications and fracture union were also recorded. All patients were followed up for at least 12 months.

RESULTS

The functional scores were similar between the two groups, and all fractures achieved good or excellent reduction postoperatively. In the coronal plane, the excellent/good ratio in group B was higher than in group A. The mean residual displacement in the coronal plane was significantly higher in group A than in group B, with group A showing greater displacement in both planes for Day I fractures and in the coronal plane for Day II fractures. The residual displacement in both planes for Day III fractures was comparable between the groups. The pelvic asymmetry deformity was equal between the two groups and among the different Day's fracture types.

CONCLUSIONS

Open reduction and internal fixation of CFDs obtained satisfactory outcomes through an anterior or posterior approach. The posterior approach achieved a better sacroiliac joint reduction. The optimal indication for the posterior approach was a Day I fracture, followed by a Day II fracture. No correlation was found between the surgical approach and reduction quality in Day III fractures.

Effect of medical choice and health behavior on the health status for patients with subluxation of the sacroiliac joint

The sacroiliac joint is an important part of human life behavior and daily activities. With the increase in people's lives and work pressure and the change of travel mode, the incidence rate of sacroiliac joint subluxation is getting higher and higher. The purpose of this study is to explore the relationship between medical choice, health behavior, and health status of patients with sacroiliac joint subluxation and put forward feasible suggestions for promoting the treatment and rehabilitation of patients. The EuroQoL 5 Dimensions 5 Levels health index survey scale was selected to investigate the health status of patients with sacroiliac joint subluxation. T test and analysis of variance were used for univariate analysis of medical choice and health behavior of patients with sacroiliac subluxation, and ordinary least squares was used for multivariate analysis. The elderly patients with subluxation of sacroiliac joint are in poor health. The health status of patients who chose to seek medical treatment for disease diagnosis and prescription was significantly worse. Patients with subluxation of sacroiliac joint with regular defecation have better health status. Patients who travel by bike or bus have worse health. The health status of those who sit still for more than 1 hour a day is significantly better. The health status of patients with sacroiliac subluxation is closely related to their choice of medical treatment and health behavior. It is suggested that rehabilitation therapy such as acupuncture and manipulation should be selected for intervention. Good health behaviors such as abstinence and regular defecation should be shaped. More attention should be paid to the health status of women at risk.

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.

The design and application of an individualized 3D printing assisted guide plates in assisting sacroiliac screws insertion

OBJECTIVE

Currently, the sacroiliac screws insertion still faces several challenges in the fixation of pelvic and acetabular injuries. This study was aimed to design a personalized three-dimensional (3D) printing assisted guide plates to assist sacroiliac screws insertion, so as to provide a reference for further clinical applications.

METHODS

Eight pelvic specimens (5 males and 3 females) of normal adults were used to simulate actual operation. After thin-layer CT scanning, the 3D models of pelvis were established based on the images data. Furthermore, in Mimics 17.0 software, the screw entry points and screw channels of sacroiliac screws were further simulated and designed, and the appropriate range of the posterior superior iliac spine was selected to establish and print the virtual guide plates. Then, the simulated screws insertion was performed in vitro, the pelvic specimens after screws insertion were scanned again by CT, and the effect of screws insertion was further evaluated.

RESULTS

A total of 16 sacroiliac screw guide plates were designed and printed, and 48 screws were inserted on both sides. Therein, 45 screws were completely located in the sacral vertebra, which was determined as grade 0, with an accuracy rate of 93.2%. The other 3 screws penetrated the anterior cortex or sacral canal of sacral vertebra, including 2 screws in Grade 1 (4.1%) and 1 screw in Grade 2 (2.1%). Compared with the simulated screw channels, the anterior and posterior offset angles of the cross section were (0.912 ± 0.625) ° and (0.802 ± 0.681) ° respectively, with no significant difference (p > 0.05). The upper and lower offset angles of coronal plane were (1.158 ± 0.823) ° and (1.034 ± 0.908) ° respectively, and there was no significant difference (p > 0.05).

CONCLUSIONS

3 D printing guide plates assisted sacroiliac screws insertion can enhance the stability of pelvic posterior ring fixation and assist surgeons to reduce the difficulty of operation.

Finite Element Analysis and Transiliac-Transsacral Screw Fixation for Posterior Pelvic Ring with Sacrum Dysplasia

OBJECTIVE

Posterior pelvic ring sacroiliac screws are preferred by clinicians for their good biomechanical performance. However, there are few studies on mechanical analysis and intraoperative screw insertion of the dysplastic sacrum and sacroiliac screw. This study investigated the biomechanical performance of oblique sacroiliac screws (OSS) in S1 combined with transiliac-transsacral screws (TTSs) in S2 for pelvic fracture or sacroiliac dislocation with dysplastic sacrum and evaluated the safety of screw placement assisted by the navigation template.

METHODS

Six models were established, including one OSS fixation in the S2 segment, one transverse sacroiliac screw (TSS) fixation in the S2 segment, one TTS fixation in the S2 segment, one OSS fixation in the S1 and S2 segments, one OSS fixation in the S1 segment and one TSS fixation in the S2 segment, one OSS fixation in the S1 segment and one TTS fixation in the S2 segment. Then, finite element analysis (FEA) was performed. Twelve dysplastic sacrum patients with pelvis fracture or sacroiliac dislocation underwent OSS insertion in the S1 combined with TTS insertion in the S2 under the assistance of the patient-specific locked navigation template. Grading and Matta scores were evaluated after surgery.

RESULTS

In the one-screw fixation group, the vertical displacements of the sacrum surface of S2 OSS, S2 TSS and S2 TTS were 1.23, 1.42, and 1.22 mm, respectively, and the maximum stress of screw were 139.45 MPa, 144.81 MPa, 126.14 MPa, respectively. In the two-screw fixation group, the vertical displacements of the sacrum surface of the S1 OSS + S2 OSS, S1 OSS + S2 TSS and S1 OSS + S2 TTS were 0.91, 1.06, and 0.75 mm, respectively, and the maximum stress of screw were 149.26 MPa, 167.13 Pa, 136.76 MPa, respectively. Clinically, a total of 12 TTS and OSS were inserted under the assistance of navigation templates, with a surgical time of 55 ± 7.69 min, bleeding of 57.5 ± 18.15 ml and radiation times of 14.5 ± 4.95. One of the TTS and one of the OSS were grade 1, and the other screws were grade 0. The Matta scores of nine patients were excellent, and three patents were good.

CONCLUSION

OSS in the S1 combined with TTS in the S2 had the best mechanical stability in six models, and it is safe for screw insertion assisted by the patient-specific locked navigation template.

Effect of Iliosacral Screw Implantation Through a New Channel in Three-Dimensional Printing Pelvic Model

BACKGROUND

The exit point of classic iliosacral screw (ISS) is deep and viewing device cannot be used, implantation of ISS may lead to malposition and nerve injury.

OBJECTIVE

The aim of this study is to explore the effect of ISS implanted through a new channel (NSIS) with the aid of a viewing device.

METHODS

With the aid of a viewing device, NISSs were implanted into 50 3D printed pelvis models (1:1), in which the entry point was located at a vertical distance of 6 mm from the middle of the superior posterior quarter of the acetabular rim, and the exit point was the intersection of the vertical extension line of S1 superior articular process and the horizontal median line of S1 transverse process. Screws with diameter of 6.5 mm and 7.3 mm and length of 90 mm were implanted into the left and right sides of the pelvic models, respectively. The implantation was observed. CT scan was performed when penetrating of channel was suspected.

RESULTS

None of the implanted screws perforated the tunnel, but 6.0% (3 models) of the screws were too long and a little bit penetrated (< 4 mm) behind the back of the tunnel, which was found in small models.

CONCLUSION

The NISS implantation is simple, safe and accurate, but individualized screw implantation with appropriate diameter and length should be more accurate.

TRIAL REGISTRATION NUMBER

WXSJY-LY-2020-00216, date of registration: June 5, 2020, retrospectively registered.

A systematic review of the transiliac internal fixator (TIFI) for posterior pelvic injuries

OBJECTIVE

To summarize the literature on transiliac internal fixator (TIFI) indications and outcomes for treating posterior pelvic ring injuries.

METHODS

We searched databases for original publications in journals. Biomechanical and clinical studies using a TIFI for posterior pelvic ring injuries were considered for inclusion. The dates of publications that were included ranged from January 2000 until December 2020.

RESULTS

A total of 13 articles were reviewed, including eight clinical studies and five biomechanical tests. We found only case series and no multicenter or randomized study. The clinical studies contained data for a total of 186 cases, including indications, treatments, complications, and outcomes, with a minimum follow-up time of 12 months. All studies reported superior results according to operation time, blood loss, complication, dislocation, and union. One biomechanical test evaluated inferior results.

CONCLUSIONS

The TIFI is a user-friendly and safe device to treat posterior pelvic injuries. It can also be used for acute, high-impact injuries, and fragility fractures. Nevertheless, there is no evidence concerning which types of pelvic fractures are most beneficial. Therefore, further biomechanical and clinical studies are necessary to resolve this question.

Treating sacroiliac joint dislocation through percutaneous sacroiliac screw fixation with the aid of 2 fluoroscopes: a novel technique

Background

Percutaneous sacroiliac screw fixation is the standard treatment for sacroiliac joint (SIJ) dislocation. In most hospitals, the procedure is guided by a C-arm X-ray fluoroscopy system, which must be repeatedly repositioned during surgery. In this study, we investigated the feasibility of using 2 fluoroscopes simultaneously.

Methods

A total of 28 consecutive patients with SIJ dislocation were included in this study. The patients were randomly allocated to groups and underwent percutaneous sacroiliac screw fixation using either 1 or 2 fluoroscopes. Total radiation exposure frequency, radiation dose, and operation time were recorded and compared. Dislocation reduction quality was assessed using the Tornetta and Matta standard, and the Majeed functional score was used to evaluate clinical, imaging, and social function following pelvic injury. Complications were also recorded.

Results

The results showed that the radiation exposure frequency was significantly less with 2 fluoroscopes than with a single fluoroscope (21.5±8.6 and 42.6±18.3 times, respectively; P<0.001). However, the radiation dose (156.3±67.2 mGy for 1 fluoroscope and 157.8±38.2 mGy for 2 fluoroscopes; P>0.05) between the 2 groups was not significantly different. The total operation time was also significantly shorter with 2 fluoroscopic devices than with a single device (35.8±12.9 and 65.5±19.7 minutes, respectively; P<0.001). The dislocation reduction quality and Majeed functional score (92.3% and 86.7% for 1 fluoroscope, 93.3% and 84.6% for 2 fluoroscopes, respectively; P>0.05) did not differ significantly between the 2 groups at the final follow-up. Complications, such as pain, superficial infection, restricted squatting, limp, and screw failure, were rarely recorded in either group.

Conclusions

The simultaneous application of 2 fluoroscopes is highly appropriate during percutaneous sacroiliac screw fixation to treat SIJ dislocation, and can significantly reduce radiation exposure frequency and operation time.

Comparison of percutaneous cross screw fixation versus open reduction and internal fixation for pelvic Day type II crescent fracture-dislocation: case-control study

Objective

To investigate the clinical outcomes of percutaneous cross screws internal fixation for pelvic Day type II crescent fracture-dislocation.

Methods

We reviewed 66 consecutive patients undergoing surgical treatment for Day type II crescent fracture-dislocation from June 2005 to December 2017. Percutaneous cross screws internal fixation was performed in 40 patients, and open reduction and internal fixation was performed in 26 patients. The patient characteristics, surgical complications, radiographic and clinical outcomes and were compared.

Results

There was no statistically difference on the mean time from injury to surgery between the two groups. The time of operation, the amount of blood loss, the length of incision, and the hospital stay were significantly shorter in the percutaneous cross screws internal fixation group. No significant difference on Matta scores and Majeed scores between the two groups. The open reduction and internal fixation group resulted in a higher rate of intraoperative hemorrhage, nerve injury, discomfort, and pain.

Conclusion

Percutaneous cross screws internal fixation for Day II type pelvic crescent fracture-dislocation was safe and effective. Minimally invasive fixation had the advantages of short operation and hospitalization time, less intraoperative bleeding, and surgical trauma.

[Minimally invasive stabilization of sacral fractures]

BACKGROUND

Sacral fractures can be of traumatic origin and can also occur as insufficiency fractures. While the therapeutic target of mechanically stable insufficiency fractures is mainly pain relief, mechanically unstable insufficiency fractures and traumatic sacral fractures following high-energy trauma require biomechanical stabilization. Various surgical strategies are available for this, whereby minimally invasive techniques are now preferred whenever possible.

OBJECTIVE

This article presents the clinical challenges and options for minimally invasive treatment of sacral fractures.

MATERIAL AND METHODS

Selected important study data are discussed and our own treatment approach is presented.

RESULTS

The most important minimally invasive techniques for operative treatment of sacral fractures are presented: sacroiliac screw osteosynthesis, lumbopelvic stabilization and sacroplasty. The selection of the surgical technique should be made on an individual basis. While sacroiliac screw osteosynthesis is the international gold standard, diverse authors have also published minimally invasive techniques for lumbopelvic stabilization. The latter enables a higher mechanical stability. In contrast, sacroplasty should only be used as an alternative treatment in insufficiency fractures. Comparative studies of the described techniques are still missing.

CONCLUSION

All surgical options have their indications. Nevertheless, the biomechanical stability which can be achieved differs widely. Therefore, an exact analysis should be carried out of what is necessary with respect to reduction and retention and what should be achieved when treating sacral fractures.

Placas anteriores são mais efetivas do que parafusos iliossacrais na fixação da articulação sacroilíaca? Estudo Biomecânico

Introduction  Sacroiliac joint dislocations are caused by high energy trauma and commonly treated with the iliosacral screw fixation or the anterior plating of the sacroiliac joint (SIJ). However, there is a lack of consensus regarding which procedure is the most successful in treating sacroiliac joint dislocations. This aims to compare stiffness and maximum load of pelvises with sacroiliac joint dislocations treated with both procedures in a synthetic bone model.

Methods  Synthetic pelvises were mounted and divided into 2 treatment groups ( n  = 5): a model with two orthogonal plates placed anteriorly to the SIJ (PPS group) and another with two iliosacral screws fixating the SIJ (SPS group), both with pubic symphysis fixation. The maximum load supported by each sample was observed and the stiffness was calculated from the curve load vs displacement. The mean values of load to failure and stiffness for each group were compared with the Mann-Whitney U test ( p  < 0.05 was considered significant for all analysis).

Results  The mean load to failure supported by the PPS group was 940 ± 75 N and the SPS was 902 ± 56 N, with no statistical difference. The SPS group showed higher values of stiffness (68.6 ± 11.1 N/mm) with statistical significant difference in comparison to the PPS sample (50 ± 4.0 N/mm). The mode of failure was different in each group tested.

Conclusion  Despite lower stiffness, the anterior plating fixation of the sacroiliac joint can be very useful when the iliosacral screw fixation cannot be performed. Further studies are necessary to observe any differences between these two procedures on the clinical and surgical setting.

Anatomical conditions and patient-specific locked navigation templates for transverse sacroiliac screw placement: a retrospective study

Objective

To analyse the anatomical conditions of transverse sacroiliac screw (TSS) about the S1 and S2 segments in order to develop and validate a locked navigational template for TSS placement.

Methods

A total of 22 patients with sacral fractures were involved in this study from May 2018 to February 2019. Patients were divided into two groups according to the surgery procedure: locked template group and conventional group. The CT data of 90 normal sacra were analysed. The long axis, short axis and lengths of TSS, cancellous corridors were measured through 3D modelling. A patient-specific locked navigation template based on simulated screws was designed and 3D printed and then used to assist in TSS placement. The operative time and radiation times were recorded. The Matta criteria and grading score were evaluated. The entry point deviation of the actual screw placement relative to the simulated screw placement was measured, and whether the whole screw was in the cancellous corridor was ob`served.

Results

S1 screws with a diameter of 7.3 mm could be inserted into 69 pelvises, and S2 screws could be inserted in all pelvises. The S1 cancellous corridor had a long axis of 25.44 ± 3.32 mm in males and 22.91 ± 2.46 mm in females, a short axis of 14.21 ± 2.19 mm in males and 12.15 ± 3.22 mm in females, a corridor length of 153.07 ± 11.99 mm in males and 151.11 ± 8.73 mm in females, and a proportional position of the optimal entry point in the long axis of the cancellous corridor of 35.96 ± 10.31% in males and 33.28 ± 7.2% in females. There were significant differences in the corridor long axis and corridor short axis between sexes (p < 0.05), and there were no significant differences in corridor length and proportional position of the optimal entry point in the long axis of the cancellous corridor between sexes (p > 0.05). The S2 cancellous corridor had a long axis of 17.58 ± 2.36 mm in males and 16 ± 2.64 mm in females, a short axis of 14.21 ± 2.19 mm in males and 13.14 ± 2.2 mm in females, a corridor length of 129.95 ± 0.89 mm in males and 136.5 ± 7.96 mm in females, and a proportional position of the optimal entry point in the long axis of the cancellous corridor of 46.77 ± 9.02% in males and 42.25 ± 11.95% in females. There were significant differences in the long axis, short axis and corridor length (p < 0.05). There was no significant difference in the proportional position of the optimal entry point in the long axis of the cancellous corridor (p > 0.05). A total of 20 transversal sacroiliac screws were successfully implanted into 10 patients with the assistance of locked navigation templates, and a total of 24 transversal sacroiliac screws were successfully implanted into 12 patients under C-arm fluoroscopy. There was a significant difference in surgical time (88 ± 14.76 min vs 102.5 ± 17.12 min, p = 0.048), radiation times (11.5 ± 1.78 vs 54.83 ± 6.59, p < 0.05) and screw grading between two groups (nineteen screws in grade 0, one screw in grade 1 and 0 screws in grade 2 vs fourteen screws in grade 0, 8 screws in grade 1 and 2 screws in grade 2, p = 0.005). All screw entry point deviations were shorter than the short axis of the cancellous corridor, and all screws were located completely within the cancellous corridor.

Conclusion

Approximately 76% of males and females can accommodate screws with diameters of 7.3 mm in S1, and all persons can accommodate the same screw in S2. From the standard lateral perspective of the sacrum, the optimal entry point of the transverse screw is in the first 1/3 of the cancellous corridor for S1 and the centre of the cancellous corridor for S2. The patient-specific locked navigation template assisted in TSS placement with less operative time, less intraoperative fluoroscopy and higher safety of screw placement compared with traditional surgery.

Combined 3D Printed Template to Guide Iliosacral Screw Insertion for Sacral Fracture and Dislocation: A Retrospective Analysis

Objective

To evaluate the accuracy and safety of a combined 3D printed guide template (combined template) to assist iliosacral (IS) screw placement for sacral fracture and dislocation.

Methods

A total of 37 patients, 24 men and 13 women, age from 22 to 68 years old, diagnosed with a sacral fracture and dislocation were involved in this study for retrospective analysis from January 2016 to February 2018. There were 19 patients in the template group (42 screws) and 18 patients in the conventional group (31 screws). In the combined template group, IS screw placement was assisted by a combined 3D printed template; in the conventional group, the IS screws were placed freehand under fluoroscopy. The accuracy of the IS screw placement was evaluated by comparing the screw angle and the location of the screw entry point between the actual and the simulated screw in the combined template group. The safety of the IS screw placement was evaluated by comparing the quality of the reduction, the grading of the screws, the operation time, and radiation exposure times between groups.

Results

A total of 73 pedicle screws were placed in 37 patients: 42 screws (30 S1, 12 S2) in the combined template group and 31 screws (23 S1, 8 S2) in the conventional group. In the conventional group, 1 patient developed symptoms of L5 nerve stimulation. In the combined template group, the average operative time of each screw was 25.01 ± 2.90 min, with average radiation exposure times of 12.05 ± 4.00. In the conventional group, the average operative time of each screw was 46.24 ± 9.59 min, with an average radiation exposure time of 56.10 ± 6.75. There were significant differences in operation and radiation exposure times between groups. The rate of screw perforation was lower in the combined template group (2 of 42 screws, 0 at grade III and 2 at grade II) than in the conventional group (5 of 38 screws, 2 at grade III and 3 at grade III). In the combined template group, the mean distance between the entry points of the actual and simulated screws was 1.4 ± 0.9 mm, with a mean angle of deviation of 2.1° ± 1.6°. All patients were followed up once every 3 months and were followed for 3 to 12 months.

Conclusion

Using the combined template to assist with the insertion of IS screws delivered good accuracy, less fluoroscopy and shorter operation time, and avoided neurovascular injury as a result of screw malposition.

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.

Comparative study of sacroiliac screw placement guided by 3D-printed template technology and X-ray fluoroscopy

OBJECTIVE

To compare the clinical effect of 3D-printed template technology with X-ray fluoroscopy in assisting surgery for sacroiliac screws placement.

DESIGN

Institutional review board-approved retrospective analysis.

PATIENTS

The clinical data of 31 cases of sacroiliac complex injury between January 2015 and December 2016 were analyzed. There were 16 patients, males 11 and females 5, who underwent surgery assisted by 3D-printed template in template group, and that of contemporaneous 15 patients, males 11 and females 4, who underwent traditional surgery were gathered as fluoroscopy group. All those patients were followed up for more than 6 months.

MAIN OUTCOME MEASURES

The operation time and X-ray fluoroscopy times for each screw placement, and the Matta and Majeed score were analyzed and the difference between the two group was tested.

RESULTS

All cases were followed up for 6-20 months, average 11.4 ± 0.6 months. In template group, 19 screws were implanted. Each screw spent 25-38 min, average 27.2 ± 5.3 min, and need 2-5 times fluoroscopy, average 2.7 ± 0.5. The fracture reduction quality was evaluated by Matta score scale: excellent 10, well 4, fair 2, good rate 87.5%; and pelvic function were evaluated by Majeed score scale: excellent 11, well 3, fair 2, and good rate 87.5%. In fluoroscopy group, 17 screws were implanted. Each screw spent 45-70 min, average 60.3 ± 5.8 min, and needs 11-23 times fluoroscopy, average 15.4 ± 3.5. The fracture reduction quality was evaluated by Matta score scale: excellent 7, well 6, fair 2, and good rate 86.7%; and pelvic function was evaluated by Majeed score scale: excellent 6, well 6, fair 3, and good rate 80.0%. The difference in operation time, X-ray fluoroscopy times between template group and fluoroscopy group had statistical significance. But the Matta and Majeed score had no difference between two groups.

CONCLUSION

Compared with traditional surgery, 3D-printed template technology-assisted surgery for sacroiliac screws placement in sacroiliac complex injury patients possesses advantage such as shortened operation time and reduced X-ray exposure times. This technology improves the safety profile of this operation and should be further studied in future clinical applications.

Fixation of Crescent Pelvic Fracture in a Tertiary Care Hospital: A Steep Learning Curve

Background

Crescent fracture-dislocation of sacroiliac joint is a type of lateral compression pelvic injury associated with instability. These fractures comprise 12% of lateral compression fractures.

Objective

The objective of this study is to share the experience and to assess the functional outcome of fixation in crescent fracture-dislocation.

Methods

We analyzed a descriptive case series with clinical data of 15 patients at the Department of Orthopedics Surgery at the Dr. Ruth K.M. Pfau Civil Hospital at Dow University of Health Sciences in Karachi, Pakistan, from January 2016 to August 2018. The patients were treated by closed and open fracture reduction and fixed with percutaneous screws and reconstruction plates.

Results

A total of 15 patients were included in this study with age ranging from 20 to 60 years (11 men [73%]; four women [27%]). According to the mechanism of injury, five (33%) had motorcycle accidents; four (27%) had collision while sitting in a car; three (20%) were pedestrians hit by a vehicle; four (27%) were injured while sitting in van; two (13%) had bus-related injury, and one (6.5%) presented with a history of wall collapse.

Five (33%) patients had type I fractures, seven (47%) had type II fractures, and three (20%) had type III fractures Associated injuries were midshaft femur fracture in two patients, contralateral superior and inferior rami fracture in three patients, and open tibia fracture in one patient. All fractures were fixed with reconstruction plates and screws. Patients were kept as non-weight-bearing on the injured joint for three weeks, mobilized non-weight-bearing on the contralateral leg after three weeks, and partial weight-bearing was started at eight weeks; full weight-bearing was started after three months. Nine patients (60%) had excellent outcomes, three (20%) had a good outcome, and three (20%) had a poor outcome.

Conclusion

Crescent fracture-dislocations are unstable injuries. These fractures should have proper reduction and fixation that will reduce pain, malunion, and shortening.

Biomechanical study of three kinds of internal fixation for the treatment of sacroiliac joint disruption using biomechanical test and finite element analysis

BACKGROUND

To compare the stability of sacroiliac joint disruption fixed with three kinds of internal fixation using both biomechanical test and finite element analysis.

METHODS

Five embalmed specimens of an adult were used. The symphysis pubis rupture and left sacroiliac joint disruption were created. The symphysis pubis was stabilized with a five-hole plate. The sacroiliac joint disruption was fixed with three kinds of internal fixation in a randomized design. Displacements of the whole specimen and shifts in the gap were recorded. Three-dimensional finite element models of the pelvis, the pelvis with symphysis pubis rupture and left sacroiliac joint disruption, and three kinds of internal fixation techniques were created and analyzed.

RESULTS

Under the vertical load, the displacements and shifts in the gap of the pelvis fixed with minimally invasive adjustable plate (MIAP) combined with one iliosacral (IS) screw were the smallest, and the average displacements of the pelvis fixed with an anterior plate were the largest one. The differences among them were significant. In finite element analysis and MIAP combined with one IS screw fixation showed relatively best fixation stability and lowest risks of implant failure than two IS screws fixation and anterior plate fixation.

CONCLUSION

The stability of sacroiliac joint disruption fixed with MIAP combined with one IS screw is better than that fixed with two IS screws and anterior plate under vertical load.