Total endoscopic anterior pelvic approach (TAPA) - A new approach to the internal fixation of the symphysis

Endoscopic-assisted anterior pelvic ring osteosynthesis for pelvic ring injuries: a technical report

INTRODUCTION

In the surgical treatment of pelvic ring injuries (PRIs), there is an increasing adoption of minimally invasive techniques to improve surgical outcomes. Since the introduction of endoscopic-assisted osteosynthesis for PRIs in 2019, various surgical challenges have been identified. To improve surgical and clinical outcomes, we modified the existing procedures and aimed to present the surgical outcomes of patients with pelvic fractures who underwent endoscopic-assisted surgery.

MATERIALS AND METHODS

We conducted a retrospective analysis of patients with PRIs treated with endoscopic technique over a 15-month period. All patients were diagnosed with diastatic symphysis, superior pubic ramus fracture, or both. The postoperative radiological and functional outcomes were assessed and reported. Details of the preoperative planning and surgical procedures were reviewed.

RESULTS

Thirteen patients with PRIs were enrolled: 10 patients for diastatic pubic symphysis (three of whom received superior ramus screw fixation) and three for isolated superior pubic ramus fractures. All surgeries were completed with endoscopic assistance, without the need for conversion to open surgery. The average surgical duration was 204.1 min, the endoscopy time was 103.7 min, and the volume of blood loss was 185.0 ml. Excellent reduction was achieved in all patients according to the Matta/Tornetta criteria and in nine patients according to the Lefaivre criteria. The mean Majeed scores were 71 and 82 and the mean Merle d'Aubigné scores 11 and 15 at 3 and 6 months postoperatively, respectively.

CONCLUSION

Endoscopic-assisted pelvic surgery is a safe and effective treatment alternative for PRIs, particularly when focusing on the anterior pelvic ring. The advantages of this approach, including small incisions and preservation of abdominal and pelvic floor muscle integrity, contribute to improved patient recovery. Future research should focus on comparative studies of this technique with other minimally invasive techniques and open surgery.

Total laparoscopic closed reduction and internal fixation for AO/OTA B2.1 pelvic fracture: A case report and literature review

Endoscopic techniques have been widely used in orthopedic surgery, such as arthroscopy and transforaminal endoscopy, but the application in fracture is rarely reported. We reported a case of a 69-year-old male with pelvic fracture (AO/OTA type B2.1) who underwent successful laparoscopy-assisted pubic ramus plate fixation without auxiliary incision. We designed and applied a separate custom-made lengthening surgical instrument for internal fixation installation suitable for laparoscopic surgery, and the entire reduction and internal fixation installation were performed under laparoscopy. The patient could sit up 1 day after surgery, and the reported pain visual analogue scale score decreased from 5 points before surgery to 1 point. At 2 weeks after surgery, the patient could walk with a single crutch. At 4 weeks after surgery, the Majeed score was 73 points, and at 10 weeks after surgery, the Majeed score increased to 81 points. Twelve weeks after surgery, the patient was able to walk independently without pain, defecation and urination function, and the Majeed score was 87. Laparoscopic surgery is a new strategy for treating pelvic ring fractures. The case proves that full laparoscopic-assisted closed reduction and internal fixation of pelvic fractures is feasible.

Pubic symphysis tethering technique under endoscopic approach for treatment of pelvic open-book injury: A cadaver study

Purpose

Pubic symphysis disruption is common in pelvic trauma. Open reduction and internal fixation with a plate is the gold standard technique. Despite increasing interest in an endoscopic approach, the challenges of specific endoscopic instrumentation, reduction and fixation remains. In this feasibility cadaveric study, we aimed to describe a novel endoscopic technique of fixation of pubic symphysis disruption with a spinal vertebral tethering system.

Methods

Endoscopic pubic symphysis fixation with the tethering method was performed on a female cadaver specimen as well as an artificial pelvic model.

Results

We describe a step-by-step technique where three abdominal portals were utilized in order to insert screws in the pubic body and superior pubic ramus under endoscopic visualization. The synthetic tether ligament was introduced through a lateral portal and fixed and tensioned to reduce and compress the pubic symphysis.

Conclusions

While open plate fixation is the current gold standard of pubic symphysis disruption there is increasing interest in the minimally invasive endoscopic approach. In this feasibility cadaveric study, we present a new minimally invasive endoscopic fixation method to treat pubic symphysis disruption with a synthetic ligament.

Minimally Invasive Pelvic and Acetabular Surgery: Case Report of a Robot-Assisted Osteosynthesis of an Open-Book Injury of the Pelvic Ring

BACKGROUND

In recent years, endoscopic treatment of pelvic ring injuries has emerged. In addition to the complex 3D anatomy of the bony pelvis, a particular challenge is its embedding in the surrounding soft tissue structures. It is known from other surgical specialties that the preparation can be facilitated by using surgical robot systems.

MATERIALS AND METHODS

In a patient with an open-book injury of the pelvic ring, a symphysis plate was performed using the DaVinci system.

RESULTS

We describe the robotic-assisted osteosynthesis on the anterior pelvic ring with available instruments.

CONCLUSION

The further development of minimally invasive surgical techniques is always linked to the development of new instruments. For trauma surgery, this means in particular the reduction of dislocated fractures. If appropriate techniques and instruments are developed here, minimally invasive treatment of injuries to the pelvic ring or acetabulum may represent an alternative to open procedures in the future.

Robotic-assisted plate fixation of the anterior acetabulum - clinical description of a new technique

INTRODUCTION

We present a detailed procedure for the robotic-assisted plate osteosynthesis of an anterior acetabular fracture. The purpose of this work was to describe a robotic-assisted minimally invasive technique as a possible method for reducing complications, pain, and hospitalization. Another goal was to present technical recommendations and to assess potential pitfalls and problems of the new surgical approach.

METHODS

Surgery was performed in an interdisciplinary setting by an experienced orthopedic surgeon and a urologist. The DaVinci System with standard instruments was used. Reduction was achieved through indirect traction of a pin that was introduced into the femoral neck and direct manipulation via the plate. The plate position and fixation were achieved through 7 additional minimally invasive incisions.

RESULTS

The technique has multiple advantages, such as no detachment of the rectus abdominal muscle, a small skin incision, and minimal blood loss. Furthermore, this approach might lower the incidence of hernia formation, infection, and postoperative pain.

DISCUSSION

We see the presented technique as a demanding yet progressive and innovative surgical method for treating acetabular fractures with indications for anterior plate fixation.

TRIAL REGISTRATION

The study was approved by the local institutional review board (Nr. 248/18).

Percutaneous Fixation for Traumatic Symphysis Pubis Disruption-Are the Results Superior Compared to Open Techniques? A Systematic Review and Meta-Analysis of Clinical and Biomechanical Outcomes

INTRODUCTION

Open reduction and reconstruction plate and screws fixation (RPSF) is considered the gold standard for the treatment of traumatic symphysis pubis diastasis (SPD). Percutaneous cannulated screw fixation (PCSF) has recently gained popularity as it may reduce operative time and morbidity. The current systematic review aims to compare the clinical and radiological outcomes of PCSF and RPSF in traumatic SPD and analyze the biomechanical effectiveness of PCSF.

MATERIAL AND METHODS

The Medline, Scopus, and Cochrane databases were searched until February 2023. The primary outcomes were the incidence of implant failure and revision surgery and the amount of displacement of symphysis pubis. Secondary outcomes were the intraoperative blood loss, the scar length, the operative time, the wound infection, and the patients' functional improvement.

RESULTS

Six clinical trial studies with a total of 184 patients and nine biomechanical studies were included. There was no significant difference between the two groups regarding the incidence of implant failure, the prevalence of revision surgery, and the amount of postoperative loss of reduction (p > 0.05 for all outcomes). The intraoperative blood loss (14.9 ± 4.2 mL for PCSF versus 162.7 ± 47.6 mL for PCSF, p < 0.001) and the incision length (1.7 ± 0.9 mL for PCSF versus 8 ± 1.4 mL for PCSF, p < 0.001) were significantly lower after PCSF. The mean operative time was 37 ± 19.1 min for PCSF and 68.9 ± 13.6 min for RPSF (p < 0.001). The infection rate was less frequent in the PCSF group (3% for PCSF versus 14.3% for RPSF, p = 0.01). One clinical trial reported better functional recovery after PCSF. In all biomechanical studies, the threshold for implant failure was beyond the applied forces corresponding to daily activities.

CONCLUSIONS

PCSF for traumatic SPD is associated with less operative time, less blood loss, and a lower infection rate when compared to conventional plate techniques without increasing the incidence of postoperative fixation failure and revision surgery. Moreover, PCSF has been proven to be biomechanically sufficient for stabilization. Therefore, it should be considered an efficient and viable alternative for the reconstruction of SPD when closed reduction can be adequately achieved.

Full endoscopic anterior intrapelvic plate osteosynthesis: a cadaveric feasibility study

In this investigation, it was assumed that it must be possible to visualize the intrapelvic aspect as accustomed by pelvic surgeons using the anterior intrapelvic (modified Stoppa) approach. Moreover, it was hypothesized, that plate mountings will not only be possible for the symphysis but also at the supra- and infrapectineal aspect as well as to the posterior column. Ten anonymized cadaveric specimens were included in this study. A standard laparoscopic totally extraperitoneal (TEP) approach was used. A total of 10 landmarks were defined that are usually within reach in the open anterior intrapelvic (AIP) approach. Moreover, five different plate mountings were tested. The locations were chosen in accordance with the indication spectrum suitable for open surgery through the traditional AIP approach. It was possible to gain intrapelvic visibility in seven of ten cases. In all of those seven cases, it was technically possible to place plates to the symphysis, superior pubic ramus, as well as longer anterior column plates up to the aspect posterior of the acetabulum. In the last four of the seven cases, it was possible to mount plates to the infrapectineal aspect as well as the posterior column, too. The team, previously trained in arthroscopic surgical techniques as well as pelvic trauma surgery, observed a steep learning curve. This investigation demonstrated, that endoscopic anterior intrapelvic plate osteosynthesis was feasible in the majority of the cases in a series of ten cadaveric models. New instruments will be needed such as extra-long rasp elevators, ball-spikes as well as devices to hold and position plates and extra-long self-holding screwdrivers. With these, endoscopic pelvic surgery will likely be a realistic option for selected pelvic trauma cases in the future.

Robotic-assisted plate osteosynthesis of the anterior pelvic ring and acetabulum: an anatomical feasibility study

Pelvic ring injuries or acetabular fractures present a challenge to trauma surgeons. Recently, endoscopic dissection techniques for visualization of the anterior pelvic ring and acetabulum have been presented. Robotic-assisted surgical systems offer advantages in terms of improved visualization and easier instrument handling. The aim of this pilot anatomic study was to verify the feasibility of robotic-assisted plate osteosynthesis on the anterior pelvic ring and acetabulum. The experiment was performed on a human whole body specimen. The DaVinci system with standard instruments as used in RARP was used. After docking the system, the anterior pelvic ring was first prepared as previously described for the endoscopic techniques. This was followed by dissection of both acetabula analogous to pelvic lymphadenectomy as performed during RARP. After the dissection was performed along the pelvic brim up to the iliosacral joint, the complete anterior column of the acetabulum including quadrilateral surface and incisura ischiadica major could be visualized. Finally, robotic-assisted endoscopic plate osteosynthesis was performed on the symphysis and anterior acetabular column as previously described in the endoscopic techniques. Robotic-assisted plate osteosynthesis of the anterior pelvic ring and acetabulum is feasible with the available robotic-assisted systems. Due to the excellent freedom of movement of the robotic arms, combined with the magnifying 3D visualization of the system, highly accurate preparation of the situs in preparation for plate osteosynthesis can be performed. The question of reduction of dislocated fractures remains open and is the subject of further investigation. Compared with conventional laparoscopy, robotic-assisted preparation nevertheless appears to offer an advantage in view of the complexity of the operation.

A biomechanical in-vitro study on an alternative fixation technique of the pubic symphysis for open book injuries of the pelvis

PURPOSE

Implant failure rates remain high after plate fixation in pelvic ring injuries. The aim of this study was to compare an alternative fixation technique with suture-button devices and anterior plate fixation in partially stable open-book injuries.

MATERIAL AND METHODS

We acquired 16 human fresh frozen anatomic pelvic specimens. The sacrospinous, sacrotuberous, and anterior sacroiliac ligaments were bilaterally released, and the pubic symphysis transected to simulate a partially stable open-book (AO/OTA 61-B3.1) injury. The specimens were randomly assigned to the two fixation groups. In the first group two suture-button devices were placed in a criss-crossed position through the symphysis. In second group a six-hole plate with standard 3.5 unlocked bicortical screws was used for fixation. Biomechanical testing was performed on a servo-hydraulic apparatus simulating bilateral stance, as described by Hearn and Varga. Cyclic compression loading with a progressively increasing peak load (0.5 N/cycle) was applied until failure. The failure mode, the load and the number of cycles at failure and the proximal and distal distance of the symphysis during testing were compared.

RESULTS

There was no implant failure in either of the two groups. Failures occurred in nine pelvises (56.2%) at the fixation between the sacrum and the mounting jig and in seven pelvises (43.8%) in the sacroiliac joint. Neither the ultimate load nor the number of cycles at failure differed between the surgical techniques (p = 0.772; p = 0.788, respectively). In the suture button group the mean ultimate load was 874.5 N and the number of cycles at failure was 1907.9. In the plate group values were 826.1 N and 1805.6 cycles, respectively. No significant differences at proximal and distal diastasis of the symphysis were monitored during the whole loading process.

CONCLUSION

The fixation with suture button implants showed comparable results to anterior plate fixation in open-book injuries of the pelvis.