What's New in Percutaneous Pelvis Fracture Surgery?

Experimental study of fractures of the posterior pelvic ring C1.1 using LC-II screws and internal fixation by plate

INTRODUCTION

To compare the biomechanical outcomes of C1.1 posterior pelvic ring fractures treated with different numbers of LC-II screws and plate internal fixation.

MATERIALS AND METHODS

Nine adult preserved pelvic specimens were used. After being measured by bone densitometry, the specimens were randomly divided into 3 groups of 3 pelvic specimens each. The C1.1 pelvic fractures were generated by iliac osteotomies and anterior pelvic ring osteotomies. The fractures were fixed and randomly divided into three groups: (1) one LC-II screw, (2) two LC-II screws, and (3) two reconstruction plates. The anterior pelvic rings were all fixed with pubic branch screws. A biomechanical testing machine loaded all specimens vertically, recording the displacement and ultimate load of the specimens to quantify the stiffness.

RESULTS

When loads up to 1000 N were applied, the displacement of the iliac bone was close between the one LC-II screw and the two LC-II screw group specimens; (P > 0.05); when loads such as 1000 N, 1200 N and 1400 N were applied, there was no significant difference in displacement between the plate fixation group and the two LC-II screw fixation group (P > 0.05), both of which were superior to the one LC-II screw fixation group (P < 0.05). There was no significant difference in compressive stiffness between the two LC-II screw fixation groups and the plate fixation group (P > 0.05), and both were superior to the one LC-II screw fixation group (P < 0.05) the ultimate load of both the two LC-II screws and the steel plate is greater than that of one LC-II screw (1.74 times the ultimate load of one LC-II screw for the two LC-II screws and 1.83 times the ultimate load of one LC-II screw for the steel plate).

CONCLUSION

For posterior pelvic ring fractures of type C1.1, placement of two LC-II screws provides comparable posterior pelvic ring stability compared to reconstructed plates. At loads below 1000 N, one LC-II screw fixation and two LC-II screws were comparable in restoring posterior pelvic ring stability.

Union and displacement characteristics following percutaneous screw fixation of superior pubic rami fractures

PURPOSE

To determine union and displacement metrics following percutaneous screw fixation (antegrade or retrograde) of superior pubic rami fractures.

METHODS

This is a retrospective cohort study from a single level 1 trauma center. Skeletally mature patients with at least one superior pubic ramus fracture present as part of a lateral compression-type pelvic ring injury were included.

RESULTS

Eighty-five (85) patients with 95 superior pubic rami fractures met the study's inclusion criteria. LC1, LC2, and LC3 injuries occurred in 76.5%, 15.3%, and 8.2% of patients, respectively. The majority of patients underwent concurrent posterior pelvic ring fixation (94.1%). Superior ramus screw placement occurred predominantly via retrograde technique (81.1%) with cannulated screws of size 6.5 mm or larger (93.7%). Of the 95 eligible fractures, 90 (94.7%) achieved union at a mean of 14.0 weeks (7-40 weeks). Of these united fractures, 69 (76.7%) healed with no measurable displacement, while the remaining 23.3% healed with residual mean displacement of 3.9 mm (range: 0.5-9.0 mm). Multivariable analysis demonstrated a positive association between age (p = 0.04) and initial displacement (p = 0.04) on the final degree of residual displacement at union. A Kaplan-Meier survival analysis identified increased age to be significantly related to increased time to union (X2 (2) = 21.034, p < 0.001).

CONCLUSIONS

Union rates following percutaneous screw fixation of superior pubic rami fractures associated with lateral compression-type pelvic ring injuries approach 95%. Though minimal in an absolute sense, increasing age and a greater degree of initial displacement may influence the final degree of residual displacement at union.

LEVEL OF EVIDENCE

IV.

Laparoscopic treatment of fourteen cases of pelvic ring disruption: a case series

PURPOSE

Open surgical approaches for the treatment of anterior pelvic arc lesions are associated with several complications. We present the first retrospective descriptive case series on the use of laparoscopy as an alternative.

METHODS

This descriptive, retrospective, single-centre study enrolled all patients who underwent laparoscopy for the treatment of pelvic ring disruption between May 2020 and March 2022. The primary outcome was the procedure failure rate based on conversion to open surgery. Secondary outcomes were the duration of the surgical procedure, x-ray exposure, length of hospitalisation, postoperative pain assessment, and functional scores at the last follow-up.

RESULTS

The study included two females and 12 males. The mean age of the study participants was 44.2 (23-67) years. In total, nine (64.3%) patients had pubic symphysis disjunction, four (28.6%) had bilateral fractures of the obturator frames, and one (7%) had both. None of the patients required conversion to open surgery. The median operating times for symphysis pubis disruption, obturator frame fracture, and patients with both injuries were 90.0 (60-120), 135 (105-180), and 240 min, respectively. The median overall operating time was 102.5 (60-240) min. The median Iowa Pelvic Score and Majeed Functional Score at the last follow-up were 87 (70-99) and 84 (70-100), respectively.

CONCLUSION

Laparoscopic internal fixation is a reliable treatment for pelvic ring disruption. The clinical and radiological outcomes of our patients suggest the usefulness of this technique as an alternative to open approaches.

Operative versus conservative treatment in pelvic ring fractures with sacral involvement

BACKGROUND

To evaluate the performance in activities of daily living (ADL), level of pain, mortality and rate of complications in patients with a pelvic ring fracture with sacral involvement who were treated conservatively compared to a surgically treated patient collective using percutaneous iliosacral screw fixation.

HYPOTHESIS

Conservative treatment does not result in inferior clinical outcome compared to operative treatment.

PATIENTS AND METHODS

A retrospective study of 112 conservatively (n=46) or operatively (n=66) treated patients with an isolated posterior or a combined posterior and anterior pelvic ring fracture was performed. The analysis included: age, sex, mechanism of injury, fracture type according to AO/OTA classification, energy of trauma sustained (no-, low-, high-energy trauma), type of treatment (operative or conservative), complications as well as duration of in-hospital stay. To assess clinical and activity outcome, the visual analog scale for pain (VAS), Barthel Scale, American Society of Anaesthesiologists (ASA) scores as well as mortality were assessed. The mean follow-up was 29.3±14.6 months. Furthermore, a geriatric subgroup (n=68, age≥60, low-energy trauma only) was analyzed.

RESULTS

The majority of the patients were female (79%) and suffered from low-energy trauma (n=64, 58%). There were no significant differences in the operative and the conservative groups and subgroups concerning VAS, Barthel scores and ASA scores. The survival analyses showed a significantly lower survival rate in the conservative group (41.8±3.6 months) compared to the operative group (55.9±2 months, p=0.002). Similar findings were encountered in the geriatric subgroup analysis.

CONCLUSION

This study demonstrates equivalent clinical outcome in conservatively and surgically treated patients using a percutaneous iliosacral screw fixation at a mid-term follow-up. However, operatively treated patients showed decreased mortality. This needs to be carefully considered in clinical decision-making but must be further explored using a prospective randomized study approach.

LEVEL OF EVIDENCE

III.

Unobstructed orthopaedic surgical robot assisted percutaneous iliosacral screw fixation of sacral brittle fractures

Pelvic fractures mostly result from high-energy injuries in life; the longitudinal fracture of the sacrum is the most common type of sacrum fracture. This study was designed to evaluate the accuracy, safety, and efficacy of percutaneous sacroiliac joint screw placement in the treatment of longitudinal sacrum fractures with the assistance of unobstructed orthopaedic surgery robots. According to different surgical methods, 32 patients were divided into robot group and free hand group, with 16 patients in each group. The operation time, intra-operative blood loss, intra-operative fluoroscopy times, screw placement angle deviation were collected. There were statistically significant differences in terms of angle deviation of screw placement (1.96 ± 0.75° vs. 2.87 ± 1.03°; p = 0.0145), deviation of the guide needle (1.92 ± 0.93 mm vs. 2.91 ± 1.22 mm; p = 0.0209), intra-operative fluoroscopy time (7.25 ± 1.72 s vs. 20.93 ± 5.64 s; p = 0.0000), insertion time of each sacroiliac joint screw (14.72 ± 2.66 min vs. 29.21 ± 5.18 min; p = 0.0000). There was no statistically significant difference in terms of blood loss (100.21 ± 7.37 mL vs. 102.52 ± 8.15 mL; p = 0.4136). These results suggest that orthopaedic surgery robot for the treatment of longitudinal sacrum fracture is safer and provides less irradiation than the traditional freehand methods.

A Toolbox of Bone Consolidation for the Interventional Radiologist

Bone consolidation is increasingly used in the treatment of both benign and malignant bone conditions. Percutaneous vertebroplasty, for example, has been shown to be useful in vertebral compression fractures in the VAPOUR trial which showed its superiority to placebo for pain reduction in the treatment of acute vertebral compressive fractures. Further tools have since been developed, such as kyphoplasty, spinal implants, and even developments in bone cements itself in attempt to improve outcome, such as chemotherapy-loaded cement or cement replacements such as radio-opaque silicon polymer. More importantly, bone fixation and its combination with cement have been increasingly performed to improve outcome. Interventional radiologists must first know the tools available, before they can best plan for their patients. This review article will focus on the tool box available for the modern interventional radiologist.

Use of 3D Fluoroscopy to Assist in the Reduction and Fixation of Pelvic and Acetabular Fractures: A Safety and Quality Case Series

SUMMARY

Multidimensional fluoroscopy has been increasingly used in orthopaedic trauma to improve the intraoperative assessment of articular reductions and implant placement. Owing to the complex osteology of the pelvis, cross-sectional imaging is imperative for accurate evaluation of pelvic ring and acetabular injuries both preoperatively and intraoperatively. The continued development of fluoroscopic technology over the past decade has resulted in improved ease of intraoperative multidimensional fluoroscopy use in pelvic and acetabular surgery. This has provided orthopaedic trauma surgeons with a valuable tool to better evaluate reduction and fixation at different stages during operative treatment of these injuries. Specifically, intraoperative 3D fluoroscopy during treatment of acetabulum and pelvis injuries assists with guiding intraoperative decisions, assessing reductions, ensuring implant safety, and confirming appropriate fixation. We outline the useful aspects of this technology during pelvic and acetabular surgery and report its utility with a consecutive case series at a single institution. The added benefits of this technology have improved the ability to effectively manage patients with pelvis and acetabulum injuries.

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.

Identifying safe corridors for anterior pelvic percutaneous instrumentation using computed tomography-based anatomical relationships

INTRODUCTION

Percutaneous anterior pelvic ring instrumentation is performed for retrograde screw fixation of ramus fractures, as well as for repair of pubic symphysis diastasis. The anatomic relationships of critical structures around the anterior pelvic ring, such as the spermatic cord and round ligament, have been described in only a few studies regarding the risk of iatrogenic injury during surgery. Our goal is to further describe these relationships, as well as provide radiographic information on safe corridors for percutaneous fixation.

METHODS

Eighty (80) axial computed tomography scans of the abdomen, obtained for non traumatic diagnostic purposes and screened for prior abdominal trauma or procedures, were evaluated by 3 fellowship trained radiologists. Mid-symphyseal cuts were used to obtain several measurements relative to the spermatic cords (SC) or round ligaments (RL): inter-cord or inter-ligament distance, skin to cortex of symphysis distance (vertical), skin to cortex of symphysis distance (oblique), safe corridor distance (between SC/RL and femoral triangle), center safe angle (relative to bilateral ischia), maximal safe angle, and minimal safe angle.

RESULTS

There were 41 male and 39 female scans included in the final analysis. The average inter-cord distance was 50.2 mm, skin to cortex vertical distance of 43.0 mm, skin to cortex oblique distance of 83.5 mm, safe corridor distance 26.3 mm, center safe angle 19.3˚, maximal safe angle 32.3˚, and minimal safe angle 13.6˚. These were further broken down by range and gender in Table 1. Agreement between radiologists was high for these different measurements with the exception of the skin to cortex oblique distance in female patients and the maximal safe angle in female patients, due to absence of round ligament in a majority of the scans. The round ligament was only present at the mid-symphyseal level for our three reviewers in 37/39, 36/39, and 24/39 of female patient scans.

CONCLUSIONS

We have identified defined safe corridors for instrumentation of the anterior pelvic ring that can assist the surgeon in percutaneous application of fixation for fracture care.

Percutaneous screw fixation of pubic symphysis disruption: A preliminary report

BACKGROUND

Percutaneous techniques are commonly used to treat pelvic ring disruptions but are not mainstream for fixation of pubic symphysis disruption worldwide. Potential advantages include less blood loss and lower risk of surgical site infection, especially in the morbidly obese or multiply injured patient. This study was performed to describe the clinical and radiographic outcomes of patients after percutaneous reduction and screw fixation of pubic symphysis disruption and to evaluate the preliminary safety and efficacy of this technique and its appropriateness for further study as an alternative method of fixation.

METHODS

A retrospective review was performed to identify all patients who underwent percutaneous fixation of pubic symphysis disruption by two surgeons at an academic Level I trauma center over a 3-year period. Patients underwent percutaneous reduction and fixation of the pubic symphysis using 1 or 2 fully or partially threaded 5.5, 6.5, or 7.3 mm cannulated screws in a transverse or oblique configuration. Associated posterior ring injuries were fixed with trans-sacral and/or iliosacral screws. The primary outcome of interest was loss of reduction, defined as symphysis distance greater than 15 mm measured on final AP pelvis radiograph. Secondary outcomes collected by chart review were operative time, blood loss, vascular or urologic injury, sexual dysfunction, infection, implant loosening or breakage, and revision surgery.

RESULTS

Twelve patients met criteria and primary and secondary outcomes were collected. Mean clinical and radiographic follow-up were 15 months each. One patient lost reduction. Mean operative time and blood loss were 124 min and 29 cc, respectively. No vascular or urologic injuries occurred. Two patients reported sexual dysfunction. No patients became infected or required revision surgery. Four patients underwent implant removal. Seventeen additional patients were excluded due to short follow-up and limited outcomes were collected. Two of these patients lost reduction. Three underwent implant removal.

CONCLUSION

These data support percutaneous reduction and screw fixation of pubic symphysis disruption as a potentially safe and effective method of treatment that warrants further investigation.