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

Screw fixation of superior pubic ramus fractures using a modified technique with a pre-bent guidewire in curved transpubic corridors - A non-inferiority pilot study

INTRODUCTION

Transpubic screw fixation is a valuable option for stabilization of superior pubic ramus fractures. However, insertion of a transpubic screw can be challenging or sometimes even impossible due to a narrow or curved transpubic screw corridor, which is present in 38 % of cases. To overcome this problem, a modified technique for insertion of a transpubic screw by advancing a pre-bent guidewire in an ESIN-like fashion is described.

MATERIALS AND METHODS

A retrospective, non-inferiority pilot study with patients, who received a transpubic screw, was performed to investigate potential procedure-associated complications as well as short-term radiological and clinical outcomes of the modified technique in comparison to the classical technique for insertion.

RESULTS

From 01/2021 to 04/2024, 24 transpubic screws were inserted at two major trauma centers, of which nine screws were inserted using the modified technique. Ten patients with a total of eleven transpubic screws (modified technique: 5; classical technique: 6) were available for this pilot study. One patient from the modified technique subgroup experienced a screw migration without affecting fracture healing and without necessitating hardware removal. The complication rate of the modified technique was not significantly inferior to the classical technique (p = 0.50). Residual displacement of the pubic ramus fracture was not significantly inferior using the modified technique compared to the classical technique (modified: 5.0 ± 2.2 mm; classical 4.4 ± 3.3 mm; p = 0.38). The clinical outcome was not significantly inferior using the modified technique compared to the classical technique regarding VAS pain (modified: 2.4 ± 4.3; classical 2.6 ± 2.5; p = 0.47), VAS satisfaction (modified: 8.8 ± 1.8; classical 9.0 ± 1.0; p = 0.42) and Majeed score (modified: 82.0 ± 12.6; classical 90.0 ± 12.5; p = 0.17).

CONCLUSION

The modified technique for insertion of a transpubic screw using a pre-bent guidewire is feasible in narrow and particularly curved transpubic corridors. It was not inferior compared to the classical technique regarding complications as well as short-term radiological and clinical outcomes.

Comparative Efficacy of Retrograde Pubic Ramus Intramedullary Nails and Percutaneous Cannulated Screws in Treating Anterior Pelvic Ring Fractures: A Retrospective Cohort Study

OBJECTIVE

To compare the clinical outcomes of retrograde pubic ramus intramedullary nail (RPRIN) and percutaneous cannulated screw (PCS) in the treatment of anterior pelvic ring fractures (APRFs).

METHODS

This retrospective cohort study included 45 patients with APRFs treated between February 2019 and October 2022 in our trauma center. Patients were divided into two groups based on the surgical method: 20 received RPRIN fixation, and 25 received PCS fixation. Key variables including operation time, fluoroscopic time, blood loss, and postoperative complications were analyzed. Fracture reduction quality was assessed using the Matta score system, and pelvic functional recovery was evaluated using the Majeed score system at the final follow-up. Quantitative variables were compared using the independent sample t test, while categorical variables were analyzed using Chi-square and Fisher's exact tests.

RESULTS

The RPRIN group had significantly shorter operation time (36.3 ± 5.6 min vs. 49.5 ± 6.9 min, P < 0.01), fluoroscopic time (32.0 ± 2.8 s vs. 48.4 ± 3.6 s, P < 0.01), and less blood loss (20.4 ± 7.6 mL vs. 34.0 ± 5.7 mL, P < 0.01) than the PCS group. Fracture reduction quality (Matta outcome) and pelvic functional recovery (Majeed outcome) were comparable between the two groups (P > 0.05). No significant complications were reported in either group.

CONCLUSIONS

Both RPRIN and PCS are effective for treating APRFs. However, RPRIN offers distinct advantages by reducing operation time, fluoroscopic time, and blood loss, making it a more efficient and less invasive option. Further multicenter studies and biomechanical analyses are warranted to confirm these findings.

Reverse guide wire technique for percutaneous anterior column screw of the acetabulum: A second look at the technique and a step-by-step guide. A surgical technique

INTRODUCTION

Pelvis and acetabulum fractures are serious injuries, especially in polytrauma patients. Traditionally, open reduction with internal fixation is the way to go; fortunately, percutaneous fixation has evolved with the advancement of understanding pelvis anatomy and fixation pathways. Nonetheless, the debate regarding indications, safety, radiation exposure, and other complications emerged. Our paper presented a reverse guide wire technique for percutaneous anterior column/superior pubic rami intramedullary screw fixation.

PRESENTATION OF CASE

A 24-year-old male presented after a road traffic accident. The patient sustained a left anterior column acetabular fracture associated with a medial wall blowout and a right posterior column fracture. Computed tomography imaging was analyzed to determine the possibility of percutaneous fixation of the anterior column fixation.

DISCUSSION

This study applied a modified PF technique, initially described by Tosounidis and Giannoudis, for pelvic fracture fixation. The approach shows promising effects in minimizing cortical breaches, particularly in osteoporotic patients, while avoiding major complications. However, limitations include presenting a single case and the inability to conduct a cohort study due to follow-up challenges. Further research is needed to assess the broader applicability of this technique.

CONCLUSION

The modified PF technique shows promising results for pelvic fracture fixation, but further studies with larger sample sizes and proper follow-up are necessary to evaluate its long-term effectiveness and safety. Future research will help clarify its role in pelvic fracture management and compare it to other techniques in terms of outcomes and complications.

Dependable Automated Approach for Measuring the Retrograde Superior Ramus Screw Corridor in Pelvic Fracture Fixation

BACKGROUND

Precise measurement of the intraosseous corridor within the superior pubic ramus is essential for the accurate percutaneous placement of a retrograde superior ramus screw (SRS). However, conventional manual measurement methods are often subjective, leading to variations in results among observers. Our goal was to develop an automated and dependable method for determining the retrograde SRS corridor.

METHODS

We developed an automated technique that utilized a computed tomography (CT) image-based search algorithm to identify the retrograde SRS corridor with the maximum diameter. We evaluated the reliability of this automated approach in comparison to a manual method using 17 pelves. Subsequently, we used both methods to measure the diameter, length, and orientation of the retrograde SRS corridor in 204 pelves in a Chinese population and assessed the intra- and interobserver agreement of each method by calculating the root-mean-square error (RMSE) and constructing Bland-Altman plots. We determined the screw applicability (percentages of hemipelves that could be treated with specific sizes of screws) for each method. Additionally, we investigated potential factors influencing the corridor, such as sex, age, height, and weight, through regression analysis.

RESULTS

The intra- and interobserver intraclass correlation coefficients (ICCs) for the automated method (0.998 and 0.995) were higher than those for the manual approach (0.925 and 0.918) in the assessment of the corridor diameter. Furthermore, the diameter identified by the automated method was notably larger than the diameter measured with the manual method, with a mean difference and RMSE of 0.9 mm and 1.1 mm, respectively. The automated method revealed a significantly smaller corridor diameter in females than in males (an average of 7.5 and 10.4 mm, respectively). Moreover, use of the automated method allowed 80.6% of the females to be managed with a 4.5-mm screw while a 6.5-mm screw could be utilized in 19.4%, surpassing the capabilities of the manual method. Female sex had the most substantial impact on corridor diameter (β = -0.583).

CONCLUSIONS

The automated method exhibited better reliability than the manual method in measuring the retrograde SRS corridor, and showed a larger corridor diameter for screw placement. Females had a significantly smaller corridor diameter than males. Given the intricate nature of the automated approach, which entails utilizing different software and interactive procedures, our current method is not readily applicable for traumatologists. We are working on developing integrated software with the goal of providing a more user-friendly solution for traumatologists in the near future.

LEVEL OF EVIDENCE

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

Percutaneous hollow nail internal fixation treatment for fractures of the pubic symphysis and its adjacent areas

Purpose

To explore the percutaneous minimally invasive treatment of pubic symphysis and its adjacent fractures.

Method

Since May 2021, 13 cases of fractures involving the pubic symphysis and its adjacent parts were treated with x-ray fluoroscopic localization and percutaneous cannulated screw fixation across the symphysis pubis, the guide pin pierced the symphysis pubis and the fracture end and stopped at the inner edge of the acetabulum. Visual analogue scale (VAS) was used to evaluate the effect of the operation, and the patients were followed up.

Result

The screw insertion operation time was 25-40 min, with an average of 31.45 min; The number of perspectives is 20-40, with an average of 28.75. The average intraoperative blood loss was 10 ml, and there were no puncture complications such as nerve or vascular damage. The initial stability of the fractured end of the patient after surgery was good. The VAS score decreased from preoperative 8-10 points to postoperative 1-2 points (average of 1.5 points). The follow-up time was 3-25 months, with an average of 8.5 months. At the last follow-up, the excellent and good rate of pelvic function according to Majeed pelvic function scoring system was 100%. One patient had screws removed 1.5 years after surgery, while the remaining twelve patients did not have screws removed. All patients did not experience any discomfort symptoms caused by pubic symphysis fixation.

Conclusion

Percutaneous hollow nail internal fixation is an effective method for treating fractures of the pubic symphysis and its adjacent parts.

The "Metaizeau trick" to facilitate medullary pubic ramus screw insertion: A technical note

Minimally invasive procedures have recently seen an increase in the treatment of pelvic ring disruptions and select acetabular fractures. Similar to ilio-sacral screws, the superior pubic ramus screw is becoming a preferred method for treating unstable pelvic ring fractures. While the osteology of the superior pubic ramus is well understood and has inherent variability, standard screw insertion techniques work effectively in most cases. If the anatomy prevents the standard approach, there are alternative methods that can be employed for successful screw placement, or there might be a need for an open reduction and internal fixation with plates. Such techniques can be material-intensive and time-consuming. In this paper, we introduce a straightforward method that utilizes the Metaizeau nail as a guide wire to facilitate screw insertion in most instances, termed the "Metaizeau trick". Metaizeau nails, commonly found in trauma centers, are designed to locate a pathway effortlessly using this method. LEVEL OF EVIDENCE: IV.

Novel Covert-Inferior Pelvic Approach with a Subpubic Plate for Anterior Pelvic Ring Fractures: Preliminary Results

BACKGROUND

Anterior pelvic ring injuries can be treated via Pfannenstiel, modified Stoppa, or ilioinguinal approaches, but these require exposing the abdominal soft tissues and may damage pelvic organs. The scar on the abdominal wall is also unacceptable for some patients. The minimally invasive anterior pelvic ring internal fixator (INFIX) is not ideal for thin patients with easily irritated skin, and it is associated with complications such as femoral nerve palsy, vascular occlusion, and lateral femoral cutaneous nerve injury. In this study, we designed a new external pelvic approach for the treatment of an anterior pelvic ring fracture.

METHODS

We retrospectively reviewed 28 patients with 36 pubic ramus fractures that had been treated via the covert-inferior pelvic approach. All patients underwent a surgical procedure between August 2019 and January 2021. According to the Nakatani classification, there were 6 cases of type-I fracture, 25 cases of type-II fracture, and 5 cases of type-III fracture. Operative time, blood loss, and postoperative radiographic and computed tomographic (CT) findings were recorded. Patients were followed for fracture healing time, functional status, esthetic satisfaction, and complications.

RESULTS

A total of 27 patients had follow-up for at least 12 months (range, 12 to 29 months). Postoperative radiographs and CT scans showed well-positioned plates and screws. The mean preoperative time was 9.4 ± 3.8 days, the mean operative time was 61.3 ± 22.67 minutes, the mean intraoperative blood loss was 63.6 ± 42.62 mL, the mean fracture healing time was 4.1 ± 1.6 months, and the mean Majeed score was 89.74 ± 8.07. There were no complications of nonunion, internal fixation failure, vascular injury, nerve palsy, or hernia. All of the patients were esthetically satisfied with the scar.

CONCLUSIONS

The covert-inferior pelvic approach combined with a subpubic plate effectively fixed Nakatani type-I, II, and III fractures. The advantages of this method include rapid recovery after the surgical procedure, safety, simplicity, a short learning curve, no damage to abdominal soft tissue, no effect on pubic symphysis micromotion, and esthetic benefits. It may be another option for anterior pelvic ring fractures and can supplement other approaches.

LEVEL OF EVIDENCE

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

Percutaneous screw fixation assisted by hollow pedicle finder for superior pubic ramus fractures

Background

Pubic ramus fracture was an injury of anterior pelvic ring, the anterior pelvic ring plays an important role in maintaining the stability of the pelvis. The purpose of this study was to investigate the effect and indication of percutaneous retrograde pubic screw fixation assisted by hollow pedicle finder for pubic ramus fractures.

Methods

The clinical data of 68 patients with pubic ramus fracture treated with cannulated screw from March 2008 to March 2020 were retrospectively analyzed. According to the surgical methods, they were divided into traditional surgery group (32 cases in group A, with traditional retrograde pubic screw fixation) and modified surgery group (36 cases in group B, with percutaneous retrograde pubic screw fixation assisted by hollow open circuit device). Operation time, blood loss, incision length, screw length and complications were recorded and compared between the two groups. On the second day after surgery, the maximum fracture displacement over plain radiographs, entrance radiographs and exit radiographs of the pelvis was evaluated according to Matta criteria to evaluate the postoperative fracture reduction. Majeed score was used to evaluate the hip function at 12 months after surgery.

Results

The operations were successfully completed in both groups. The operation time, blood loss and incision length in group B were significantly less than those in group A (P < 0.05). There was no significant difference in screw length between the two groups (t = 0.797, P = 0.431). All patients were followed up for 8–38 months (mean 21.8 months). There were no vascular and nerve injury, fracture of internal fixator, screw entry into joint cavity, fracture nonunion and other complications in both groups. The fracture healing time of the two groups was 23.1 ± 2.1 weeks in group A while 22.7 ± 2.1 weeks in group B, respectively, and there was no statistical difference in the fracture healing time between the two groups (P > 0.05). In group A, there were 3 cases of incision infection, 1 case of incision fat liquefaction and 2 cases of lower extremity deep venous thrombosis, and the complication rate was 18.8%. There was only 1 case of lower extremity deep vein thrombosis in group B, and the complication rate was 2.8%, which was significantly lower than that in group A. The fracture in one case after surgery was found to be displaced in group A and no fracture was found in group B. There was no significant difference between the two groups in Matta imaging evaluation on the next day after surgery and Majeed function evaluation at 12 months after surgery (P > 0.05).

Conclusion

Percutaneous retrograde pubic ramus screw fixation assisted by hollow pedicle finder is effective in the treatment of pelvic pubic ramus fracture. It has the advantages of less incision, shorter operation time, less blood loss and lower incidence of complications compared with traditional methods. However, correct surgical indications should be required when we apply this surgical method.

Laparoscopic Acetabular Surgery (LASY) - vision or illusion?

Displaced acetabular fractures usually require open surgical approaches. Aim of this cadaver study was to evaluate a laparoscopic approach to prepare the anterior acetabular column and the quadrilateral plate in analogy to the laparoscopic pelvic lymphadenectomy. The laparoscopic preparation and anatomy is presented and illustrated step by step in a human cadaver followed by a modular plate osteosynthesis of the anterior column involving the quadrilateral plate is performed via a minimally invasive approach using standard laparoscopic instruments. In conclusion we could demonstrate that the laparoscopic preperitoneal preparation of the acetabulum according to the laparoscopic pelvic lymphadenectomy provides more free range for the surgical instruments compared to a previously described total extraperitoneal approach. The development of specific reduction tools and implants is under investigation. Until then, at least the laparoscopic preparation could be introduced in the clinical setting in the near future. TYPE OF STUDY: Technical note - Cadaver study.

Anatomical evaluation of the transpubic screw corridor based on a 3D statistical model of the pelvic ring

Retrograde transpubic screw fixation is a common procedure for the treatment of anterior pelvic ring fractures. With its sparing surgical approach and significant pain relief after screw fixations allowing early mobilisation, it has gained importance especially in the treatment of insufficiency fractures in elderly patients. However, positioning of transpubic screw osteosynthesis is not always possible due to narrowness and curvature of the screw corridor. The aim of the present study was to evaluate availability and length of the screw corridor using a 3D statistical model of the pelvic ring consisting out of 150 uninjured pelves. Virtual bore probes with a diameter of 7.5 mm were analysed as to accessibility, length and grey value distribution in Hounsfield Unit (HU). A transpubic corridor with a diameter of ≥ 7.5 mm was available in 185 of 300 investigated superior pubic rami with mean screw length of 131.7 mm. Accessibility of the screw corridor was higher in males than in females. However, screw length showed no systematic differences between the sexes or ethnicities. Analysis of the grey value distribution demonstrated the strongest bone to be located at the lateral ilium and the supraacetabular region.

Biomechanical Comparison of Five Fixation Techniques for Unstable Fragility Fractures of the Pelvic Ring

Background: Incidence of pelvic ring fractures has increased over the past four decades, especially after low-impact trauma—classified as fragility fractures of the pelvis (FFP). To date, there is a lack of biomechanical evidence for the superiority of one existing fixation technique over another. An FFP type IIc was simulated in 50 artificial pelvises, assigned to 5 study groups: Sacroiliac (SI) screw, SI screw plus supra-acetabular external fixator, SI screw plus plate, SI screw plus retrograde transpubic screw, or S1/S2 ala–ilium screws. The specimens were tested under progressively increasing cyclic loading. Axial stiffness and cycles to failure were analysed. Displacement at the fracture sites was evaluated, having been continuously captured via motion tracking. Results: Fixation with SI screw plus plate and SI screw plus retrograde transpubic screw led to higher stability than the other tested techniques. The S1/S2 ala–ilium screws were more stable than the SI screw or the SI screw plus external fixator. Conclusions: In cases with displaced fractures, open reduction and plate fixation provides the highest stability, whereas in cases where minimally invasive techniques are applicable, a retrograde transpubic screw or S1/S2 ala–ilium screws can be considered as successful alternative treatment options.

Low Superior Pubic Ramus Screw Failure Rate With Combined Anterior and Posterior Pelvic Ring Fixation

OBJECTIVES

To determine whether fracture pattern, implant size, fixation direction, or the amount of posterior pelvic ring fixation influences superior ramus medullary screw fixation failure.

DESIGN

Retrospective cohort review.

SETTING

Regional Level 1 trauma center.

PATIENTS/PARTICIPANTS

After exclusion criteria, 95 patients with 111 superior ramus fractures with 3 months minimum follow-up were included.

INTERVENTION

All patients underwent anterior and posterior pelvic ring fixation.

MAIN OUTCOME MEASUREMENTS

Comparison of immediate postoperative radiographs and/or computer tomography scan with the latest postoperative image to calculate interval fracture displacement and implant position. Postoperative fracture displacement or implant position change greater than 1 cm were considered fixation failures.

RESULTS

Five screws were defined as failures (4.5%), including 3 retrograde, 3 with bicortical fixation, 4 with a 4.5-mm screw, and 1 with a 7.0-mm screw. Fracture patterns included 2 oblique and 3 comminuted fractures. Based on the Nakatani classification, there were 3 zone II, 1 zone I, and 1 zone III. Failure modes included 3 with cut-out along the screw head and 1 cut-out and 1 cut-through at the screw tip.

CONCLUSIONS

Our incidence of superior pubic ramus intramedullary screw fixation failure was 4.5%. Even with anterior and posterior fixation along with precise technique, failures still occur without a common failure predictor. The percutaneous advantages and proven strength provided by an intramedullary implant make it desirable to help reestablish global pelvic ring stability. Biomechanical and clinical studies are needed to further understand intramedullary superior ramus screw fixation.

LEVEL OF EVIDENCE

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

Biomechanical Analysis of Retrograde Superior Ramus Screw Fixation Constructs

OBJECTIVE

To investigate the biomechanical performance of different size and length retrograde superior ramus screws.

MATERIALS AND METHODS

A vertical superior ramus fracture was created in osteoporotic composite hemipelvis bone models (Sawbones, Vashon Island, WA). After reduction, 4 fixation groups were created by inserting either a solid 4.5 mm (Depuy Synthes, Paoli, PA) or cannulated 7.0 mm screw (Zimmer, Warsaw, IN) of either 80 mm (short) or 140 mm (long) in length. An intact and an unstabilized osteotomy group were also created. Samples underwent cyclic loading for 5000 cycles with data acquisition at regular intervals. At the end of cyclic loading, load to failure was performed.

RESULTS

The displacement after 5000 cycles for 4.5 mm short screws was significantly greater than 4.5 mm long and 7.0 mm short screws. At 5000 cycles, the 4.5-mm short screws had a significantly lower stiffness and lower load to failure than all other screws and were not different from the osteotomy model.

CONCLUSIONS

Short 4.5-mm screws demonstrated increased displacement, lower stiffness, and decreased load to failure compared with all other screws. The biomechanical performance of 4.5-mm short screws was no different than unstabilized controls. Longer bicortical screw fixation is suggested when possible. Additional biomechanical and clinical studies are needed to fully understand the significance of these findings.

[The application of percutaneous retrograde pubic screw implantation assisted by hollow pedicle opener in treatment of pubic branch fracture]

OBJECTIVE

To evaluate the effectiveness of percutaneous retrograde pubic screw implantation assisted by hollow pedicle opener in pubic branch fractures.

METHODS

The clinical data of 42 patients with pubic branch fractures treated by hollow screw fixation between March 2008 and March 2019 were analyzed retrospectively. According to the operation method, they were divided into the traditional operation group (20 cases in group A, fixed with traditional retrograde pubic screws) and the modified operation group (22 cases in group B, fixed with percutaneous retrograde pubic screws assisted by hollow pedicle opener). There was no significant difference ( P>0.05) between the two groups in terms of gender, age, cause of injury, fracture classification, comorbidity, and time from injury to operation. The operation time, blood loss, incision length, screw length, and complications were recorded and compared between the two groups. The fracture reduction was evaluated according to Matta standard on the next day after operation, and the function was evaluated by Majeed score at 12 months after operation.

RESULTS

The operation was successfully completed in both groups. The operation time, blood loss, and incision length of group B were significantly less than those of group A ( P<0.05); there was no significant difference in screw length between the two groups ( t=0.793, P=0.437). All patients were followed up 8-24 months, with an average of 16.8 months. There was no complication in the two groups, such as injury of blood vessels and nerves, fracture of internal fixation, screw entering into joint cavity, and nonunion of fracture. There was no significant difference in the fracture healing time between the two groups ( t=-1.068, P=0.299). There were 2 cases of incision infection, 1 case of incision fat liquefaction, 2 cases of lower extremity deep vein thrombosis in group A, the incidence of complications was 25.0%; there was only 1 case of lower extremity deep vein thrombosis in group B, the incidence of complication was 4.5%, which was lower than that in group A, but the difference was not significant ( χ 2=2.104, P=0.147). In group A, 1 case was found to be dislocated, but in group B, there was no dislocated fracture. There was no significant difference between the two groups in the evaluation of Matta imaging on the next day after operation and the evaluation of Majeed function at 12 months after operation ( P>0.05).

CONCLUSION

Percutaneous retrograde pubic screw implantation assisted by hollow pedicle opener is effect for the pubic branch fractures with the advantage of smaller incision, shorter operation time, and less bleeding compared with traditional methods.

Biomechanical comparison of three minimally invasive fixations for unilateral pubic rami fractures

BACKGROUND

To compare the mechanical characteristics of a percutaneous superior pubic intramedullary screw, percutaneous bridging plate and percutaneous screw-rod system of the anterior ring for the treatment of unilateral vertical pubic fractures to provide a reference for clinical application.

METHODS

A finite element model of pelvic anterior ring injury (unilateral vertical pubic fracture) was produced. The fractures were fixed with a percutaneous superior pubic intramedullary screw, percutaneous bridging plate and percutaneous screw-rod system of the anterior ring and their combinations in 5 types of models. The fracture stabilities under vertical, bilateral and anterior-posterior load were quantified and compared based on the displacement of the hip joints' midpoint as quantificational index of fracture stability.

RESULTS

In the condition of bilateral and anterior-posterior load, the vertical, bilateral and anterior-posterior displacements of the hip joints' midpoint of different models were significantly different respectively. In general, the displacements of the 5 pelvic anterior ring fixations were ranked from maximum to minimum as follows: bridging plate, pelvic anterior screw-rod system, combination of bridging plate and pelvic anterior screw-rod system, superior pubic intramedullary screw and combination of superior pubic intramedullary screw and pelvic anterior screw-rod system.

CONCLUSION

For the fixation in unilateral pubic fractures of pelvic ring injury, the percutaneous superior pubic intramedullary screw is optimal, the percutaneous pelvic anterior screw-rod system is the second choice, and percutaneous bridging plate ranks the third. The percutaneous pelvic anterior screw-rod system can significantly increase fixation stability of the percutaneous superior pubic intramedullary screw and the percutaneous bridging plate.

[Research progress on minimally invasive treatment of anterior pelvic ring fracture]

OBJECTIVE

To summarize the related research results of minimally invasive treatment of anterior pelvic ring fracture, and to improve the understanding of minimally invasive treatment of anterior pelvic ring fracture.

METHODS

The literature of minimally invasive treatment of anterior pelvic ring fracture at domestic and overseas in recent years was reviewed, and the reduction and fixation methods of minimally invasive treatment were summarized and analyzed.

RESULTS

The pelvic reduction frame may be an effective auxiliary method for minimally invasive reduction of pelvis. The fixation methods of anterior pelvic ring include percutaneous screw fixation, stent fixation, and percutaneous plate fixation.

CONCLUSION

One kind of fixation is not applicable to all types of anterior pelvic ring fracture, and the fixation method should be selected according to the type of fracture and the patient's condition to minimize the complications.

Minimal-invasive stabilization of anterior pelvic ring fractures with retrograde transpubic screws

BACKGROUND

In the vast majority of patients with pelvic ring lesions, there is a combination of fractures of the posterior and anterior pelvic ring. Anterior fractures are painful and contribute to loss of stability of the pelvic ring. For these reasons, stabilization of pubic rami fractures is recommended together with posterior pelvic ring fixation. Retrograde transpubic screw osteosynthesis enjoys increasing acceptance due to its minimal invasive technique and adequate stability.

PATIENTS AND METHODS

We retrospectively reviewed the results of 158 retrograde transpubic screw osteosyntheses in 128 patients with pelvic ring lesions including a pubic ramus fracture. Sixty-three patients suffered a high-energy injury, 65 a fragility fracture of the pelvis.

RESULTS

One hundred and forty-six screws (92.4%) were inserted through a percutaneous procedure. There were no vascular, neurological or urological complications. Fifty-nine screws (39%) yielded an excellent reduction with less than one cortical width of displacement. Slight secondary displacement was seen in 33 of these fractures (55.9%). Early surgical complications were seen in 16 screws (10.1%): suboptimal pathway in 10, local hematoma in 4 and local infection in 3. Early revision surgery was done in 7 screws (4.4%). Median follow-up was 27.6 weeks, 83 screws (52.5%) had a follow-up of more than 6 months. During follow-up, 7.6% of screws loosened. Operative revision was performed in 13%. 75 fractures (90.3%) with a follow-up of ≥ 6 months showed radiographic evidence of healing. There was no difference in the healing rate of high-energy and fragility fractures. Nonunion rate was not dependent on the quality of primary reduction, secondary displacement, or screw loosening. Infection (p 0.001) and surgery ≥ 6 months after trauma (p 0.02) more often led to nonunion.

CONCLUSION

Retrograde transpubic screw osteosynthesis is a reliable method for splinting pubic rami fractures in high and low energy pelvic trauma. Although a slight secondary fracture displacement is seen in most cases, it does not affect fracture healing. Retrograde transpubic screw is a adequate minimal-invasive osteosynthesis to stabilize the anterior pelvic ring, especially in fragility fracture of the pelvis. Delayed operation (> 6 months) and infection show higher rate of nonunion.

Are Routine Postoperative Computer Tomography Scans Warranted for All Patients After Operative Fixation of Pelvic Ring Injuries?

OBJECTIVE

To evaluate the efficacy of routine postoperative computed topography (CT) scan after percutaneous fixation of unstable pelvic ring injuries.

DESIGN

Retrospective chart review.

SETTING

Level I Trauma Center.

PATIENTS/PARTICIPANTS

A total of 362 consecutive patients underwent operative fixation of unstable pelvic ring injuries during the study period.

INTERVENTION

Postoperative CT scan of the pelvis was obtained in 331 (91%) of the 362 patients treated operatively for unstable pelvic ring injuries.

MAIN OUTCOME MEASUREMENTS

Revision surgery based on routine postoperative CT scan.

RESULTS

Two patients (0.55%) returned to the operating room on the basis of postoperative CT scans due to malpositioned implants. There were no significant differences of age, sex, body mass index, Injury Severity Score, mechanism of injury, smoking status, or diabetes status between those who did and did not undergo revision surgery. A dysmorphic pelvis was identified in 154 (47%) patients. Both patients undergoing revision surgery were determined to have a dysmorphic pelvis while no patients with normal pelvic anatomy returned to the operating room based on postoperative CT (2/154, 1.3% vs. 0/177, 0%, P = 0.22).

CONCLUSIONS

Although there remains a role for postoperative CT scans in the appropriately selected patient, in the hands of experienced orthopaedic traumatologists, patients with adequate intraoperative fluoroscopy and a nondysmorphic pelvis may not require routine postoperative three-dimensional imaging.

LEVEL OF EVIDENCE

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

Fixation of Anterior Pelvic Ring Injuries

Treatment of anterior pelvic ring injuries involves both acute stabilization during the initial resuscitation and definitive fixation. Definitive management has evolved substantially over the past 40 years with improved patient mobilization and long-term outcomes. Although its use has recently declined, external fixation remains a favorable option in certain situations. Symphyseal plating is the preferred technique for stabilization of symphyseal diastasis because of superior stability and low morbidity. Ramus screws can be effective for simple ramus fractures but require a careful technique because of the proximity of neurovascular structures. The subcutaneous internal fixator provides a good option for obese patients in whom external fixation would be poorly tolerated. Regardless of fixation strategy, posterior ring reduction and stabilization is crucial.

Intramedullary Fixation Techniques for the Anterior Pelvic Ring

The superior ramus is an irregularly shaped, undulating, and curvilinear osseous structure that can provide an osseous conduit for intramedullary screws. A wide spectrum of variability between the curve and obliquity of the superior ramus osseous fixation pathway (OFP) exists in both the anteroposterior and the coronal planes. A detailed understanding of the osseous topography and how it correlates with fluoroscopic imaging is mandatory. Obtaining the correct intraoperative inlet and combined obturator oblique-outlet fluoroscopic views specific to each patient's anatomy is necessary for safe implant insertion. Intramedullary screws can be inserted in either an antegrade or a retrograde direction depending on a number of variables, including fracture location, the proximity of patient's external genitalia to the skin insertion side, and the possible impact of thigh girth on the surgeons hand position. Multiple screw insertion techniques are possible, but a simple and reproducible technique is described. The size and number of screws that can be inserted is variable, differs between surgeons, but is ultimately dependent on the cortical limits of the superior ramus OFP. Standard screw insertion techniques are successful in most patients. If the osseous corridor or external anatomy impedes standard insertional techniques, several modifications exist that can allow successful screw insertion. A thorough understanding of each patient's anatomy, injury, and precise surgical technique with the appropriate fluoroscopic views are required to safely place intraosseous intramedullary implants into the superior ramus OFP.