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Rahmani R, Stegelmann SD, Andreshak T. S2 alar- iliac screws are superior to traditional iliac screws for spinopelvic fixation in adult spinal deformity: a systematic review and meta-analysis. Spine Deform 2024; 12:829-842. [PMID: 38427156 DOI: 10.1007/s43390-024-00834-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/20/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Spinopelvic fixation (SPF) using traditional iliac screws has provided biomechanical advantages compared to previous constructs, but common complications include screw prominence and wound complications. The newer S2 alar-iliac (S2AI) screw may provide a lower profile option with lower rates of complications and revisions for adult spinal deformity (ASD). The purpose of this study was to compare rates of complications and revision following SPF between S2AI and traditional iliac screws in patients with ASD. METHODS A PRISMA-compliant systematic literature review was conducted using Cochrane, Embase, and PubMed. Included studies reported primary data on adult patients undergoing S2AI screw fixation or traditional IS fixation for ASD. Primary outcomes of interest were rates of revision and complications, which included screw failure (fracture and loosening), symptomatic screw prominence, wound complications (dehiscence and infection), and L5-S1 pseudarthrosis. RESULTS Fifteen retrospective studies with a total of 1502 patients (iliac screws: 889 [59.2%]; S2AI screws: 613 [40.8%]) were included. Pooled analysis indicated that iliac screws had significantly higher odds of revision (17.1% vs 9.1%, OR = 2.45 [1.25-4.77]), symptomatic screw prominence (9.9% vs 2.2%, OR = 6.26 [2.75-14.27]), and wound complications (20.1% vs 4.4%, OR = 5.94 [1.55-22.79]). S2AI screws also led to a larger preoperative to postoperative decrease in pain (SMD = - 0.26, 95% CI = -0.50, - 0.011). CONCLUSION The findings from this review demonstrate higher rates of revision, symptomatic screw prominence, and wound complications with traditional iliac screws. Current data supports the use of S2AI screws specifically for ASD. PROSPERO ID CRD42022336515. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Roman Rahmani
- Mercy Health St. Vincent Medical Center, Toledo, OH, USA
| | - Samuel D Stegelmann
- HCA Medical City Healthcare UNT-TCU GME (Denton), 3535 S Interstate 35, Denton, TX, 76210, USA.
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Fuchs V, Rieger B. A New Approach to the Treatment of Sacroiliac Joint Pain and First Patient-Reported Outcomes Using a Novel Arthrodesis Technique for Sacroiliac Joint Fusion. Orthop Res Rev 2024; 16:43-57. [PMID: 38318227 PMCID: PMC10840548 DOI: 10.2147/orr.s434566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/16/2024] [Indexed: 02/07/2024] Open
Abstract
Purpose To report the development of a new sacroiliac joint (SIJ) arthrodesis system that can be used for isolated fusion of the SIJ and, unlike known implant systems, in combination with lumbar instrumentation or as an alternative to existing sacropelvic fixation (SPF) methods, and the patient-reported outcomes in two cases. Materials and Methods After a comprehensive review of 207 pelvic computed tomography (CT) datasets, an implant body was designed. Its shape was modeled based on the SIJ recess. A screw anchored in the ilium secures the position of the implant and allows connection to lumbar instrumentation. Two patients with confirmed SIJ syndrome underwent surgery with the anatomically adapted implant. They were evaluated preoperatively, 6 months, and 12 months postoperatively. Visual Analogue Scale (VAS), Oswestry Disability Index (ODI), Million Visual Analogue Scale (MVAS), Roland Morris Score (RMS), reduction of SIJ/leg pain, and work status were assessed. Bony fusion of the SIJ was evaluated by radiographs and CT 12 months after the procedure. Results Analysis of pelvic CT data revealed a wedge-shaped implant body in four different sizes. In the two patients, VAS decreased from 88 to 33 points, ODI improved from 67 to 35%, MVAS decreased from 80 to 36%, and RMS decreased from 18 to 9 points 12 months after surgery. SIJ pain reduction was 80% and 90%, respectively. Follow-up CT and radiographs showed solid bony integration. Conclusion The implant used takes into account the unique anatomy of the SIJ and also meets the requirements of a true arthrodesis. Initial results in two patients are promising. Biomechanical and clinical studies will have to show whether the considerable theoretical advantages of the new implant system over existing SIJ implants - in particular the possibility of connection to a lumbar stabilization system - and SPFs can be put into practice.
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Affiliation(s)
- Volker Fuchs
- Department of Orthopedics, AMEOS Hospital of Halberstadt, Halberstadt, Germany
| | - Bernhard Rieger
- Department of Neurosurgery, AMEOS Hospital of Halberstadt, Halberstadt, Germany
- Department of Neurosurgery, Technical University of Dresden, Dresden, Germany
- Department of Biomedical Engineering, Technical University of Kosice, Kosice, Slovakia
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Zhao J, Nie Z, Zhou J, Liao D, Liu D. Incidence and Risk Factors of the Caudal Screw Loosening after Pelvic Fixation for Adult Spinal Deformity: A Systematic Review and Meta-analysis. Asian Spine J 2024; 18:137-145. [PMID: 38379148 PMCID: PMC10910138 DOI: 10.31616/asj.2022.0421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 04/03/2023] [Accepted: 06/05/2023] [Indexed: 02/22/2024] Open
Abstract
The purpose of this study was to assess the factors affecting caudal screw loosening after spinopelvic fixation for adult patients with spinal deformity. This meta-analysis calculated the weighted mean difference (WMD) and odds ratio (OR) using Review Manager ver. 5.3 (RevMan; Cochrane, London, UK). The loosening group was older than the control group (WMD, 2.17; 95% confidence interval [CI], 0.48-3.87; p=0.01). The S2 alar-iliac (S2AI) could prevent the caudal screw from loosening (OR, 0.43; 95% CI, 0.20-0.94; p=0.03). However, gender distribution (p=0.36), the number of fusion segments (p=0.24), rod breakage (p=0.97), T-score (p=0.10), and proximal junctional kyphosis (p=0.75) demonstrated no difference. Preoperatively, only pelvic incidence (PI) in the loosening group was higher (WMD, 5.08; 95% CI, 2.71-7.45; p<0.01), while thoracic kyphosis (p=0.09), lumbar lordosis (LL) (p=0.69), pelvic tilt (PT) (p=0.31), pelvic incidence minus lumbar lordosis (PI-LL) (p=0.35), sagittal vertical axis (SVA) (p=0.27), and T1 pelvic angle (TPA) demonstrated no difference (p=0.10). PI-LL (WMD, 6.05; 95% CI, 0.96-11.14; p=0.02), PT (WMD, 4.12; 95% CI, 0.99-7.26; p=0.01), TPA (WMD, 4.72; 95% CI, 2.35-7.09; p<0.01), and SVA (WMD, 13.35; 95% CI, 2.83-3.87; p=0.001) were higher in the screw loosening group immediately postoperatively. However, TK (p=0.24) and LL (p=0.44) demonstrated no difference. TPA (WMD, 8.38; 95% CI, 3.30-13.47; p<0.01), PT (WMD, 6.01; 95% CI, 1.47-10.55; p=0.01), and SVA (WMD, 23.13; 95% CI, 12.06-34.21; p<0.01) were higher in the screw loosening group at the final follow-up. However, PI-LL (p=0.17) demonstrated no significant difference. Elderly individuals were more susceptible to the caudal screw loosening, and the S2AI screw might better reduce the caudal screw loosening rate than the iliac screws. The lumbar lordosis and sagittal alignment should be reconstructed properly to prevent the caudal screw from loosening. Measures to block sagittal alignment deterioration could also prevent the caudal screw from loosening.
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Affiliation(s)
- Jian Zhao
- Department of Orthopaedics, The General Hospital of Western Theater Command, Chengdu,
China
| | - Zheng Nie
- Department of Anatomy, Development and Regeneration Key Lab of Sichuan Province, Chengdu Medical College, Chengdu,
China
| | - Jiangjun Zhou
- Department of Orthopaedic, The 908th Hospital of Joint Logistic Support Force of PLA, Nan Chang,
China
| | - Dongfa Liao
- Department of Orthopaedics, The General Hospital of Western Theater Command, Chengdu,
China
| | - Da Liu
- Department of Orthopaedics, The General Hospital of Western Theater Command, Chengdu,
China
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Shin HK, Park JH, Jeon SR, Roh SW, Jo DJ, Hyun SJ, Cho YJ. Sacropelvic Fixation for Adult Deformity Surgery Comparing Iliac Screw and Sacral 2 Alar-Iliac Screw Fixation: Systematic Review and Updated Meta-Analysis. Neurospine 2023; 20:1469-1476. [PMID: 38171313 PMCID: PMC10762417 DOI: 10.14245/ns.2346654.327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/04/2023] [Accepted: 08/09/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVE Two commonly used techniques for spinopelvic fixation in adult deformity surgery are iliac screw (IS) and sacral 2 alar-iliac screw (S2AI) fixations. In this article, we systematically meta-analyzed the complications of sacropelvic fixation for adult deformity surgery comparing IS and S2AI. METHODS The PubMed, Embase, Web of Science, and Cochrane clinical trial databases were systematically searched until March 29, 2023. The proportion of postoperative complications, including implant failure, revision, screw prominence, and wound complications after sacropelvic fixation, were pooled with a random-effects model. Subgroup analyses for the method of sacropelvic fixation were conducted. RESULTS Ten studies with a total of 1,931 patients (IS, 925 patients; S2AI, 1,006 patients) were included. The pooled proportion of implant failure was not statistically different between the IS and S2AI groups (21.9% and 18.9%, respectively) (p = 0.59). However, revision was higher in the IS group (21.0%) than that in the S2AI group (8.5%) (p = 0.02). Additionally, screw prominence was higher in the IS group (9.6%) than that in the S2AI group (0.0%) (p < 0.01), and wound complication was also higher in the IS group (31.7%) than that in the S2AI group (3.9%) (p < 0.01). CONCLUSION IS and S2AI fixations showed that both techniques had similar outcomes in terms of implant failure. However, S2AI was revealed to have better outcomes than IS in terms of revision, screw prominence, and wound complications.
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Affiliation(s)
- Hong Kyung Shin
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Hoon Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ryong Jeon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Woo Roh
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Jean Jo
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yong-Jae Cho
- Department of Neurosurgery, Ewha Womans University School of Medicine, Seoul, Korea
| | - for the Korean Spinal Deformity Society (KSDS)
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
- Department of Neurosurgery, Ewha Womans University School of Medicine, Seoul, Korea
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Galovich LÁ, Bordón JM, Blanco IC, Peiro A, Mengis CL, Piñera ÁR, Tomé-Bermejo F, Gallego J. Anatomic trajectory for iliac screw placement adapts better to the morphological features of the pelvis of each individual than the S2 alar iliac screw: a radiological study. Acta Neurochir (Wien) 2023; 165:2607-2614. [PMID: 37458861 PMCID: PMC10477215 DOI: 10.1007/s00701-023-05692-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 03/14/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE The iliac fixation (IF) through the S2 ala permits the minimization of implant prominence and tissue dissection. An alternative to this technique is the anatomic iliac screw fixation (AI), which considers the perpendicular axis to the narrowest width of the ileum and the width of the screw. The morphological accuracy of the iliac screw insertion of two low profile iliac fixation (IF) techniques is investigated in this study. METHODS Twenty-nine patients operated on via low profile IF technique were divided into two groups, those treated using 28 screws with the starting point at S2, and those treated with 30 AI entry point. Radiological parameters (Tsv-angle, Sag-Angle, Max-length, sacral-distance, iliac-width, S2-midline, skin-distance, iliac-wing, and PSIS distance) and clinical outcomes (early and clinic complications) were evaluated by two blinded expert radiologists, and the results were compared in both groups with the real trajectory of the screws placed. RESULTS Differences between ideal and real trajectories were observed in 6 of the 9 evaluated parameters in the S2AI group. In the AI group, these trajectories were similar, except for TSV-Angle, Max-length, Iliac-width, and distance to iliac-wing parameters. Moreover, compared with S2AI, AI provided better adaptation to the pelvic morphology in all parameters, except for sagittal plane angulation, skin distance, and iliac width. CONCLUSIONS AI ensures the advantages of low profile pelvic fixation like S2AI, with a starting point in line with S1 pedicle anchors and low implant prominence, and moreover adapts better to the morphological features of the pelvis of each individual.
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Affiliation(s)
- Luis Álvarez Galovich
- Unidad de Patología de Columna, Hospital Universitario Fundación Jiménez Díaz, Avda. Reyes Católicos, 2, 28040 Madrid, Spain
| | - Julia Montoya Bordón
- Servicio de Radiodiagnostico, Hospital Universitario Fundación Jiménez Díaz, Avda. Reyes Católicos, 2, 28040 Madrid, Spain
| | - Irantzu Castelbon Blanco
- Servicio de Patología de Columna, Instituto de Investigación Sanitaria Fundación Jiménez Díaz, Avda. Reyes Católicos, 28040 Madrid, Spain
| | - Alejandro Peiro
- Unidad de Patología de Columna, Hospital Universitario Fundación Jiménez Díaz, Avda. Reyes Católicos, 2, 28040 Madrid, Spain
| | - Charles Louis Mengis
- Unidad de Patología de Columna, Hospital Universitario Fundación Jiménez Díaz, Avda. Reyes Católicos, 2, 28040 Madrid, Spain
| | - Ángel R. Piñera
- Unidad de Patología de Columna, Hospital Universitario Fundación Jiménez Díaz, Avda. Reyes Católicos, 2, 28040 Madrid, Spain
| | - Félix Tomé-Bermejo
- Universidad Autónoma de Madrid, Faculty of Medicine and Surgery, Ciudad Universitaria de Cantoblanco, 28049 Madrid, Spain
| | - Jesus Gallego
- Unidad de Patología de Columna, Hospital Universitario Fundación Jiménez Díaz, Avda. Reyes Católicos, 2, 28040 Madrid, Spain
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Zhang Y, Song J, Lu Y, Yi M, Lin W, Yao M, Luo Z, Zhang G, Ding L. Modified unilateral iliac screw fixation with partial reduction in the treatment of high-grade spondylolisthesis at L5/S1 in adult patients: introduction of key technique, report of clinical outcomes and analysis of spinopelvic parameters. BMC Musculoskelet Disord 2023; 24:451. [PMID: 37268898 DOI: 10.1186/s12891-023-06552-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 05/19/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Management of high-grade spondylolisthesis (HGS) remains challenging. Spinopelvic fixation such as iliac screw (IS) was developed to deal with HGS. However concerns regarding constructs prominence and increased infection-related revision surgery have complicated it's use. We aim to introduce the modified iliac screw (IS) technique in treating high-grade L5/S1 spondylolisthesis and it's clinical and radiological outcomes. METHODS Patients with L5/S1 HGS who underwent modified IS fixation were enrolled. Pre- and postsurgical upright full spine radiographs were obtained to analyze sagittal imbalance, spinopelvic parameters, pelvic incidence-lumbar lordosis mismatch (PI-LL), slip percentage, slip angle (SA), and lumbosacral angle (LSA). Visual analogue scale (VAS), Oswestry disability index (ODI) were evaluated pre- and postoperatively for clinical outcomes assessment. Estimated blood loss, operating time, perioperative complications and revision surgery were documented. RESULTS From Jan 2018 to March 2020, 32 patients (15 males) with mean age of 58.66 ± 7.77 years were included. The mean follow-up period was 49 months. The mean operation duration was 171.67 ± 36.66 min. At the last follow-up: (1) the VAS and ODI score were significantly improved (p < 0.05), (2) PI increased by an average of 4.3°, the slip percent, SA and LSA were significantly improved (p < 0.05), (3) four patients (16.7%) with global sagittal imbalance recovered a good sagittal alignment, PI-LL within ± 10° was observed in all patients. One patient experienced wound infection. One patient underwent a revision surgery due to pseudoarthrosis at L5/S1. CONCLUSION The modified IS technique is safe and effective in treating L5/S1 HGS. Sparing use of offset connector could reduce hardware prominence, leading to lower wound infection rate and less revision surgery. The long-term clinical affection of increased PI value is unknown.
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Affiliation(s)
- Yao Zhang
- Department of Spinal Surgery, Beijing Shijitan Hospital, Capital Medical University, No.10, Tieyi Road, Yangfangdian, Haidian District, Beijing, 10038, People's Republic of China
| | - Jipeng Song
- Department of Spinal Surgery, Beijing Shijitan Hospital, Capital Medical University, No.10, Tieyi Road, Yangfangdian, Haidian District, Beijing, 10038, People's Republic of China
| | - Yuzheng Lu
- Department of Spinal Surgery, Beijing Shijitan Hospital, Capital Medical University, No.10, Tieyi Road, Yangfangdian, Haidian District, Beijing, 10038, People's Republic of China
| | - Meng Yi
- Department of Spinal Surgery, Beijing Shijitan Hospital, Capital Medical University, No.10, Tieyi Road, Yangfangdian, Haidian District, Beijing, 10038, People's Republic of China
| | - Wancheng Lin
- Department of Spinal Surgery, Beijing Shijitan Hospital, Capital Medical University, No.10, Tieyi Road, Yangfangdian, Haidian District, Beijing, 10038, People's Republic of China
| | - Mingtao Yao
- Department of Spinal Surgery, Beijing Shijitan Hospital, Capital Medical University, No.10, Tieyi Road, Yangfangdian, Haidian District, Beijing, 10038, People's Republic of China
| | - Zhengning Luo
- Department of Spinal Surgery, Beijing Shijitan Hospital, Capital Medical University, No.10, Tieyi Road, Yangfangdian, Haidian District, Beijing, 10038, People's Republic of China
| | - Genai Zhang
- Department of Spinal Surgery, Beijing Shijitan Hospital, Capital Medical University, No.10, Tieyi Road, Yangfangdian, Haidian District, Beijing, 10038, People's Republic of China
| | - Lixiang Ding
- Department of Spinal Surgery, Beijing Shijitan Hospital, Capital Medical University, No.10, Tieyi Road, Yangfangdian, Haidian District, Beijing, 10038, People's Republic of China.
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Zhong D, Ke Z, Wang L, Liu Y, Lin L, Zeng W, Zhou W, Wang Y. Comparative Clinical Efficacy and Safety of Sacral-2-Alar Iliac Screw Versus Iliac Screw in the Lumbosacral Reconstruction of Spondylodiscitis. World Neurosurg 2023; 171:e237-e244. [PMID: 36496146 DOI: 10.1016/j.wneu.2022.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE This study aimed to evaluate the clinical efficacy and safety of S2-alar-iliac (S2AI) and iliac screw (IS) techniques in treating lumbosacral spondylodiscitis. METHODS Between January 2020 and January 2022, 28 patients suffering from lumbosacral spondylodiscitis underwent lumbosacral fixation and were divided into the IS group (14 patients) and the S2AI group (14 patients). Surgical details, demographic characteristics, preoperative and postoperative Oswestry Disability Index, visual analog scale, and complications were analyzed. RESULTS Twenty-eight patients were included in this study, including 14 patients treated with IS and 14 patients treated with S2AI. The 2 groups were similar in sex, age, follow-up period, total drainage volume, hospitalization stay, and fusion time. (P > 0.05) The estimated blood loss and surgical time of S2AI during surgery were significantly lower than those of IS. (P < 0.05) The visual analog scale and Oswestry Disability Index scores significantly improved in both groups from preoperative to the last follow-up. Sacroiliac joint pain was found in both groups in the follow-up period, but the incidence was not significantly different (P = 0.663). Compared with the IS approach, the incidence of symptomatic screw prominence was lower in the S2AI group, but the difference was not significant. (P = 0.088). CONCLUSIONS S2AI, as well as IS techniques, can achieve promising results for reconstructing lumbosacral stability in spondylodiscitis. In addition, the S2AI technique can also reduce surgical trauma and operation time.
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Affiliation(s)
- Dian Zhong
- Department of Orthopedic Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - ZhenYong Ke
- Department of Orthopedic Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - LiYuan Wang
- Department of Orthopedic Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Liu
- Department of Orthopedic Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lu Lin
- Department of Orthopedic Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Zeng
- Department of Orthopedic Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - WenYi Zhou
- Department of Orthopedic Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Wang
- Department of Orthopedic Surgery, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Hey HWD, Ramos MRD, Tay HW, Lin S, Liu KG, Wong HK. The lateral entry point S2 alar-iliac (L-S2AI) screw: a preoperative computed tomography analysis of adult spinal deformity patients. Spine Deform 2022; 10:669-78. [PMID: 35088384 DOI: 10.1007/s43390-021-00462-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/11/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To radiographically compare lateral entry point S2-alar-iliac (L-S2AI) screw with conventional S2AI (C-S2AI) and conventional iliac screw (CIS) lengths and trajectories. METHODS Twenty-five preoperative CT scans of consecutive patients undergoing adult spinal deformity realignment surgery over a random 2-year period were analysed. Maximum in-bone length, caudal and lateral trajectories of CIS, C-S2AI, and L-S2AI screws were measured and compared using One-way ANOVA with Tukey's post hoc tests. Multivariate logistic regression was performed to identify predictors of high screw length discrepancy between C-S2AI and L-S2AI. RESULTS Potential screw length was longest for CIS, followed by L-S2AI, then C-S2AI (114.5 ± 8.3 mm vs 101.4 ± 9.6 mm vs 80.6 ± 5.9 mm, respectively) in all patients (p < 0.001). Actual screw lengths found both CIS and L-S2AI to be longer than C-S2AI (95.3 ± 8.5 mm and 93.4 ± 7.5 mm vs 82.1 ± 7.3 mm; p = 0.008 and 0.003). Potential lateral angulation was smallest for CIS, followed by L-S2AI, then C-S2AI (21.9 ± 7.0° vs 31.9 ± 7.1° vs 40.9 ± 6.7°, respectively) in all patients (p < 0.001). L-S2AI and C-S2AI had the same caudal angulation (24.9 ± 6.8°), which was smaller than CIS (30.8 ± 5.8°) in all patients (p < 0.001). Univariate, but not multivariate analysis, revealed that lumbar lordosis > 40° (OR 7.2, p = 0.041), diagnosis of degenerative spondylolisthesis (OR 10.5, p = 0.017), and > 7 instrumented levels (OR 2.6, p = 0.049) were significantly associated with high screw discrepancies. CONCLUSION The L-S2AI screw combines advantages of CIS and C-S2AI screws, which includes increased screw length, reduced lateral angulation, a low-profile screw head, ease of connection to proximal hardware, and the biomechanical advantage of a quadcortical purchase.
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Oberkircher L, Masaeli A, Hack J, Figiel J, Bliemel C, Ruchholtz S, Krüger A. Pull-out strength evaluation of cement augmented iliac screws in osteoporotic spino-pelvic fixation. Orthop Traumatol Surg Res 2021; 107:102945. [PMID: 33895387 DOI: 10.1016/j.otsr.2021.102945] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/29/2021] [Accepted: 02/08/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Spino-pelvic fixation has been widely accepted for surgical treatment of sacral tumor, scoliosis surgery and pelvic fractures. Cement augmentation of screws is an option to improve implant stability in osteoporotic bone quality. Aim of the present study is to compare iliac screw fixation without cement fixation and two cement application options in a biomechanical testing. HYPOTHESIS Cement augmentation of iliac screws leads to superior pull-out strength. MATERIAL AND METHODS Thirty female and osteoporotic human iliac bones were used. Three operation treatment groups were generated: Screw fixation (cannulated screws) without cement augmentation [Operation treatment (OT) A], screw fixation with cement augmentation before screw placement (cannulated screws) (OT B) and screw fixation with perforated screws and cement augmentation after screw placement (OTC). Pull-out tests were performed with a rate of 6mm/min. A load versus displacement curve was generated. Maximum pull-out force (N) was measured in the load-displacement curve. RESULTS Paired group 1 (OT A vs. OT B): Screw fixation without cement augmentation: 592.6N±335.07 and screw fixation with cement augmentation before screw placement: 996N±287.43 (p=0.0042). Paired group 2 (OT A vs. OT C): screw fixation without cement augmentation: 716.2N±385.86 and fenestrated screw fixation with cement augmentation after screw placement: 1324.88N±398.76 (p=0.0489). Paired group 3 (OT B vs. OT C): Screw fixation with cement augmentation before screw placement: 1077.2±486.66 and fenestrated screw fixation with cement augmentation after screw placement: 1298.2N±726.19 (p=0.3286). DISCUSSION Regarding iliac screw fixation for spino-pelvic ostesynthesis in osteoporotic bone, cement augmentation is significantly superior to solid iliac screw fixation respecting pull-out-strength. Nevertheless, further biomechanical studies are needed to verify these findings. LEVEL OF EVIDENCE Not applicable; biomechanical cadaver study.
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Affiliation(s)
- Ludwig Oberkircher
- Philipps University Marburg, Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany.
| | - Adrian Masaeli
- Philipps University Marburg, Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany
| | - Juliana Hack
- Philipps University Marburg, Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany
| | - Jens Figiel
- Department of diagnostic and interventional radiology, Philipps University Marburg, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany
| | - Christopher Bliemel
- Philipps University Marburg, Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany
| | - Steffen Ruchholtz
- Philipps University Marburg, Center for Orthopaedics and Trauma Surgery, University Hospital Giessen and Marburg, Location Marburg, Baldingerstrasse, 35037 Marburg, Germany
| | - Antonio Krüger
- Department of trauma surgery, orthopaedics, spine surgery and pediatric trauma surgery, Asklepios Hospital Lich, Goethestrasse 4, 35423 Lich, Germany
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10
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Choi HY, Jo DJ. Utilization of S1 Foraminal Hooks for Augmentation of S1 Screws in Adult Spinal Deformity Surgery: Comparative Study With Iliac Screws. Neurospine 2021; 18:554-561. [PMID: 34610686 PMCID: PMC8497253 DOI: 10.14245/ns.2142148.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To compare the outcomes of S1 foraminal hooks and iliac screws regarding fusion rate at the lumbosacral junction and protective effects on S1 screws. METHODS From January 2017 to December 2019, consecutive patients who underwent long fusions (uppermost instrumented vertebra at or above L1) to the sacrum for adult spinal deformity were enrolled. Patients were divided into S1 foraminal hook group and iliac screw group. Radiographic parameters and the incidence of pseudarthrosis and instrument failure at the lumbosacral junction were compared between the groups. RESULTS Twenty-nine patients (male:female = 1:28) with a mean age of 73.6 ± 6.8 years were evaluated. Sixteen patients (55.2%) had S1 foraminal hook fixation and 13 patients (44.8%) had iliac screw fixation. Lumbar lordosis, sacral slope, and sagittal vertical axis did not differ between the groups preoperatively and postoperatively. The rate of L5/S1 pseudarthrosis was significantly higher in S1 foraminal hook group (5 of 16, 31.3%), compared to iliac screw group (0 of 13, 0%; p = 0.048). Instrument failure at the lumbosacral junction trended toward a higher rate in S1 foraminal hook group (6 of 16, 37.5%) than in iliac screw group (1 of 13, 7.7%), without statistical significance (p = 0.09). Proximal junctional kyphosis/failure occurred less often in S1 foraminal hook group (2 of 16, 12.5%) than in iliac screw group (3 of 13, 30.8%) without statistical significance (p = 0.36). CONCLUSION Treatment with S1 foraminal hooks achieved equivalent satisfactory sagittal correction with proportioned alignment compared to that with iliac screws. However, S1 foraminal hooks did not provide enough structural support to the lumbosacral junction in long fusions to the sacrum.
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Affiliation(s)
- Ho Yong Choi
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea.,Department of Neurosurgery, College of Medicine, Kangwon National University, Chuncheon, Korea
| | - Dae Jean Jo
- Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University College of Medicine, Seoul, Korea
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11
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Welle K, Khoury M, Prangenberg C, Täger S, Goost H, Kabir K. [Minimally invasive lumbopelvic stabilization of sacral fracture and sacroiliac injury]. Oper Orthop Traumatol 2021; 33:538-545. [PMID: 34468791 DOI: 10.1007/s00064-021-00730-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 05/05/2019] [Accepted: 04/15/2020] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Rapid mobilization with full weight bearing by minimally invasive fixation of Os ilium to L5 in fractures of the sacrum and disruption of the sacroiliac joint (SIJ). INDICATIONS Unstable injuries of the posterior pelvic ring in fractures of the sacrum and disruption of the SIJ. CONTRAINDICATIONS Fracture of ilium and not injury related implants in the screw trajectory, neurological deficits regarding the fracture, decubitus in the area of surgical approach. SURGICAL TECHNIQUE Minimally invasive screw placement in the pedicles of L5, access of ilium screw via the posterior superior iliac spine. Radiological display for the iliacal screw bearing trajectory in Os Ilium as a drop-shaped/triangle canal. Insert a Jamshidi needle orthograde in the beam path, change to guide wire and placement of iliacal screw after resection of the bone in the screw head area. Submuscular insertion of the longitudinal rods, in case of double-sided instrumentation similar procedure on the opposite side, reduction of the fracture and fixation of the rods to screws. POSTOPERATIVE MANAGEMENT Postoperative mobilization with full weight bearing under physiotherapeutic guidance. RESULTS Patients treated with lumbopelvic stabilization in our facility between 2012 and 2017 were identified via the hospital database and retrospectively evaluated. In 24 patients with median age of 60.1 years and a follow-up-time of 11.8 months, we found no implant displacement, infection and no wound healing problems. Full weight bearing was permitted in 21 of 24 cases, in 3 cases partial load bearing due to other injuries. Three patients reported moderate mechanical irritation of iliacal screws; 1 patient reported severe irritability with removal of the implants after bony healing of fracture 1 year postoperatively.
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Affiliation(s)
- K Welle
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland
| | - M Khoury
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland
| | - C Prangenberg
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland
| | - S Täger
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland
| | - H Goost
- Abteilung für Orthopädie und Unfallchirurgie, Krankenhaus Wermelskirchen, Wermelskirchen, Deutschland
| | - K Kabir
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland.
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12
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Luo Q, Kim YC, Kim KT, Ha KY, Ahn J, Kim SM, Kim MG. Use of iliac screw associated with more correction of lumbar lordosis than S2-alar-iliac screw for adult spinal deformity. BMC Musculoskelet Disord 2021; 22:676. [PMID: 34376177 PMCID: PMC8356396 DOI: 10.1186/s12891-021-04568-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/02/2021] [Indexed: 12/20/2023] Open
Abstract
Background To date, there is a paucity of reports clarifying the change of spinopelvic parameters in patients with adult spinal deformity (ASD) who underwent long segment spinal fusion using iliac screw (IS) and S2-alar-iliac screw (S2AI) fixation. Methods A retrospective review of consecutive patients who underwent deformity correction surgery for ASD between 2013 and 2017 was performed. Patients were divided into two groups based on whether IS or S2AI fixation was performed. All radiographic parameters were measured preoperatively, immediately postoperatively, and the last follow-up. Demographics, intraoperative and clinical data were analyzed between the two groups. Additionally, the cohort was subdivided according to the postoperative change in pelvic incidence (PI): subgroup (C) was defined as change in PI ≥5° and subgroup (NC) with change < 5°. In subgroup analyses, the 2 different types of postoperative change of PI were directly compared. Results A total of 142 patients met inclusion criteria: 111 who received IS and 31 received S2AI fixation. The IS group (65.6 ± 26°, 39.8 ± 13.8°) showed a significantly higher change in lumbar lordosis (LL) and upper lumbar lordosis (ULL) than the S2AI group (54.4 ± 17.9°, 30.3 ± 9.9°) (p < 0.05). In subgroup (C), PI significantly increased from 53° preoperatively to 59° postoperatively at least 50% of IS cohort, with a mean change of 5.8° (p < 0.05). The clinical outcomes at the last follow-up were significantly better in IS group than in S2AI group in terms of VAS scores for back and leg. The occurrence of sacroiliac joint pain and pelvic screw fracture were significantly greater in S2AI group than in IS group (25.8% vs 9%, p < 0.05) and (16.1% vs 3.6%, p < 0.05). Conclusions Compared with the S2AI technique, the IS technique usable larger cantilever force demonstrated more correction of lumbar lordosis, and possible increase in pelvic incidence. Further study is warranted to clarify the clinical impaction of these results.
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Affiliation(s)
- Qiang Luo
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea.,Department of Orthopaedic Surgery, Graduate School of Medicine, Kyung Hee University, Kyungheedae-ro, Dongdaemun-gu, Seoul, South Korea
| | - Yong-Chan Kim
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea.
| | - Ki-Tack Kim
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea
| | - Kee-Yong Ha
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea
| | - Joonghyun Ahn
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea
| | - Sung-Min Kim
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea
| | - Min-Gyu Kim
- Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, Seoul, 05278, South Korea
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13
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Nowak S, Müller J, Weidemeier ME, Schroeder HWS, Müller JU. Tear-drop technique in iliac screw placement: a technical analysis. Acta Neurochir (Wien) 2021; 163:1577-1581. [PMID: 33674887 PMCID: PMC8116289 DOI: 10.1007/s00701-021-04788-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 02/22/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Instrumentation of the lumbosacral region is one of the more challenging regions due to the complex anatomical structures and biomechanical forces. Screw insertion can be done both navigated and based on X-ray verification. In this study, we demonstrate a fast and reliable open, low exposure X-ray-guided technique of iliac screw placement. METHODS Between October 2016 and August 2019, 48 patients underwent sacropelvic fixation in tear-drop technique. Screw insertion was performed in open technique by using an X-ray converter angulated 25-30° in coronal and sagittal view. The anatomical insertion point was the posterior superior iliac spine. Verification of correct screw placement was done by intraoperative 3D scan. RESULTS In total, 95 iliac screws were placed in tear-drop technique with a correct placement in 98.1%. CONCLUSIONS The tear-drop technique showed a proper screw position in the intraoperative 3D scan and therefore may be considered an alternative technique to the navigated screw placement.
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Affiliation(s)
- Stephan Nowak
- Universitätsmedizin Greifswald, Klinik und Poliklinik für Neurochirurgie, Sauerbruchstraße, 17475, Greifswald, Germany.
| | - Jonas Müller
- Universitätsmedizin Greifswald, Klinik und Poliklinik für Neurochirurgie, Sauerbruchstraße, 17475, Greifswald, Germany
| | - Martin E Weidemeier
- Universitätsmedizin Greifswald, Klinik und Poliklinik für Neurochirurgie, Sauerbruchstraße, 17475, Greifswald, Germany
| | - Henry W S Schroeder
- Universitätsmedizin Greifswald, Klinik und Poliklinik für Neurochirurgie, Sauerbruchstraße, 17475, Greifswald, Germany
| | - Jan-Uwe Müller
- Universitätsmedizin Greifswald, Klinik und Poliklinik für Neurochirurgie, Sauerbruchstraße, 17475, Greifswald, Germany
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14
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Gao Z, Sun X, Chen C, Teng Z, Xu B, Ma X, Wang Z, Yang Q. Comparative radiological outcomes and complications of sacral-2-alar iliac screw versus iliac screw for sacropelvic fixation. Eur Spine J 2021; 30:2257-70. [PMID: 33987735 DOI: 10.1007/s00586-021-06864-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 12/13/2020] [Accepted: 05/01/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE To compare the outcomes of sacropelvic fixation (SPF) using sacral-2-alar iliac (S2AI) screw with SPF using iliac screw (IS). METHODS A comprehensive search of PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Scopus was performed for comparative studies between S2AI and IS for SPF. Two independent investigators selected qualified studies and extracted data indispensably. With 95% confidence intervals (CI), the odds ratio (OR) was applied to dichotomous outcomes and standardized mean difference (SMD) was applied to continuous outcomes for each item. RESULTS We included data from thirteen studies involving 722 patients (S2AI, 357 patients; IS, 365 patients). In the pediatric population, the S2AI group had a smaller pelvic obliquity (PO) than the IS group at final follow-up (SMD, - 0.38; 95% CI, - 0.72 to - 0.04). Patients who underwent S2AI screws showed reduced rates of re-operation (S2AI, 13%; IS, 28%), implant failure (S2AI, 12%; IS, 26%) [screw loosening (S2AI, 8%; IS, 20%); screw breakage (S2AI, 2%; IS, 12%)], implant prominence (S2AI, 2%; IS, 14%), pseudarthrosis (S2AI, 3%; IS, 15%), wound infection (S2AI, 8%; IS, 22%) and less blood loss (S2AI, 2035.4 ml; IS, 2708.4 ml). CONCLUSION Radiological outcomes indicate an effective maintenance of the correction and arrest of progression of deformity by S2AI, which is equal or better than IS. SPF with S2AI screw has obviously lower incidence of postoperative complications and less blood loss. Given these advantages, the S2AI screw seems to be a beneficial alternative to IS.
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15
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Lee S, Jung SK, Keshen SG, Lewis SJ, Park JH. Accuracy Analysis of Iliac Screw Using Freehand Technique in Spinal Surgery : Relation between Screw Breach and Revision Surgery. J Korean Neurosurg Soc 2020; 63:210-217. [PMID: 31931555 PMCID: PMC7054120 DOI: 10.3340/jkns.2019.0090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/12/2019] [Indexed: 11/27/2022] Open
Abstract
Objective To analyze the accuracy of iliac screws using freehand technique performed by the same surgeon. We also analyzed how the breach of iliac screws was related to the clinical symptoms resulting in revision surgery.
Methods From January 2009 to November 2015, 100 patients (193 iliac screws) were analyzed using postoperative computed tomography scans. The breaches were classified based on the superior, inferior, lateral, and medial iliac wall violation by the screw. According to the length of screw extrusion, the classification grades were as follows : grade 1, screw extrusion <1 cm; grade II, 1 cm ≤ screw extrusion <2 cm; grade III, 2 cm ≤ screw extrusion <3 cm; and grade IV, 3 cm ≤ screw extrusion. We also reviewed the revision surgery associated with iliac screw misplacement.
Results Of the 193 inserted screws, 169 were correctly located and 24 were misplaced screws. There were eight grade I, six grade II, six grade III, and four grade IV screw breaches, and 11, 8, 2, and 3 screws violated the medial, lateral, superior, and inferior walls, respectively. Four revision surgeries were performed for the grade III or IV iliac screw breaches in the lateral or inferior direction with respect to its related symptoms.
Conclusion In iliac screw placement, 12.4% breaches developed. Although most breaches were not problematic, symptomatic violations (2.1%) could result in revision surgery. Notably, the surgeon should keep in mind that lateral or inferior wall breaches longer than 2 cm can be risky and should be avoided.
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Affiliation(s)
- Subum Lee
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Ku Jung
- Department of Emergency Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Sam G Keshen
- Division of Orthopaedic Surgery, University Health Network, Toronto Western Hospital, Toronto, Canada
| | - Stephen J Lewis
- Division of Orthopaedic Surgery, University Health Network, Toronto Western Hospital, Toronto, Canada
| | - Jin Hoon Park
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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16
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Ramchandran S, George S, Asghar J, Shufflebarger H. Anatomic Trajectory for Iliac Screw Placement in Pediatric Scoliosis and Spondylolisthesis: An Alternative to S2-Alar Iliac Portal. Spine Deform 2019; 7:286-292. [PMID: 30660223 DOI: 10.1016/j.jspd.2018.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/04/2018] [Accepted: 08/05/2018] [Indexed: 12/18/2022]
Abstract
STUDY DESIGN Single-center retrospective study. OBJECTIVE To analyze two-year postoperative outcomes following spinopelvic fixation in pediatric patients using the anatomic trajectory (AT) portal for iliac screws. SUMMARY Iliac fixation is crucial in situations requiring fusion to sacrum. Challenges include complex anatomy, pelvic deformation, severe deformity, and previous surgery. The PSIS portal requires significant dissection, rod connectors, and complex bends. The SAI portal requires navigating the screw across the SI joint to the ilium. The anatomic trajectory (AT), first reported in 2009, is between the PSIS and SAI portal, without prominence, connectors, or complex bends. METHODS Fifty-four patients aged ≤18 years requiring instrumentation to the Ilium with minimum follow-up of two years (mean 44 months) were clinically and radiographically evaluated. Changes in coronal curve magnitude and pelvic obliquity were assessed using paired t test for patients with cerebral palsy. Spondylolisthesis reduction was assessed in patients with moderate- to high-grade spondylolisthesis (Meyerding grade 3 and 4). RESULTS A total of 108 iliac screws were inserted using AT portal in 54 patients. Twenty-eight neuromuscular and syndromic patients had an initial mean coronal curve of 85° corrected to 23° at two years (p < .001) and a pelvic obliquity of 22° corrected to 4° (p < .001). Twenty patients with moderate- to high-grade spondylolisthesis treated with reduction and interbody fixation improved significantly with respect to their slip angles (7° ± 14.7° to -7.9° ± 6.1°, p = .003). In the neuromuscular group, two surgical site infections occurred, two had implant fractures, and 12 had asymptomatic iliac screw loosening, none requiring revision. In the spondylolisthesis group, there were no neurologic complications and one had prominent screw requiring removal. Of 108 iliac screws, 2 rod connectors were employed. CONCLUSION Iliac screw insertion using the AT portal is a safe and effective method of pelvic fixation in pediatric patients with satisfactory radiographic correction and minimal complications. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Subaraman Ramchandran
- Center for Spinal Disorders, Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 S.W. 62nd Ave, Miami, FL 33155, USA.
| | - Stephen George
- Center for Spinal Disorders, Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 S.W. 62nd Ave, Miami, FL 33155, USA
| | - Jahangir Asghar
- Center for Spinal Disorders, Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 S.W. 62nd Ave, Miami, FL 33155, USA
| | - Harry Shufflebarger
- Center for Spinal Disorders, Department of Orthopedic Surgery, Nicklaus Children's Hospital, 3100 S.W. 62nd Ave, Miami, FL 33155, USA
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Banno T, Hasegawa T, Yamato Y, Togawa D, Yoshida G, Kobayashi S, Yasuda T, Arima H, Oe S, Mihara Y, Ushirozako H, Matsuyama Y. Multi-Rod Constructs Can Increase the Incidence of Iliac Screw Loosening after Surgery for Adult Spinal Deformity. Asian Spine J 2019; 13:500-510. [PMID: 30691258 PMCID: PMC6547396 DOI: 10.31616/asj.2018.0209] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 10/17/2018] [Indexed: 12/05/2022] Open
Abstract
Study Design A retrospective study. Purpose To investigate the incidence of iliac screw loosening with a two-rod vs. multi-rod construct and the effect on clinical and radiographic outcomes after surgery for adult spinal deformity (ASD). Overview of Literature Multi-rod construct is useful for preventing rod fracture in ASD surgery. However, limited information is available regarding the incidence of iliac screw loosening after corrective fusion surgery using a multi-rod construct. Methods Total 106 patients with ASD (24 men and 82 women; mean age, 68 years) who underwent corrective fusion surgery using bilateral iliac screws and were followed up for at least 1 year were reviewed. The following variables were compared between patients who underwent surgery with a two-rod and multi-rod construct: age, sex, bone mineral density (BMD), fusion level, high-grade osteotomy, L5/S interbody fusion, screw loosening (upper instrumented vertebra [UIV], S1, and iliac), rod fracture, proximal junctional kyphosis, spinopelvic parameters, and Oswestry Disability Index (ODI) score. We also compared patients with and without iliac screw loosening in the multi-rod construct group. Results Of the 106 patients, 55 underwent surgery with a conventional two-rod construct and 51 with a multi-rod construct (three rods in 16, four rods in 35). Iliac and UIV screw loosening was observed in 24 patients (21%) and 35 patients (33%), respectively. The multi-rod group showed significantly higher incidence of iliac and UIV screw loosening and lower incidence of rod fracture. Patients with iliac screw loosening had a lower BMD than those without screw loosening; however, no significant differences were observed in the spinopelvic parameters or the ODI score. Conclusions The use of multi-rod constructs led to a higher incidence of junctional screw loosening than the use of conventional two-rod constructs, especially in patients with osteoporosis. Iliac screw loosening did not affect sagittal alignment or clinical outcome in the short term.
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Affiliation(s)
- Tomohiro Banno
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomohiko Hasegawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yu Yamato
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Daisuke Togawa
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Go Yoshida
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Sho Kobayashi
- Department of Orthopaedic Surgery, Hamamatsu Medical Center, Hamamatsu, Japan
| | - Tatsuya Yasuda
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hideyuki Arima
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Shin Oe
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuki Mihara
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroki Ushirozako
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yukihiro Matsuyama
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Tavares Junior MCM, de Souza JPV, Araujo TPF, Marcon RM, Cristante AF, de Barros Filho TEP, Letaif OB. Comparative tomographic study of the S2-alar- iliac screw versus the iliac screw. Eur Spine J 2018; 28:855-862. [PMID: 30382431 DOI: 10.1007/s00586-018-5806-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 10/24/2018] [Indexed: 11/27/2022]
Abstract
AIMS Iliac screws and S2-alar-iliac screws provide adequate mechanical stability for the fixation of lumbosacral spine pathologies, which has led to a significant increase in the use of these techniques in the routine practice of spine surgeons. However, studies on the ideal technical positioning for both techniques are limited. STUDY DESIGN This is an observational, retrospective, analytical descriptive study. OBJECTIVE To analyze, describe and compare the insertion and positioning parameters of the S2-alar-iliac and iliac screw techniques in adult patients without spinal deformities. METHODS The present study comprises a retrospective analysis of lumbosacral computed tomography images selected continuously in 2016 from 25 patients at a university hospital. Mann-Whitney-Shapiro-Wilk tests were performed. Data reliability was assessed using intraclass correlation. RESULTS The mean length of the iliac screw was greater than that of the S2-alar-iliac screw, and the S2-alar-iliac screw sat 20.5 mm deeper than the iliac screw. The mean of the greatest bone thickness for the iliac screw was 20.72 mm; that of the S2-alar-iliac screw was 23.24 mm. The mean distance from the iliac screw entry point to the skin was 32.46 mm, and the mean distance from the S2-alar-iliac screw entry point to the skin was 52.87 mm. CONCLUSION The trajectory of the S2-alar-iliac screws studied via computed tomography was greater in terms of bone thickness and deeper relative to the skin compared with the iliac screws. The S2-alar-iliac technique may have desirable clinical advantages in terms of the diameter of the screws and reduced protrusion when used in adults. These slides can be retrieved from Electronic supplementary material.
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Affiliation(s)
| | - João Paço Vaz de Souza
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
| | | | - Raphael Martus Marcon
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
| | - Alexandre Fogaça Cristante
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
| | | | - Olavo Biraghi Letaif
- Department of Orthopedics and Traumatology, IOT HCFMUSP, 171 Dr. Ovídio Pires de Campos St., São Paulo, SP, 05403010, Brazil
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Li Y, Sang X, Wang Z, Cheng L, Liu H, Qin T, Di K. Iliac screw for reconstructing posterior pelvic ring in Tile type C1 pelvic fractures. Orthop Traumatol Surg Res 2018; 104:923-8. [PMID: 29913269 DOI: 10.1016/j.otsr.2018.04.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/20/2018] [Accepted: 04/30/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND It is often difficult to achieve stable fixation in Tile type C1 pelvic fractures and there is no standard fixation technique for these types of injuries. HYPOTHESIS Iliac screw fixation can be used for treating Type C1 pelvic fractures. PATIENTS AND METHODS A retrospective review was performed on 47 patients who underwent iliac screw fixation in posterior column of ilium (PCI) for Tile type C1 pelvic fractures from July 2007 to December 2014. All patients were treated with fracture reduction, sacral nerve root decompression (if needed), internal fixation by iliac screw and connecting rod. The data on surgical time, intraoperative bleeding volume, postoperative neurologic functions and postoperative complications were analyzed. Patients were follow-up for at least 12months. RESULTS The mean surgical time was 148minutes, and the mean intraoperative bleeding volume was 763ml. Patients were encouraged in-bed activities immediately after surgery. The postoperative Majeed functional score was 48-100 points (mean 80.2), corresponding to an excellent and good recovery of 91.5%. Postoperative X-radiographs and CT scans indicated satisfactory fracture reduction. DISCUSSION Iliac screw fixation combined with sacral nerve canal decompression could effectively restore pelvic alignment and improve neurological functions for complex pelvic trauma.
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George SG, Lebwohl NH, Pasquotti G, Williams SK. Percutaneous and open iliac screw safety and accuracy using a tactile technique with adjunctive anteroposterior fluoroscopy. Spine J 2018; 18:1570-1577. [PMID: 29476809 DOI: 10.1016/j.spinee.2018.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT All currently described percutaneous iliac screw placement methods are entirely dependent on fluoroscopy. PURPOSE The purpose of this study was to determine the safety and the accuracy of percutaneous and open iliac screw placement using a primarily tactile technique with adjunctive anteroposterior (AP) fluoroscopy. STUDY DESIGN/CONTEXT All patients who underwent open and percutaneous iliac screw placement over a 5-year period were identified. Charts were reviewed to assess for any instances of neurologic or vascular injury associated with iliac screw placement. Screw accuracy was judged with postoperative computed tomography (CT) scans. PATIENT SAMPLE A total of 133 patients were identified who underwent open or percutaneous iliac screw placement. Computed tomography scans were available for 57 patients, and all of these patients were included in the study, with a total of 115 iliac screws. OUTCOME MEASURES Radiographic measurements were performed, consisting of the distance of the iliac screw to the sciatic notch on postoperative radiographs and CT scans. Computed tomography scans were used to determine iliac screw accuracy. METHODS Charts were reviewed to assess for any neurologic or vascular injuries related to screw placement. The distance of the iliac screw to the sciatic notch was measured and compared on AP radiography and CT scans. Computed tomography scans were assessed for any screw violation of the iliac cortex or the sciatic notch. The accuracy of open iliac screw placement was compared with minimally invasive percutaneous placement. RESULTS There were no neurologic or vascular injuries related to screw placement in the 133 patients. Computed tomography scans were available for 115 iliac screws, with 3 cortical breaches, all by less than 2 mm. All 112 other screws were accurately intraosseous. There was a strong correlation between the iliac screw to the sciatic notch distance when measured by CT scan compared with AP radiography (r=0.9), thus validating the accuracy of AP fluoroscopy in guiding iliac screw placement with respect to the sciatic notch. Iliac screw accuracy was equal with the open and percutaneous insertion techniques. CONCLUSIONS The described surgical technique represents a safe and reliable surgical option for iliac screw placement. Intraoperative AP fluoroscopy accurately reflects the distance of the iliac screw to the sciatic notch. Percutaneous iliac screws placed with this technique are as accurate as open iliac screws.
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Affiliation(s)
- Stephen G George
- Department of Orthopaedics, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL 33155, USA
| | - Nathan H Lebwohl
- Department of Orthopaedics, University of Miami Miller School of Medicine, 1611 NW 12th Ave #303, Miami, FL 33136, USA
| | - Giulio Pasquotti
- Department of Radiology, Azienda Ospedaliera Universitaria di Padova, Via Giustiniani, 2-35128, Padova, Italy
| | - Seth K Williams
- Department of Orthopaedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, 4602 Eastpark Blvd, MC AC-06, Madison, WI 53718, USA.
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Khashan M, Camisa W, Berven S, Leasure J. Stand-alone anterior interbody fusion for substitution of iliac fixation in long spinal fixation constructs. Arch Orthop Trauma Surg 2018; 138:479-486. [PMID: 29288274 DOI: 10.1007/s00402-017-2865-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The use of distal sacral anchorage solely, in long spinal fusions, may lead to substantial complications. Extending the fixation down to the ilium and the addition of anterior column support are both used to facilitate construct stability and improve fusion rates. In the current study, we aimed to determine whether supplementation of long thoracolumbar fixation constructs with stand-alone anterior interbody fusion (ALIF) cage with embedded screws can eliminate the biomechanical need for iliac screws fixation biomechanically. METHODS Seven lumbopelvic human cadavers (L1-full pelvis) were used. All specimens were tested with the following fixation constructs: bilateral L1-S1, bilateral L1-S1 with unilateral iliac screw, and bilateral L1-S1 with bilateral iliac screw. The three constructs were tested with and without the addition of stand-alone ALIF cage. We evaluated the multidirectional rigidity and the axial S1 screw strain. RESULTS The addition of an ALIF cage solely did not affect rigidity and resulted in mixed S1 screw strain results. One iliac screw was superior to ALIF in rigidity and inferior in S1 screws strain. Bilateral iliac fixation produced similar rigidity and lower S1 screws strain than unilateral iliac fixation. When ALIF was combined with bilateral iliac screws, it resulted in equal rigidity and lower S1 screws strain. CONCLUSION Our results do not support stand-alone ALIF cage as a substitute for iliac fixation in in long posterior lumbosacral fusion. They do support the use of stand-alone ALIF for the supplementation of bilateral iliac fixation in long lumbosacral fusions.
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Affiliation(s)
- Morsi Khashan
- University of California San Francisco-Department of Orthopaedics Surgery, 400 Parnassus Ave, San Francisco, CA, 94143, USA. .,Orthopedic Division, Tel-aviv Sourasky Medical Center, 6 Wizman Street, 64239, Tel Aviv, Israel.
| | - William Camisa
- The Taylor Collaboration, 450 Stanyan St., San Francisco, CA, 94117, USA
| | - Sigurd Berven
- University of California San Francisco-Department of Orthopaedics Surgery, 400 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Jeremi Leasure
- The Taylor Collaboration, 450 Stanyan St., San Francisco, CA, 94117, USA
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Abstract
Spinopelvic injuries result from high energy trauma with overloading through the sacrum. These lesions can accomplish either bone fractures, ligament injuries or, most commonly, both. They may be accompanied with other associated life threatening injuries and cause biomechanical instability with potential fracture non-union, mal-union and subsequent lifetime pain and disability. Surgical stabilization of spinopelvic injuries requires planning in order to apply the appropriate osteosynthesis principles (compression; neutralization; buttressing and tension band). In general terms simple sacral fractures can be treated under compression by iliosacral screws. However, as more complex ones cannot be compressed, they need vertical support and neutralization of shearing forces (neutralization and buttressing principles). For that purpose, spinopelvic instrumentations appear to be the current appropriate technique of stabilization. In the herein paper the general principles of sacral fracture osteosynthesis are discussed, as well as its application to spinopelvic injuries. Controversies on positioning, surgical approach, per-operative traction, sacral laminectomy, type of biomechanical construct, length of fixation, screws length, mode of weight bearing, and osteosynthesis hardware removal are discussed.
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23
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Hoernschemeyer DG, Pashuck TD, Pfeiffer FM. Analysis of the s2 alar- iliac screw as compared with the traditional iliac screw: does it increase stability with sacroiliac fixation of the spine? Spine J 2017; 17:875-879. [PMID: 28185981 DOI: 10.1016/j.spinee.2017.02.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 01/03/2017] [Accepted: 02/02/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Arthrodesis of the lumbosacral junction continues to be a challenge in pediatric and adult spinal deformity surgery. PURPOSE To evaluate the biomechanical rigidity of two types of lumbosacral fixation. Our hypothesis was that the use of S2 alar-iliac (S2AI) fixation will result in statistically similar biomechanical fixation as compared with use of an iliac screw with a 95% confidence interval. STUDY SETTING Controlled biomechanical laboratory METHODS: Ten human cadaveric lumbosacral specimens were separated into two test groups: (1) S2AI (n=5) and (2) iliac screw (n=5). S2AI and iliac screws were placed according to current clinical practice techniques. Specimens were mounted in an unconstrained dual leg stance configuration for testing in flexion, extension, lateral bending, and axial rotation. These loads were induced by moving the offset loading arm 10 mm in the respective direction from the point of neutral motion with displacement control up to a 10 N-m moment, except axial rotation which used a 4 N-m moment. Optical tracking was used to monitor motion of the vertebra, pelvis, and fixation instrumentation during testing. Specimens were tested in intact and instrumented states. The stiffness values between S2AI and iliac screw configurations were compared. DISCLOSURE The present study received external research support (>$50,000 -<$75,000) from Stryker Spine (Allendale, NJ, USA). RESULTS There was a consistent trend of increased construct stiffness for all S2AI samples compared with the iliac screw group. However, none of the groups tested reached statistical significance for a 95% confidence interval. CONCLUSIONS S2AI screws are just as stable as iliac screws with biomechanical testing in flexion, extension, rotation, lateral bending, and axial rotation. Given the similarities of biomechanical testing to human movements, these findings support S2AI screws as a viable option for lumbosacral fixation.
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Affiliation(s)
| | - Troy D Pashuck
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
| | - Ferris M Pfeiffer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, MO, USA
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Yu YH, Lu ML, Tseng IC, Su CY, Hsu YH, Yeh WL, Wu CC. Effect of the subcutaneous route for iliac screw insertion in lumbopelvic fixation for vertical unstable sacral fractures on the infection rate: A retrospective case series. Injury 2016; 47:2212-2217. [PMID: 27375014 DOI: 10.1016/j.injury.2016.06.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 06/17/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To report the perioperative results and surgical outcomes of patients with vertical unstable sacral fractures who underwent lumbopelvic fixation through a modified subcutaneous route for iliac screw fixation. SUMMARY OF BACKGROUND DATA Treating vertical unstable sacral fractures is still challenging for orthopedic surgeons. Among various methods for treating these fractures, lumbopelvic fixation provides a high reduction quality and promising stability for early weight-bearing ambulation. However, wound healing disturbance and surgical site infection (SSI) are the drawbacks of this extensive technique, especially after inserting iliac screws. METHODS Here, we provide an alternative subcutaneous route for iliac screw insertion during lumbopelvic fixation surgery to lessen soft tissue retraction and injury, and thus decrease soft tissue complications. RESULTS Using this modified technique, 28 patients with vertical unstable sacral fractures were treated between 2012 and 2014. One patient had an SSI (infection rate: 3.5%). All fractures were united with a mean sacral kyphosis correction angle of 10.5°. The mean Majeed score of the 17 patients during the 12-month follow-up was 84.5. CONCLUSIONS The subcutaneous route for iliac screw insertion is a simple, safe, and effective technique when performing lumbopelvic fixation for vertical unstable sacral fractures.
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Affiliation(s)
- Yi-Hsun Yu
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - Meng-Ling Lu
- Division of Spine, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - I-Chuan Tseng
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - Chun-Yi Su
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - Yung-Heng Hsu
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - Wen-Lin Yeh
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
| | - Chi-Chung Wu
- Division of Orthopedic Traumatology, Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, 33302, Tao-Yuan, Taiwan.
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Burns CB, Dua K, Trasolini NA, Komatsu DE, Barsi JM. Biomechanical Comparison of Spinopelvic Fixation Constructs: Iliac Screw Versus S2-Alar-Iliac Screw. Spine Deform 2016; 4:10-15. [PMID: 27852493 DOI: 10.1016/j.jspd.2015.07.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 06/09/2015] [Accepted: 07/03/2015] [Indexed: 10/22/2022]
Abstract
STUDY DESIGN Biomechanical cadaveric study. OBJECTIVE To compare the biomechanical properties of the iliac and S2-Alar-Iliac (S2AI) screw in a similar spinopelvic fixation construct. SUMMARY OF BACKGROUND DATA Spinopelvic fixation is used in the correction of pelvic obliquity, high-grade spondylolisthesis, and long spinal fusions. With the development of pedicle screw fixation, the iliac screw has been used as an anchor point to the pelvis. The associated morbidity with this fixation has led to the development of the S2AI screw. Many studies have examined the biomechanical properties of iliac and S2AI screws; however, a direct comparison has not been performed. METHODS Eight cadaveric spines were instrumented with pedicle screws bilaterally at L5 and S1. Four specimens were further instrumented with iliac screws placed with a starting point at the posterior superior iliac spine, and four specimens were instrumented with S2AI screws placed with a starting point 1 mm inferolateral to the S1 foramen. Screws were connected with 6.35 mm rods. Subfailure testing was performed by loading at 1°/second to a torque of 10 Nm in four directions: left bending, right bending, extension, and flexion. Specimens then underwent a monotonic load to failure under flexion at a rate of 1°/second. RESULTS There were no significant differences for torsional stiffness in extension, flexion, left bending, or right bending between S2AI and iliac screw constructs. There were no significant differences in S2AI versus iliac screws for failure torque (30.9 ± 12.00 Nm vs. 22.61 ± 6.25 Nm) and yield torque (11.86 ± 0.41 Nm vs. 12.01 ± 1.70 Nm). CONCLUSION Iliac screws have been associated with increased dissection, wound complications, an additional construct failure point, and hardware prominence. The S2AI screw was developed as an alternative and has been associated with less morbidity. The iliac and S2AI screw demonstrate no statistical difference in stiffness and load-to-failure in a spinopelvic fixation model. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Camden B Burns
- Department of Orthopaedic Surgery, Stony Brook University School of Medicine, Stony Brook, NY 11794, USA
| | - Karan Dua
- Department of Orthopaedic Surgery, Stony Brook University School of Medicine, Stony Brook, NY 11794, USA
| | - Nicholas A Trasolini
- Department of Orthopaedic Surgery, Stony Brook University School of Medicine, Stony Brook, NY 11794, USA
| | - David E Komatsu
- Department of Orthopaedic Surgery, Stony Brook University School of Medicine, Stony Brook, NY 11794, USA
| | - James M Barsi
- Department of Orthopaedic Surgery, Stony Brook University School of Medicine, Stony Brook, NY 11794, USA.
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Park SA, Kwak DS, You SL. Entry zone of iliac screw fixation to maintain proper entry width and screw length. Eur Spine J 2015; 24:2573-9. [PMID: 26002356 DOI: 10.1007/s00586-015-4042-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the entry zone of iliac screw fixation to maintain proper entry width and screw length. METHODS Computed tomography images of pelvic bones from 90 human cadavers were reconstructed into 3-dimensional models. In each model, a sectional image crossing the posterior superior iliac spine (PSIS) and anterior inferior iliac spine (AIIS) and consecutive sectional images up to 20 mm superiorly and inferiorly from the PSIS with 1-mm intervals aiming the AIIS were obtained. One virtual iliac screw with 10-mm diameter was introduced onto the PSIS at the middle and at the lateral and medial 1/4 points on the prominence of the posterior iliac spine. The entry width of the bony prominence and the corresponding maximal screw length available were evaluated for each entry point. RESULTS The entry width was smallest on the inferior 20 mm (4.7 ± 3.0 mm) and gradually increased up to the superior 10 mm (19.1 ± 3.9 mm) sectional images. The maximal screw length was smallest on the superior 20 mm (76.7 ± 39.7 mm) and gradually increased down to the inferior 10 mm (112.3 ± 15.1 mm) sectional images. The maximal screw lengths were significantly greatest at the most medial point and smallest at the most lateral point on the superior 20- and 10-mm sectional images and at the PSIS. CONCLUSIONS The iliac screw fixation entry zone to maintain proper screw length and entry width is outlined from 20 mm superiorly to 10 mm inferiorly from the PSIS and is located more medially from the prominence of the posterior iliac spine.
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Affiliation(s)
- Soo-An Park
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu-si, Gyeonggi-do, South Korea
| | - Dai-Soon Kwak
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 137-701, Korea.
| | - Sung-Lim You
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu-si, Gyeonggi-do, South Korea
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Desrochers-Perrault F, Aubin CE, Wang X, Schwend RM. Biomechanical analysis of iliac screw fixation in spinal deformity instrumentation. Clin Biomech (Bristol, Avon) 2014; 29:614-21. [PMID: 24906687 DOI: 10.1016/j.clinbiomech.2014.04.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 03/28/2014] [Accepted: 04/28/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND High rates of iliac screw fixation failures have been reported in spinopelvic instrumentations. The objective was to assess the iliac screw loads as functions of instrumentation variables. METHODS Spinopelvic instrumentations of six neuromuscular scoliosis were simulated using patient-specific modeling techniques to evaluate the intra- and postoperative iliac screw loads as functions of instrumentation variables: the combined use of sacral screws, the uses of lateral offset connectors and cross-rod connectors, and the iliac screw insertion point and trajectory. FINDINGS Sacral screws, lateral connectors and the iliac screw insertion point had significant effects on iliac screw axial forces (69-297N) and toggle moments (0.8-2.9Nm) (p<0.05). The addition of sacral screws made the iliac screw forces lower for some functional loads but higher for other functional loads, and resulted in an increase of intraoperative screw forces when attaching the rods onto these additional screws. When lateral offset connectors were used, the toggle moments were 16% and 25% higher, respectively for the left and right sides. Inserting iliac through the sacrum resulted in 17% lower toggle moment compared to insertion through the iliac crest. Cross-rod connectors had no significant effect on the intraoperative iliac screw forces. Postoperative functional loading had an important effect (additional 34% screw axial force and 18% toggle moment). INTERPRETATION It is possible to reduce the iliac screw loads by adapting instrumentation variables and strategies. Reducing the loads could decrease the risk of failure associated with iliac screw fixations.
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Affiliation(s)
- Frederique Desrochers-Perrault
- Polytechnique Montreal, Department of Mechanical Engineering, P.O. Box 6079, Station "Centre-ville", Montreal, Quebec H3C 3A7, Canada; Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, Quebec H3T 1C5, Canada
| | - Carl-Eric Aubin
- Polytechnique Montreal, Department of Mechanical Engineering, P.O. Box 6079, Station "Centre-ville", Montreal, Quebec H3C 3A7, Canada; Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, Quebec H3T 1C5, Canada.
| | - Xiaoyu Wang
- Polytechnique Montreal, Department of Mechanical Engineering, P.O. Box 6079, Station "Centre-ville", Montreal, Quebec H3C 3A7, Canada; Research Center, Sainte-Justine University Hospital Center, 3175, Cote Sainte-Catherine Road, Montreal, Quebec H3T 1C5, Canada
| | - Richard M Schwend
- Children's Mercy Hospital, 2401, Gillham Rd., Kansas City, MO 64108, USA
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Garg S, Holland C, LaGreca J, McNair B, Erickson M. Predicting Failure of Iliac Fixation in Neuromuscular Spine Deformity. Spine Deform 2014; 2:214-218. [PMID: 27927421 DOI: 10.1016/j.jspd.2014.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 01/17/2014] [Accepted: 01/19/2014] [Indexed: 10/25/2022]
Abstract
STUDY DESIGN Retrospective comparative cohort study. OBJECTIVES Identify whether there are patient or surgical risk factors to predict the probability of failure of iliac screw fixation after correction of neuromuscular scoliosis. SUMMARY OF BACKGROUND DATA There are high reported failure rates of pelvic fixation in long posterior spinal fusion (PSF) constructs to the sacrum for neuromuscular scoliosis. METHODS Patients aged 5 to 25 years, at a single institution, had PSF to the sacrum from 2001 to 2009 with pelvic fixation using iliac screws. Clinical data were retrospectively reviewed to identify patient and surgical variables related to surgery. Failure of iliac fixation was identified strictly as a broken screw, disengagement of the screw from the connector or the connector from the rod, or set plug failure. Lucency around the screws greater than 2 mm was recorded but not considered a failure. Variables were analyzed in a statistical model to identify predictors of failure. RESULTS A total of 108 patients met inclusion criteria; 100 (38 female and 62 male) had appropriate radiographs and minimum 2-year follow-up (average, 5.5 years). Coronal deformity correction averaged 59%. Most patients (89%) had fill of 6 of 8 possible distal fixation points composed of L4, L5, S1, and ilium bilaterally. Iliac screw failure occurred in 27 patients (27%). The initial single predictor statistical model identified 2 possible predictors of failure (patient: spastic tone; and surgical: absence of distal crosslink). In the multivariable model, spastic tone remained a predictor of failure (p = .0103), whereas absence of distal crosslink bordered on significance (p = .0516). CONCLUSIONS Iliac screw fixation failure is common in patients with long PSF constructs for neuromuscular scoliosis. Spastic tone is a risk factor for failure of pelvic fixation. A distal crosslink may protect against pelvic fixation failure. Alternative techniques for pelvic fixation should be studied in an attempt to improve the failure rates of iliac screw pelvic fixation.
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Affiliation(s)
- Sumeet Garg
- Orthopedics Institute, Children's Hospital Colorado, University of Colorado, 13123 East 16th Avenue, Box 060, Aurora, CO 80045, USA.
| | - Courtney Holland
- Orthopedics Institute, Children's Hospital Colorado, University of Colorado, 13123 East 16th Avenue, Box 060, Aurora, CO 80045, USA
| | - Jaren LaGreca
- Orthopedics Institute, Children's Hospital Colorado, University of Colorado, 13123 East 16th Avenue, Box 060, Aurora, CO 80045, USA
| | - Bryan McNair
- Orthopedics Institute, Children's Hospital Colorado, University of Colorado, 13123 East 16th Avenue, Box 060, Aurora, CO 80045, USA
| | - Mark Erickson
- Orthopedics Institute, Children's Hospital Colorado, University of Colorado, 13123 East 16th Avenue, Box 060, Aurora, CO 80045, USA
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Park YS, Kim HS, Baek SW, Lee SH. Lumbosacral fixation using the diagonal S2 screw for long fusion in degenerative lumbar deformity: technical note involving 13 cases. Clin Orthop Surg 2013; 5:225-9. [PMID: 24009909 PMCID: PMC3758993 DOI: 10.4055/cios.2013.5.3.225] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 03/02/2013] [Indexed: 12/03/2022] Open
Abstract
Placing instrumentation into the ilium has been shown to increase the biomechanical stability and the fusion rates, but it has some disadvantages. The diagonal S2 screw technique is an attractive surgical procedure for degenerative lumbar deformity. Between 2008 and 2010, we carried out long fusion across the lumbosacral junction in 13 patients with a degenerative lumbar deformity using the diagonal S2 screws. In 12 of these 13 patients, the lumbosacral fusion was graded as solid fusion with obvious bridging bone (92%). One patient had a rod dislodge at one S2 screw and breakage of one S1 screw and underwent revision nine months postoperatively. So, we present alternative method of lumbopelvic fixation for long fusion in degenerative lumbar deformity using diagonal S2 screw instead of iliac screw.
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Affiliation(s)
- Ye-Soo Park
- Department of Orthopaedic Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea.
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30
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Rhee WT, You SH, Jang YG, Lee SY. Lumbo-sacro-pelvic Fixation Using Iliac Screws for the Complex Lumbo-sacral Fractures. J Korean Neurosurg Soc 2007; 42:495-8. [PMID: 19096599 DOI: 10.3340/jkns.2007.42.6.495] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Accepted: 11/12/2007] [Indexed: 11/27/2022] Open
Abstract
Fractures of lumbo-sacral junction involving bilateral sacral wings are rare. Posterior lumbo-sacral fixation does not always provide with sufficient stability in such cases. Various augmentation techniques including divergent sacral ala screws, S2 pedicle screws and Galveston rods have been reported to improve lumbo-sacral stabilization. Galveston technique using iliac bones would be the best surgical approach especially in patients with bilateral comminuted sacral fractures. However, original Galveston surgery is technically demanding and bending rods into the appropriate alignment is time consuming. We present a patient with unstable lumbo-sacral junction fractures and comminuted U-shaped sacral fractures treated by lumbo-sacro-pelvic fixation using iliac screws and discuss about the advantages of the iliac screws over the rod system of Galveston technique.
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Affiliation(s)
- Woo-Tack Rhee
- Department of Neurosurgery, Gangneung Asan Hospital, College of Medicine, Ulsan University, Gangneung, Korea
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