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Zhang J, Wei Y, Wang J, Yu B. Numerical study of pedicle screw construction and locking compression plate fixation in posterior pelvic ring injuries: Analyzed by finite element method. Medicine (Baltimore) 2024; 103:e38258. [PMID: 38758846 PMCID: PMC11098222 DOI: 10.1097/md.0000000000038258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 04/25/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND The aim of this study was to compare the biomechanical performance of pedicle screw construction and locking compression plate fixation in posterior pelvic ring injuries analyzed by finite element method. METHODS A 3-dimensional finite element model of the spine-pelvis-femur complex with ligaments was reconstructed from computed tomography images. An unstable posterior pelvic ring injury was created, which was fixed with a pedicle screw construction or locking compression plate. A follower load of 400 N was applied to the upper surface of the vertebrae to simulate the upper body weight, while the ends of the proximal femurs were fixed. The construct stiffness, the maximum vertical displacement, the maximum posterior displacement, the maximum right displacement, and the overall maximum displacement of the sacrum, and stress distributions of the implants and pelvises were assessed. RESULTS The construct stiffness of the pedicle screw model (435.14 N/mm) was 2 times that of the plate model (217.01 N/mm). The maximum vertical displacement, the maximum posterior displacement, the maximum right displacement, and the overall maximum displacement of the sacrum in the pedicle screw model were smaller than those in the plate model (0.919, 1.299, 0.259, and 1.413 mm in the pedicle screw model, and 1.843, 2.300, 1.053, and 2.895 mm in the plate model, respectively). The peak stresses of the implant and pelvis in the pedicle screw model decreased by 80.4% and 25% when compared with the plate model (44.57 and 34.48 MPa in the pedicle screw model, and 227.47 and 45.97 MPa in the plate model, respectively). CONCLUSION The study suggested that the pedicle screw construction could provide better fixation stability than the locking compression plate and serves as the recommended fixation method for the treatment of posterior pelvic ring injuries.
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Affiliation(s)
- Jun Zhang
- Department of Orthopaedics, Pudong New Area People’s Hospital, Shanghai, China
| | - Yan Wei
- Department of Surgery, Pudong New Area People’s Hospital, Shanghai, China
| | - Jian Wang
- Department of Orthopaedics, Pudong New Area People’s Hospital, Shanghai, China
| | - Baoqing Yu
- Department of Orthopaedics, Seventh People’s Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Sevillano-Perez E, Postigo Pozo S, Guerado E, Zamora-Navas P, Prado-Novoa M. Biomechanical models of in vitro constructs for spinopelvic osteosynthesis. Injury 2021; 52 Suppl 4:S16-S21. [PMID: 33678461 DOI: 10.1016/j.injury.2021.02.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 02/02/2023]
Abstract
Spinopelvic lesions are the result of high-energy vertical trauma with axial skeletal overload where the spine impacts onto the sacrum, dissociating the lumbar spine from the pelvis. Therefore, lumbopelvic instrumentations are aimed to counteract these vertical forces, although various biomechanical aspects of the combinations of different constructs (with or without iliosacral screws) or the number of lumbar fixation levels (L5 or the combination of L5 with L4) are subject to controversy. The number of patients in each published series is too short, and the nature of the fixation is very different from one article to another, making comparison very difficult. In this paper the methodology for laboratory studies is discussed. The design of the test bench fixture, biomechanical testing protocol and data analysis are very important when inference to the clinical setting is desired.
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Affiliation(s)
- E Sevillano-Perez
- Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, University of Malaga, Autovía A-7. Km 187, 29603 Marbella, Malaga, Spain
| | - S Postigo Pozo
- Department of Mechanical Engineering, University of Malaga. Malaga, Spain
| | - E Guerado
- Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, University of Malaga, Autovía A-7. Km 187, 29603 Marbella, Malaga, Spain; Department of Orthopaedic Surgery and Traumatology. Hospital Universitario Costa del Sol. University of Malaga. Marbella, Malaga, Spain.
| | - P Zamora-Navas
- Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, University of Malaga, Autovía A-7. Km 187, 29603 Marbella, Malaga, Spain
| | - M Prado-Novoa
- Department of Mechanical Engineering, University of Malaga. Malaga, Spain
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Surachman AJD, Yanuarso, Akbar DL. Emergency decompression and stabilization of 1 st thoracic spinal cord injury and sacral fracture in a Covid-19 patient: A case report. Int J Surg Case Rep 2021; 81:105670. [PMID: 33688462 PMCID: PMC7934667 DOI: 10.1016/j.ijscr.2021.105670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Spinal cord injury is mostly caused by traumatic accident and usually associated with several injuries. The ideal treatment of orthopaedic injury is to perform surgical decompression and stabilization early. CASE PRESENTATION A 24-year-old-male patient came in emergency department with history of severe pain in his thoracic vertebrae after fell from 10 m height. His buttock was hit the ground first and patient was alert. He felt hypoesthesia below the injured level and dysfunctional motor and sensory of both lower extremities. We put pedicle screw at the C7, Th1, Th2 and Th 3. Then we put rods and nuts. After that, we did decompression by laminectomy of the C7 and Th1 and we put vacuumed drain for the wound. CLINICAL DISCUSSION This patient was diagnosed with traumatic spinal cord injury of 1st thoracic vertebra ASIA Impairment Scale (AIS) C and sacral fracture Denis classification zone II of right side with confirmed Covid-19 case. First patient treated with 1000 mg methyl prednisolone. An early surgical treatment was open reduction and internal fixation (ORIF) sacral fracture. We put a two-hole 4.5 narrow dynamic compression plate (DCP) at the lateral side of posterior ridge of iliac bone, between posterior superior iliac spine (PSIS) and posterior inferior iliac spine (PIIS). CONCLUSION Immediate surgical decompression and stabilization for spinal cord injury give significant improvement in motor and sensory function. Appropriate management for Covid-19 patient with Favipiravir and some supplements, had been proved control the virus and give patient good quality of life.
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Affiliation(s)
| | - Yanuarso
- Orthopaedics and Traumatology Department, Indonesia Army Central Hospital, Jakarta, Indonesia
| | - Danar Lukman Akbar
- Resident of Orthopaedics and Traumatology Department, Dr. Cipto Mangunkusumo National Central General Hospital/ Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia.
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Crist BD, Pfeiffer FM, Khazzam MS, Kueny RA, Della Rocca GJ, Carson WL. Biomechanical evaluation of location and mode of failure in three screw fixations for a comminuted transforaminal sacral fracture model. J Orthop Translat 2018; 16:102-111. [PMID: 30723687 PMCID: PMC6350021 DOI: 10.1016/j.jot.2018.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/12/2018] [Accepted: 06/20/2018] [Indexed: 12/04/2022] Open
Abstract
Background Pelvic ring–comminuted transforaminal sacral fracture injuries are rotationally and vertically unstable and have a high rate of failure. Objective Our study purpose was to use three-dimensional (3D) optical tracking to detect onset location of bone–implant interface failure and measure the distances and angles between screws and line of applied force for correlation to strength of pelvic fracture fixation techniques. Methods 3D relative motion across sacral–rami fractures and screws relative to bone was measured with an optical tracking system. Synthetic pelves were used. Comminuted transforaminal sacral–rami fractures were modelled. Each pelvis was stabilised by either (1) two iliosacral screws in S1, (2) one transsacral screw in S1 and one iliosacral screw in S1 and (3) one trans-alar screw in S1 and one iliosacral screw in S1; groups 4–6 consisted of fixation groups with addition of anterior inferior iliac pelvic external fixator. Eighteen-instrumented pelvic models with right ilium fixed simulate single-leg stance. Load was applied to centre of S1 superior endplate. Five cycles of torque was initially applied, sequentially increased until permanent deformation occurred. Five cycles of axial load compression was next applied, sequentially increased until permanent deformation occurred, followed by axial loading to catastrophic failure. A Student t test was used to determine significance (p < 0.05). Results The model, protocol and 3D optical system have the ability to locate how sub-catastrophic failures initiate. Our results indicate failure of all screw-based constructs is due to localised bone failure (screw pull-in push-out at the ipsilateral ilium–screw interface, not in sacrum); thus, no difference was observed when not supplemented with external fixation. Conclusion Inclusion of external fixation improved resistance only to torsional loading. Translational Potential of this Article Patients with comminuted transforaminal sacral–ipsilateral rami fractures benefit from this fixation.
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Affiliation(s)
- Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - Ferris M Pfeiffer
- Department of Orthopaedic Surgery, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA.,Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - Michael S Khazzam
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, 1801 Inwood Road, Dallas, TX 75390, USA
| | - Rebecca A Kueny
- Institute of Biomechanics, TUHH Hamburg University of Technology, Denickestraße 15, 21073, Hamburg, Germany
| | - Gregory J Della Rocca
- Department of Orthopaedic Surgery, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
| | - William L Carson
- Thompson Laboratory for Regenerative Orthopaedics, University of Missouri, Columbia, 1100 Virginia Ave., Columbia, MO 65212, USA
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Abstract
Fixation of comminuted vertically unstable sacral fractures continues to be a surgical dilemma. Although triangular osteosynthesis is a good construct and resists vertical translation, complications still occur. Herein, we introduce a new biplanar fixation technique, using segmental spinal instrumentation as an alternative to triangular osteosynthesis. This technique is remarkably valuable in cases with sacral morphology and/or complex fracture patterns that preclude safe percutaneous iliosacral screw insertion.
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Eastman J, Deafenbaugh B, Christiansen B, Garcia-Nolen T, Lee M. Achieving interfragmentary compression without special drilling technique or screw design. J Orthop Res 2018; 36:1099-1105. [PMID: 28885726 DOI: 10.1002/jor.23724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 08/29/2017] [Indexed: 02/04/2023]
Abstract
UNLABELLED Traditional fracture fixation teaching suggests that fully threaded screws do not provide interfragmentary compression unless placed through a glide hole. Based on this assumption, pelvic surgeons typically use fully threaded screws in the treatment of comminuted transforaminal sacral fractures to limit iatrogenic neuroforaminal stenosis. Clinical experience with fully threaded screws suggests that interfragmentary compression actually does occur. We hypothesized that the use of a fully threaded screw does not produce any interfragmentary compression and that there is no difference in insertional torque between partially threaded and fully threaded screws. To test this hypothesis, fully and partially threaded 7.0 millimeter (mm) cannulated screws were placed across two synthetic bone blocks fabricated to simulate normal and osteoporotic bone. We compared two groups of normal and osteoporotic blocks for compression achieved and maximal insertional torque generated with fully threaded and partially threaded screw insertion. A micro computed tomography (CT) scan of the composite blocks was obtained to investigate for structural changes created during screw insertion. For both groups, compression was achieved with fully threaded screws and the maximal insertional torque was higher using fully threaded screws. Micro CT analysis demonstrated local bone damage with structural disruption in the near segment of the fully threaded screw path in comparison to the partially threaded. CLINICAL SIGNIFICANCE this study demonstrates that compression is generated using fully threaded screws without using a predrilled glide hole. The insertional torque required to generate compression with fully threaded screws is increased but is clinically applicable. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1099-1105, 2018.
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Affiliation(s)
- Jonathan Eastman
- Department of Orthopaedic Surgery, Davis Medical Center, University of California, 4860 Y Street, Suite 1700, Sacramento, 95817, California
| | - Bradley Deafenbaugh
- Department of Orthopaedics, Naval Medical Center San Diego, San Diego, California
| | - Blaine Christiansen
- Department of Orthopaedic Surgery, Davis Medical Center, University of California, 4860 Y Street, Suite 1700, Sacramento, 95817, California
| | - Tanya Garcia-Nolen
- Department of Veterinary Medicine: Anatomy, Physiology, Cell Biology, University of California, Davis, California
| | - Mark Lee
- Department of Orthopaedic Surgery, Davis Medical Center, University of California, 4860 Y Street, Suite 1700, Sacramento, 95817, California
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Kaye ID, Yoon RS, Stickney W, Snavely J, Vaccaro AR, Liporace FA. Treatment of Spinopelvic Dissociation: A Critical Analysis Review. JBJS Rev 2018; 6:e7. [PMID: 29381571 DOI: 10.2106/jbjs.rvw.16.00119] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ian David Kaye
- Division of Spine Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Richard S Yoon
- Division of Orthopaedic Trauma, Orlando Regional Medical Center, Orlando Health, Orlando, Florida
| | - William Stickney
- Division of Orthopaedic Trauma, Jersey City Medical Center, RWJBarnabas Health, Jersey City, New Jersey
| | - Joseph Snavely
- Division of Orthopaedic Trauma, Orlando Regional Medical Center, Orlando Health, Orlando, Florida
| | - Alexander R Vaccaro
- Division of Spine Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Frank A Liporace
- Division of Orthopaedic Trauma, Jersey City Medical Center, RWJBarnabas Health, Jersey City, New Jersey
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McLachlin S, Lesieur M, Stephen D, Kreder H, Whyne C. Biomechanical analysis of anterior ring fixation of the ramus in type C pelvis fractures. Eur J Trauma Emerg Surg 2017; 44:185-190. [PMID: 28391395 DOI: 10.1007/s00068-017-0788-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 03/20/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE This biomechanical study compared the stability of four different ramus fracture fixation methods for Type C pelvic ring injuries in the absence of posterior fixation. METHODS A 5-mm vertical osteotomy of the mid-superior and inferior pubic ramus was created in 12 synthetic pelvic models. Four surgical constructs were compared: (1) two-pin AIIS external fixation, (2) 3.5-mm reconstruction plating, (3) bicortical, fully threaded 3.5-mm, and (4) 6.5-mm pubic ramus screws. Specimens were tested in a simulated one-legged stance on a hemiarthroplasty implant in three stages: (1) no applied load, (2) application of the loading fixture preload to the sacrum (6N), and (3) following six cycles of a 250N load. Stability was assessed based on resultant displacement of the fracture sites at the superior ramus and the anterior sacroiliac joint. RESULTS The bicortical, fully threaded 6.5-mm pubic ramus screw provided the most stable ramus fracture fixation (0.5 ± 0.4 mm) displacement under load and was the only construct to finish testing without gross posterior pelvic disruption. Plate constructs finished the final loading stage with only a small increase (3.1 ± 2.3 mm) in ramus fracture gap size, but had significant displacement at the SI joint (>20 mm). 3.5-mm screw constructs had 1.6 ± 0.7 mm of ramus displacement in the preload stage, but had complete posterior pelvic disruption (>20 mm) that prevented further testing. External fixation was unstable at the ramus and sacroiliac sites in the initial setup. CONCLUSIONS The bicortical, fully threaded 6.5-mm pubic ramus screw was the only anterior fixation construct tested that controlled motion at both the anterior and posterior pelvic rings in the absence of posterior fixation.
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Affiliation(s)
- S McLachlin
- Orthopaedic Biomechanics Laboratory, Sunnybrook Research Institute, 2075 Bayview Ave., Room S611, Toronto, M4N 3M5, ON, Canada
| | - M Lesieur
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - D Stephen
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - H Kreder
- Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada
| | - C Whyne
- Orthopaedic Biomechanics Laboratory, Sunnybrook Research Institute, 2075 Bayview Ave., Room S611, Toronto, M4N 3M5, ON, Canada. .,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada. .,Division of Orthopaedic Surgery, University of Toronto, Toronto, ON, Canada.
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Dilogo IH, Satria O, Fiolin J. Internal fixation of S1-S3 iliosacral screws and pubic screw as the best configuration for unstable pelvic fracture with unilateral vertical sacral fracture (AO type C1.3). J Orthop Surg (Hong Kong) 2017; 25:2309499017690985. [PMID: 28270058 DOI: 10.1177/2309499017690985] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Although internal fixation is the definitive treatment in unstable pelvic fractures with disruption of the anterior arch and a vertical fracture of the sacrum (AO type C1.3), there have been no agreement of the best technique of internal fixation yet. We aimed to derive comparable objective data on stiffness and load to failure in this type of fracture fixations. METHODS Synbone was modified into AO type C1.3 fracture model, while treatments were divided into six internal fixation treatment groups using tension band plate (TBP), symphysis pubis plate (SP) with iliosacral screw at S1 and S2 (IS S1-S2), pubic screw (PS) with iliosacral TBP, PS and IS S1-S2, SP and IS S1-S3, PS and S1-S3 and finally PS and IS S1-S3. Sensor was applied to detect the shifting and rotation of fracture fragments. Mechanical strength test conducted with the application of axial force on the sacrum vertebra (S1). RESULTS The highest translational stiffness was observed in the group IS S1-S3 + PS (830.36 N/mm, p = 0.031) and there was no difference on the rigidity of the rotation between the groups posterior fixation using IS S1-S2 and IS S1-S3 ( p = 0.51). Meanwhile the highest load to failure was found in group IS S1-S3 + PS (1522.20 N). PS provided advantages compared to the use of plate. CONCLUSIONS Group of PS and S1-S3 IS is the configuration of internal fixation with best translational and rotational stiffness and the largest load to failure compared to other techniques in AO type C1.3 fracture.
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Affiliation(s)
- Ismail Hadisoebroto Dilogo
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Depok, Indonesia
| | - Oryza Satria
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Depok, Indonesia
| | - Jessica Fiolin
- Department of Orthopaedic and Traumatology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Depok, Indonesia
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Does Lumbopelvic Fixation Add Stability? A Cadaveric Biomechanical Analysis of an Unstable Pelvic Fracture Model. J Orthop Trauma 2017; 31:37-46. [PMID: 27997465 DOI: 10.1097/bot.0000000000000703] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE We sought to determine the role of lumbopelvic fixation (LPF) in the treatment of zone II sacral fractures with varying levels of sacral comminution combined with anterior pelvic ring (PR) instability. We also sought to determine the proximal extent of LPF necessary for adequate stabilization and the role of LPF in complex sacral fractures when only 1 transiliac-transsacral (TI-TS) screw is feasible. MATERIALS AND METHODS Fifteen L4 to pelvis fresh-frozen cadaveric specimens were tested intact in flexion-extension (FE) and axial rotation (AR) in a bilateral stance gliding hip model. Two comminution severities were simulated through the sacral foramen using an oscillating saw, with either a single vertical fracture (small gap, 1 mm) or 2 vertical fractures 10 mm apart with the intermediary bone removed (large gap). We assessed sacral fracture zone (SZ), PR, and total lumbopelvic (TL) stability during FE and AR. The following variables were tested: (1) presence of transverse cross-connector, (2) presence of anterior plate, (3) extent of LPF (L4 vs. L5), (4) fracture gap size (small vs. large), (5) number of TI-TS screws (1 vs. 2). RESULTS The transverse cross-connector and anterior plate significantly increased PR stability during AR (P = 0.02 and P = 0.01, respectively). Increased sacral comminution significantly affected SZ stability during FE (P = 0.01). Two versus 1 TI-TS screw in a large-gap model significantly affected TL stability (P = 0.04) and trended toward increased SZ stabilization during FE (P = 0.08). Addition of LPF (L4 and L5) significantly improved SZ and TL stability during AR and FE (P < 0.05). LPF in combination with TI-TS screws resulted in the least amount of motion across all 3 zones (SZ, PR, and TL) compared with all other constructs in both small-gap and large-gap models. CONCLUSIONS The role of LPF in the treatment of complex sacral fractures is supported, especially in the setting of sacral comminution. LPF with proximal fixation at L4 in a hybrid approach might be needed in highly comminuted cases and when only 1 TI-TS screw is feasible to obtain maximum biomechanical support across the fracture zone.
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Abstract
OBJECTIVES To aid in surgical planning by quantifying and comparing the osseous exposure between the anterior and posterior approaches to the sacroiliac joint. METHODS Anterior and posterior approaches were performed on 12 sacroiliac joints in 6 fresh-frozen torsos. Visual and palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J. RESULTS The average surface areas of exposed bone were 44 and 33 cm for the anterior and posterior approaches, respectively. The anterior iliolumbar ligament footprint could be visualized in all anterior approaches, whereas the posterior aspect could be visualized in all but one posterior approach. The anterior approach provided visual and palpable access to the anterior superior edge of the sacroiliac joint in all specimens, the posterior superior edge in 75% of specimens, and the inferior margin in 25% and 50% of specimens, respectively. The inferior sacroiliac joint was easily visualized and palpated in all posterior approaches, although access to the anterior and posterior superior edges was more limited. The anterior S1 neuroforamen was not visualized with either approach and was more consistently palpated when going posterior (33% vs. 92%). CONCLUSIONS Both anterior and posterior approaches can be used for open reduction of pure sacroiliac dislocations, each with specific areas for assessing reduction. In light of current plate dimensions, fractures more than 2.5 cm lateral to the anterior iliolumbar ligament footprint are amenable to anterior plate fixation, whereas those more medial may be better addressed through a posterior approach.
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The Influence of Pelvic Ramus Fracture on the Stability of Fixed Pelvic Complex Fracture. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2015; 2015:790575. [PMID: 26495033 PMCID: PMC4606186 DOI: 10.1155/2015/790575] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 03/30/2015] [Accepted: 04/05/2015] [Indexed: 01/05/2023]
Abstract
This study aims to evaluate the biomechanical mechanism of pelvic ring injury for the stability of pelvis using the finite element (FE) method. Complex pelvic fracture (i.e., anterior column with posterior hemitransverse lesion) combined with pelvic ramus fracture was used to evaluate the biomechanics stability of the pelvis. Three FE fracture models (i.e., Dynamic Anterior Plate-Screw System for Quadrilateral Area (DAPSQ) for complex pelvic fracture with intact pubic ramus, DAPSQ for complex pelvic fracture with pubic ramus fracture, and DAPSQ for complex pelvic fracture with fixed pubic ramus fracture) were established to explore the biomechanics stability of the pelvis. The pubic ramus fracture leads to an unsymmetrical situation and an unstable situation of the pelvis. The fixed pubic ramus fracture did well in reducing the stress levels of the pelvic bone and fixation system, as well as displacement difference in the pubic symphysis, and it could change the unstable situation back to a certain extent. The pelvic ring integrity was the prerequisite of the pelvic stability and should be in a stable condition when the complex fracture is treated.
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Sathiyakumar V, Shi H, Thakore RV, Lee YM, Joyce D, Ehrenfeld J, Obremskey WT, Sethi MK. Isolated sacral injuries: Postoperative length of stay, complications, and readmission. World J Orthop 2015; 6:629-635. [PMID: 26396939 PMCID: PMC4573507 DOI: 10.5312/wjo.v6.i8.629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 06/17/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate inpatient length of stay (LOS), complication rates, and readmission rates for sacral fracture patients based on operative approach.
METHODS: All patients who presented to a large tertiary care center with isolated sacral fractures in an 11-year period were included in a retrospective chart review. Operative approach (open reduction internal fixation vs percutaneous) was noted, as well as age, gender, race, and American Society of Anesthesiologists’ score. Complications included infection, nonunion and malunion, deep venous thrombosis, and hardware problems; 90-d readmissions were broken down into infection, surgical revision of the sacral fracture, and medical complications. LOS was collected for the initial admission and readmission visits if applicable. Fisher’s exact and non-parametric t-tests (Mann-Whitney U tests) were employed to compare LOS, complications, and readmissions between open and percutaneous approaches.
RESULTS: Ninety-four patients with isolated sacral fractures were identified: 31 (30.4%) who underwent open reduction and internal fixation (ORIF) vs 63 (67.0%) who underwent percutaneous fixation. There was a significant difference in LOS based on operative approach: 9.1 d for ORIF patients vs 6.1 d for percutaneous patients (P = 0.043), amounting to a difference in cost of $13590. Ten patients in the study developed complications, with no significant difference in complication rates or reasons for complications between the two groups (19.4% for ORIF patients vs 6.3% for percutaneous patients). Eight patients were readmitted, with no significant difference in readmission rates or reasons for readmission between the two groups (9.5% percutaneous vs 6.5% ORIF).
CONCLUSION: There is a significant difference in LOS based on operative approach for sacral fracture patients. Given similar complications and readmission rates, we recommend a percutaneous approach.
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Vigdorchik JM, Jin X, Sethi A, Herzog DT, Oliphant BW, Yang KH, Vaidya R. A biomechanical study of standard posterior pelvic ring fixation versus a posterior pedicle screw construct. Injury 2015; 46:1491-6. [PMID: 25986670 DOI: 10.1016/j.injury.2015.04.038] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 01/29/2015] [Accepted: 04/25/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The purpose of this study was to biomechanically test a percutaneous pedicle screw construct for posterior pelvic stabilisation and compare it to standard fixation modalities. METHODS Utilizing a sacral fracture and sacroiliac (SI) joint disruption model, we tested 4 constructs in single-leg stance: an S1 sacroiliac screw, S1 and S2 screws, the pedicle screw construct, and the pedicle screw construct+S1 screw. We recorded displacement at the pubic symphysis and SI joint using high-speed video. Axial stiffness was also calculated. Values were compared using a 2-way ANOVA with Bonferroni adjustment (p<0.05). RESULTS In the sacral fracture model, the stiffness was greatest for the pedicle screw+S1 construct (p<0.001). There was no significant difference between the pedicle screw construct and S1 sacroiliac screw (p=1). For the SI joint model, the S1+S2 SI screws had the largest overall load and stiffness (p<0.001). The S1 screw was significantly stronger than pedicle screw construct (p=0.001). CONCLUSIONS The pedicle screw construct biomechanically compares to currently accepted methods of fixation for sacral fractures when the fracture is uncompressible. It should not be used for SI joint disruptions as one SI or an S1+S2 are significantly stiffer and cheaper.
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Affiliation(s)
- Jonathan M Vigdorchik
- Department of Orthopedic Surgery, Detroit Receiving Hospital, Detroit Medical Center, 4201 St. Antoine Blvd., Suite 4G, Detroit, MI 48201, United States
| | - Xin Jin
- Department of Biomedical Engineering, Wayne State University, 818 West Hancock, Detroit, MI 48201, United States
| | - Anil Sethi
- Department of Orthopedic Surgery, Detroit Receiving Hospital, Detroit Medical Center, 4201 St. Antoine Blvd., Suite 4G, Detroit, MI 48201, United States.
| | - Darren T Herzog
- Department of Orthopedic Surgery, Detroit Receiving Hospital, Detroit Medical Center, 4201 St. Antoine Blvd., Suite 4G, Detroit, MI 48201, United States
| | - Bryant W Oliphant
- Department of Orthopedic Surgery, Detroit Receiving Hospital, Detroit Medical Center, 4201 St. Antoine Blvd., Suite 4G, Detroit, MI 48201, United States
| | - King H Yang
- Department of Biomedical Engineering, Wayne State University, 818 West Hancock, Detroit, MI 48201, United States
| | - Rahul Vaidya
- Department of Orthopedic Surgery, Detroit Receiving Hospital, Detroit Medical Center, 4201 St. Antoine Blvd., Suite 4G, Detroit, MI 48201, United States
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Morshed S, Choo K, Kandemir U, Kaiser SP. Internal Fixation of Posterior Pelvic Ring Injuries Using Iliosacral Screws in the Dysmorphic Upper Sacrum. JBJS Essent Surg Tech 2015; 5:e3. [PMID: 30473911 PMCID: PMC6221427 DOI: 10.2106/jbjs.st.n.00006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Introduction The correct usage of preoperative and intraoperative imaging allows fixation of posterior pelvic ring injuries with safely positioned iliosacral screws in the setting of sacral dysmorphism. Step 1 Preoperative Planning Obtain CT reformats along the longitudinal axis of the sacrum to determine the orientation and diameter of the osseous corridor for selection of the ideal screw size, length, and trajectory. Step 2 Patient Positioning Proper positioning enables reduction and accurate iliosacral screw placement. Step 3 Fracture Reduction Reduction of the posterior pelvic ring confers stability; if closed reduction is unsuccessful, proceed with open reduction. Step 4 Identification of the Entry Point The entry point for an iliosacral screw into the upper sacral segment of a dysmorphic pelvis lies more posterior and caudal on the outer table of the posterior ilium than does a transsacral screw; adjust the entry point on the basis of inlet and outlet fluoroscopic views. Step 5 Drilling Technique Insert a stout cannulated drill bit of 4.5 to 5 mm (depending on the core diameter of the intended iliosacral screw) over the Kirschner wire and drill it into the sacral body under fluoroscopic guidance, in accordance with the preoperative plan. Step 6 Screw Insertion With the guidewire in the ideal position, measure the screw length off the inserted guidewire and advance a tap into the pathway; insert the screw and verify its position on the inlet, outlet, and lateral sacral views. Results Understanding the three-dimensional anatomy of the posterior pelvic ring is essential to successful reduction and fixation of unstable pelvic injuries with use of percutaneous iliosacral screws.IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Saam Morshed
- Orthopaedic Trauma Institute, University of California, San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110
| | - Kevin Choo
- Orthopaedic Trauma Institute, University of California, San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110
| | - Utku Kandemir
- Orthopaedic Trauma Institute, University of California, San Francisco, 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110
| | - Scott Patrick Kaiser
- Department of Orthopaedic Surgery, University of California, San Francisco, 500 Parnassus Avenue, MU-320W, San Francisco, CA 94143. E-mail address:
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Zhang L, Peng Y, Du C, Tang P. Biomechanical study of four kinds of percutaneous screw fixation in two types of unilateral sacroiliac joint dislocation: a finite element analysis. Injury 2014; 45:2055-9. [PMID: 25457345 DOI: 10.1016/j.injury.2014.10.052] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 10/14/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the biomechanical stability of four different kinds of percutaneous screw fixation in two types of unilateral sacroiliac joint dislocation. METHODS Finite element models of unstable Tile type B and type C pelvic ring injuries were created in this study. Modelling was based on fixation with a single S1 screw (S1-1), single S2 screw (S2-1), two S1 screws (S1-2) and a combination of a single S1 and a single S2 screw (S1–S2). The biomechanical test of two types of pelvic instability (rotational or vertical) with four types of percutaneous fixation were compared. Displacement, flexion and lateral bend (in bilateral stance) were recorded and analyzed. RESULTS Maximal inferior translation (displacement) was found in the S2-1 group in type B and C dislocations which were 1.58 mm and 1.90 mm, respectively. Maximal flexion was found in the S2-1 group in type B and C dislocations which were 1.55° and 1.95°, respectively. The results show that the flexion from most significant angulation to least is S2-1, S1-1, S1-2, and S1–S2 in type B and C dislocations. All the fixations have minimal lateral bend. CONCLUSION Our findings suggest single screw S1 fixation should be adequate fixation for a type B dislocation. For type C dislocations, one might consider a two screw construct (S1–S2) to give added biomechanical stability if clinically indicated.
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Functional outcome of unstable pelvic ring injuries after iliosacral screw fixation: single versus two screw fixation. Eur J Trauma Emerg Surg 2014; 41:387-92. [DOI: 10.1007/s00068-014-0456-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
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Spalteholz M, Gahr RH. [4-point internal fixator stabilization of a sacral insufficiency fracture]. Unfallchirurg 2014; 118:181-7. [PMID: 25027355 DOI: 10.1007/s00113-014-2590-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Sacral insufficiency fractures develop due to a discrepancy between physiological load and load-bearing capacity. Besides osteoporosis as the main predisposing factor, other diseases lead to a loss of the bony elastic resistivity and therefore are able to cause these characteristic bilateral sacral stress fractures. Most patients complain of low back pain and show difficulties in mobilization.The non-operative therapy is based on analgesics and pain-adapted mobilization. Due to the noticeable functional deficit and persistent discomfort, surgery is necessary in many cases. Various operative methods are available, without significant differences regarding stability. We present the case of a 56-year-old man, in whom the progression of B-cell chronic lymphocytic leukemia (B-CLL) led to the development of osteolysis in the posterior pelvic ring and caused a sacral insufficiency fracture. Due to the progressive deterioration of mobilization and the persistent severe pain, we decided to stabilize the posterior pelvic ring. After surgery the patient could be mobilized and the pain was significantly reduced.
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Affiliation(s)
- M Spalteholz
- Klinik für Unfallchirurgie und Orthopädie/Traumazentrum, Klinikum St. Georg gGmbH, Delitzscher Straße 141, 04129, Leipzig, Deutschland,
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Dudda M, Hoffmann M, Schildhauer T. Sakrumfrakturen und lumbopelvine Instabilitäten bei Beckenringverletzungen. Unfallchirurg 2013; 116:972-8. [DOI: 10.1007/s00113-012-2335-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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A biomechanical comparison of ipsilateral and contralateral pedicle screw placement for modified triangular osteosynthesis in unstable pelvic fractures. J Orthop Trauma 2013. [PMID: 23187154 DOI: 10.1097/bot.0b013e3182787d54] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Iliosacral fixation of unstable pelvic fractures does not produce enough stability to allow for immediate postoperative weight bearing. Triangular osteosynthesis creates additional resistance to vertical displacement and rotation. A disadvantage is the loss of the L5/S1 motion segment. We propose a modification of the standard triangular osteosynthesis construct in which the contralateral S1 pedicle is used. As the ipsilateral L5 pedicle is unavailable for fixation in a saw-bones composite pelvic model, we compared ipsilateral and contralateral S1 pedicle screw constructs. We hypothesized that ipsilateral and contralateral S1 pedicle screw constructs would demonstrate no difference in displacement or rotation. METHODS Seven saw bones pelvic models were tested. A 5-mm vertical fracture gap was created through the left sacrum while the pubic symphysis was completely dissociated. Each pelvis was tested sequentially in 4 triangular osteosynthesis configurations: ipsilateral S1 screw with anterior plate, contralateral S1 screw with anterior plate, contralateral S1 screw without anterior plate, and ipsilateral S1 screw without anterior plate. Specimens were cyclically loaded from 100-200 N at 0.25 Hz for 25 cycles and then loaded up to 300 N at 10 mm/min while displacement and rotation at the sacral and pubic fracture sites were measured. RESULTS There was no difference in any of the displacement measures between ipsilateral and contralateral constructs. When comparing rotation, the contralateral configuration experienced significantly less rotation than the ipsilateral configuration with and without the anterior plate applied. CONCLUSIONS Within the limitations of the current model, contralateral S1 constructs for modified triangular osteosynthesis were biomechanically equal to ipsilateral constructs in preventing displacement and superior in preventing rotation.
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Vigdorchik JM, Esquivel AO, Jin X, Yang KH, Onwudiwe NA, Vaidya R. Biomechanical stability of a supra-acetabular pedicle screw internal fixation device (INFIX) vs external fixation and plates for vertically unstable pelvic fractures. J Orthop Surg Res 2012; 7:31. [PMID: 23017093 PMCID: PMC3511881 DOI: 10.1186/1749-799x-7-31] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 09/26/2012] [Indexed: 12/13/2022] Open
Abstract
Background We have recently developed a subcutaneous anterior pelvic fixation technique (INFIX). This internal fixator permits patients to sit, roll over in bed and lie on their sides without the cumbersome external appliances or their complications. The purpose of this study was to evaluate the biomechanical stability of this novel supraacetabular pedicle screw internal fixation construct (INFIX) and compare it to standard internal fixation and external fixation techniques in a single stance pelvic fracture model. Methods Nine synthetic pelves with a simulated anterior posterior compression type III injury were placed into three groups (External Fixator, INFIX and Internal Fixation). Displacement, total axial stiffness, and the stiffness at the pubic symphysis and SI joint were calculated. Displacement and stiffness were compared by ANOVA with a Bonferroni adjustment for multiple comparisons Results The mean displacement at the pubic symphysis was 20, 9 and 0.8 mm for external fixation, INFIX and internal fixation, respectively. Plate fixation was significantly stiffer than the INFIX and external Fixator (P = 0.01) at the symphysis pubis. The INFIX device was significantly stiffer than external fixation (P = 0.017) at the symphysis pubis. There was no significant difference in SI joint displacement between any of the groups. Conclusions Anterior plate fixation is stiffer than both the INFIX and external fixation in single stance pelvic fracture model. The INFIX was stiffer than external fixation for both overall axial stiffness, and stiffness at the pubic symphysis. Combined with the presumed benefit of minimizing the complications associated with external fixation, the INFIX may be a more preferable option for temporary anterior pelvic fixation in situations where external fixation may have otherwise been used.
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22
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A new classification for complex lumbosacral injuries. Spine J 2012; 12:612-28. [PMID: 22964014 DOI: 10.1016/j.spinee.2012.01.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Revised: 12/24/2011] [Accepted: 01/22/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT The optimal classification and treatment algorithm for complex lumbosacral injuries, in particular high-energy sacral fractures and lumbosacral dissociation (LSD) injuries, remains controversial. Currently used classification systems are largely descriptive, lacking validity, reproducibility, treatment considerations, and prognostic information. PURPOSE We set out to develop a comprehensive, yet practical, classification system for complex lumbosacral injuries that assists in clinical decision making. STUDY DESIGN We developed a new classification system for complex lumbosacral injuries derived through literature review, expert opinion, and our clinical experience treating combat casualties over the past 10 years. We have seen an increased incidence of complex sacral fractures and LSD injuries after high-energy blast trauma, motor vehicle collisions, and aircraft crashes. METHODS We performed an extensive literature review and discussed the proposed classification with spinal trauma surgeons from a variety of institutions familiar with the treatment of complex high-energy sacral fractures and LSD injuries. We identified the significant clinical and radiographic variables encountered in the decision-making process for the treatment of complex lumbosacral injuries. Existing classification systems were reviewed in light of these essential characteristics, and their limitations were defined and addressed with the new system. RESULTS A new classification system called lumbosacral injury classification system (LSICS) was devised based on three injury characteristics: injury morphology, posterior ligamentous complex integrity, and neurologic status. A composite injury severity score was calculated by summing a weighted score from each category, allowing patients to be stratified into surgical and nonsurgical treatment groups based on threshold values. Modifiers to determining appropriate selection for operative treatment include systemic injury load and physiological status of the polytraumatized patient, soft-tissue status, and expected time to mobility. Finally, an algorithm was developed to determine the optimum operative technique based on the previously outlined injury characteristics. CONCLUSIONS The LSICS provides a comprehensive and practical approach for evaluating injury severity and guiding clinical decision making. This system provides common language for surgeons to communicate various injury patterns and formulate treatment modalities. Further studies are necessary to determine the reliability and validity of this new classification system.
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Papathanasopoulos A, Tzioupis C, Giannoudis VP, Roberts C, Giannoudis PV. Biomechanical aspects of pelvic ring reconstruction techniques: Evidence today. Injury 2010; 41:1220-7. [PMID: 21288466 DOI: 10.1016/j.injury.2010.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2010] [Indexed: 02/07/2023]
Abstract
Despite the remarkable advances achieved within the boundaries of the new discipline of Pelvic surgery, pelvic ring disruptions remain challenging and complex problems in orthopaedics. The long-term complications related to reconstruction techniques of these injuries have motivated researchers and surgeons to explore various alternative treatment modalities. Several biomechanical studies have addressed these issues. We performed a medline search including studies published during the last 30 years. Our search yielded 114 studies, 39 of which met the pre-specified inclusion criteria and were further critically analysed and discussed regarding the biomechanical aspects of pelvic ring reconstruction techniques. Based on observational approach and evaluation of the studies specific keypoints are highlighted comprising the clinical translation of the biomechanical supported findings.
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Affiliation(s)
- A Papathanasopoulos
- Academic Department of Trauma & Orthopaedic Surgery, LIMM section Musculoskeletal Disease, School of Medicine, University of Leeds, UK
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Tonetti J, Carrat L, Blendea S, Merloz P, Troccaz J, Lavallée S, Chirossel JP. Clinical Results of Percutaneous Pelvic Surgery. Computer Assisted Surgery Using Ultrasound Compared to Standard Fluoroscopy. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/10929080109146084] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Barrick EF, O'mara JW, Lane HE. Iliosacral Screw Insertion Using Computer-Assisted CT Image Guidance: a Laboratory Study. ACTA ACUST UNITED AC 2010. [DOI: 10.3109/10929089809148149] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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A comprehensive analysis with minimum 1-year follow-up of vertically unstable transforaminal sacral fractures treated with triangular osteosynthesis. J Orthop Trauma 2009; 23:313-9; discussion 319-21. [PMID: 19390356 DOI: 10.1097/bot.0b013e3181a32b91] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE To analyze the radiographic, clinical, and functional results of triangular osteosynthesis constructs for the treatment of vertically unstable comminuted transforaminal sacral fractures. SETTING Level I trauma center. METHODS During a 3-year period (July 1, 2003 to June 30, 2006), 58 patients with vertically unstable pelvic injuries were treated with triangular osteosynthesis fixation by a single surgeon at a single institution. Patients were followed-up prospectively as a single cohort, with institutional review board approval. Inclusion criteria for this study were skeletally mature patients with a vertically unstable pelvic ring injury associated with a comminuted transforaminal sacral fracture. Minimum follow-up, both clinically and radiographically, was 1 year. Computed tomography scan was performed on all patients at 6 months to assess healing of the fracture. If the fracture healed, the fixation was removed. Functional outcome was assessed using the Short Form 36, version 2, and short version of Musculoskeletal Functional Assessment questionnaires at 6 months (before fixation removal) and 12 months. RESULTS Forty of 58 patients with an average age of 39 years were available for a minimum of 1-year follow-up. Wound complications requiring surgical debridement occurred in 5 patients (13%), all of whom had severe soft tissue wounds with internal degloving. Two patients required removal of infected fixation. Iatrogenic L5 nerve injury occurred in 5 patients (13%). Ten patients (25%) had a delayed union on computed tomography scans, and 3 patients had a nonunion as a result of residual fracture gap and incomplete reduction. Six patients (15%) were found to have pronounced tilting of the L5 vertebral body (scoliosis) and distraction of the L5/S1 facet joint ipsilateral to the fixation. This did not correct with removal of the fixation. Failure of the triangular osteosynthesis construct resulting in malunion occurred in 2 patients (5%). All but 2 patients (95%) complained of painful and prominent implants. Functional outcome scoring showed that patients continued to function below the population mean at 1 year but continued to improve, particularly with function and daily activity. Ninety-seven percent of patients returned to some form of work or schooling. CONCLUSIONS Triangular osteosynthesis fixation is a reliable form of fixation that allows early full weight-bearing at 6 weeks while preventing loss of reduction in comminuted vertical shear transforaminal sacral fractures. For this study group, operative reduction was maintained until healing in 95% of patients. However, the 1-year follow-up shows a substantial rate of potential technical problems and complications. Of primary concern were the asymmetric L5 tilting with L5-S1 facet joint distraction and the need for a second surgery in all patients to remove painful fixation. Iatrogenic nerve injury occurred in 5 patients (13%) and is thought to arise secondary to fracture manipulation and reduction. We recommend selective use of this technique for comminuted transforaminal sacral fractures in situations only where reliable iliosacral or trans-sacral screw fixation is not obtainable.
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Treatment of posterior pelvic ring injuries with minimally invasive percutaneous plate osteosynthesis. INTERNATIONAL ORTHOPAEDICS 2009; 33:1435-9. [PMID: 19352659 DOI: 10.1007/s00264-009-0756-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 03/03/2009] [Accepted: 03/04/2009] [Indexed: 10/20/2022]
Abstract
From January 2004 to July 2007, 21 patients with injuries at the posterior pelvic ring were treated with locking compression plate osteosynthesis through a minimally invasive approach and followed up for a mean of 12.2 months. Preoperative and postoperative radiography was conducted to assess the reduction and union. The mean operation time was 60 minutes (range: 40-80). Intraoperative blood loss was 50-150 ml. All patients achieved union at the final follow-up. The overall radiological results were excellent or good in 17 patients (85%). The functional outcome was excellent or good in 18 patients (90%). There was no iatrogenic nerve injury, deep infection or failure of fixation. We believe that fixation with a locking compression plate is an effective method for the treatment of injuries of the posterior pelvic ring in view of its convenience, minimal traumatic invasion and lower morbidity.
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Suzuki T, Hak DJ, Ziran BH, Adams SA, Stahel PF, Morgan SJ, Smith WR. Outcome and complications of posterior transiliac plating for vertically unstable sacral fractures. Injury 2009; 40:405-9. [PMID: 19095233 DOI: 10.1016/j.injury.2008.06.039] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 05/23/2008] [Accepted: 06/12/2008] [Indexed: 02/02/2023]
Abstract
Vertically unstable sacral fractures often make it difficult to achieve rigid fixation and there is no consensus on the optimal fixation technique for these injuries. The purpose of this study was to evaluate complication rate and short-term outcome of vertically unstable sacral fractures treated by posterior transiliac plate fixation. We performed a retrospective review of prospectively collected data of patients who underwent posterior transiliac plating for sacral fractures at two institutions. All patients were treated with the standard posterior approach using a 4.5-mm reconstruction plate and followed for at least 12 months. Patients' demographics, Majeed functional questionnaire surveys, and radiographic outcomes were collected. There were 19 patients with a mean age of 37.5-years. The mean follow-up was 26.3 months. The most frequent mechanism of injury was a fall from a height. According to the AO/OTA classification, there were 10 C1, 6 C2, and 3 C3, which were classified as 2 Denis I, 20 Denis II, and 2 Denis III, including 5 bilateral sacral fractures. Neurological deficit at the initial examination was recorded in 10 patients. The mean ISS was 20.7 and the mean timing of the internal fixation was 6.4 days. Anterior internal fixation of pelvic ring was added in eight patients. A Morel-Lavallee lesion was identified in 5 patients during the operation. Reductions were graded as nine excellent, seven good, and three fair according to the method of Tornetta. There were two postoperative surgical wound infections, both occurring in patients with a Morel-Lavallee lesion. All the sacral fractures united eventually and no implant failure occurred, though there were two patients with a small loss of reduction (<5mm) over the follow-up period. A total of 18 patients completed the functional assessment with a mean score of 78.5 points. Posterior plate fixation of vertically unstable sacral fractures is effective in maintaining fracture reduction even in the presence of significant posterior comminution. We caution its use in the presence of a known Morel-Lavallee lesion, as this may increase the wound complication and infection risk.
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Affiliation(s)
- Takashi Suzuki
- Department of Orthopaedic Surgery, Denver Health Medical Centre, University of Colorado School of Medicine, 777 Bannock Street, Denver, CO 80204, USA.
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Culemann U, Seelig M, Lange U, Gänsslen A, Tosounidis G, Pohlemann T. [Biomechanical comparison of different stabilisation devices for transforaminal sacral fracture. Is an interlocking device advantageous?]. Unfallchirurg 2008; 110:528-36. [PMID: 17318310 DOI: 10.1007/s00113-007-1236-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Reliable osteosynthesis for fractures in the different regions of the human pelvis are described in the literature while there is no common and satisfying treatment for unstable sacral fractures. Because of the posterior pelvic rings special anatomic conditions a local plate osteosynthesis seems to be advantageous. In many fields of modern fracture treatment locking implants show superior results. The prototype of a local locking plate osteosynthesis was compared to a common local plate and two sacroiliac screws. METHODS The implants were tested using six plastic models of the pelvis and three embalmed human specimens. A Tile C1 fracture was created by disruption of the pubic symphysis and a transforaminal osteotomy. The specimens were exposed to axial loading in an upright single-leg stance with a maximum of 800 N for the plastic models and 200 N for the human specimens. An ultrasonic-based measuring system recorded translations (X, Y, Z) and rotations (alpha, beta, gamma). Parameters such as pattern of motion, translation/rotation, load to failure and remaining dislocation were evaluated. RESULTS Concerning most of the evaluated parameters the local plate osteosynthesis was inferior compared with two sacroiliac screws. There were no significant differences between the locking implant and the local plate osteosynthesis. Compared with the two sacroiliac screws the locking implant shows biomechanically equal results but allows greater anterior rotation and remaining dislocation. Because of the lower bone quality, the results from the anatomic specimen tested were not utilisable. CONCLUSIONS The locking implant is biomechanically an alternative compared with two sacroiliac screws. Problems occurred due to the preset direction of the locking head screws.
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Affiliation(s)
- U Culemann
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum des Saarlandes, Kirrberger Strasse 1, 66421 Homburg/Saar.
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Minimally invasive transiliac plate osteosynthesis for type C injuries of the pelvic ring: a clinical and radiological follow-up. J Orthop Trauma 2007; 21:595-602. [PMID: 17921833 DOI: 10.1097/bot.0b013e318158abcf] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate radiological and functional outcome in patients treated with minimally invasive transiliac plate osteosynthesis for unstable pelvic injuries. DESIGN Retrospective analysis of a prospective treatment protocol in a consecutive patient series. SETTING Level 1 trauma center. PATIENTS Between January 1998 and December 2005, 31 patients with type C injuries of the pelvic ring were treated with minimally invasive transiliac plate osteosynthesis. According to the AO classification, 16 patients had a C1-injury, 9 had a C2 fracture, and 6 patients sustained a C3 injury of the pelvic ring. Anterior-posterior, inlet, and outlet radiographs were obtained preoperatively, immediately postoperatively, and during follow-up. Clinical outcome was determined according to the Hannover pelvic outcome score. INTERVENTION Posterior plate osteosynthesis for type C injuries of the pelvic ring. MAIN OUTCOME MEASUREMENT Preoperative and postoperative dislocation of the posterior pelvic ring, loss of reduction, implant failure, implant removal, clinical results of the pelvic injury and general limitations following the trauma. RESULTS Maximum average dislocation of the posterior pelvic ring was 16.1 mm preoperatively; postoperatively, it was 6.1 mm. A total of 23 patients (74.2%) could be followed up after an average of 20 months (range 7-57 months). Seven patients underwent follow-up treatment at other hospitals closer to their respective residences, whereas 1 patient passed away in the early postoperative phase due to multiorgan failure. Loss of reduction occurred in 2 cases. The clinical outcome regarding the pelvis was very good in 8 cases, good in 9 cases, fair in 4 cases, and poor in 2 cases. Social reintegration according to the Hannover pelvic outcome score was complete in 9 cases, poor in 10 cases, and incomplete in 10 cases. CONCLUSION Posterior plate osteosynthesis is a sufficiently stable method for the treatment of unstable pelvic ring injuries with a low risk of iatrogenic nervous tissue and vascular lesions. The disadvantages are limited reduction possibilities, the necessity of bilateral bridging of the sacroiliac joint in a unilateral injury, as well as a higher rate of symptomatic hardware.
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Korovessis PG, Magnissalis EA, Deligianni D. Biomechanical evaluation of conventional internal contemporary spinal fixation techniques used for stabilization of complete sacroiliac joint separation: a 3-dimensional unilaterally isolated experimental stiffness study. Spine (Phila Pa 1976) 2006; 31:E941-51. [PMID: 17139210 DOI: 10.1097/01.brs.0000247951.10364.c2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Comparative 3-dimensional biomechanical testing. OBJECTIVE To compare 5 fixation techniques, 3 using screws or screw and plates and 2 spinal, used for stabilization of complete unilateral sacroiliac dislocation in composite models. SUMMARY OF BACKGROUND DATA Harrington compression rods have been used for posterior iliosacral stabilization. Recently, the use of compact spinal instrumentation has been introduced for stabilization of iliosacral joint separation to achieve immediate and permanent stability, allowing early mobilization. To the authors' knowledge, no comparative mechanical studies between commonly used internal fixation techniques and contemporary spinal instrumentation have been performed. METHODS Fifteen identical composite models of the left hemipelvis and sacrum were used to simulate consistently the "worst-case scenario" of complete unilateral sacroiliac dislocation. Subgroups of 3 models each were used to apply 5 (A-E) alternative fixation iliosacral joint fixation techniques: 1 multiaxial 7.5 mm Cotrel-Dubousset screw inserted in the posterior superior iliac spine and connected with a long Cotrel-Dubousset horizontal rod with 6.5 mm multiaxial Cotrel-Dubousset screws inserted bilaterally in the S1 pedicles (technique A); 1 multiaxial 7.5 mm Cotrel-Dubousset titanium pedicle screw inserted in the posterior superior iliac spine and connected with a short horizontal Cotrel-Dubousset-rod to a 6.5 mm multiaxial Cotrel-Dubousset-screw inserted to the ipsilateral S1 pedicle (technique B); 1, 6.5 mm cancellous AO-screw (technique C); 2, 6.5 mm cancellous AO screws (technique D); and 2 dynamic stainless steel compression plates (technique E) placed anteriorly. Constructs were biomechanically tested. The ilium was unilaterally rigidly fixed, the sacrum was put horizontal in the mediolateral direction with a forward tilt of 30 degrees (close to physiologic conditions) in the sagittal plane, and a vertical quasi-static compressive load ranging from 0 to 500 N was applied on the endplate of S1, reproducing a "worst case" loading scenario. Construct stiffness, frontal plus sagittal kinematics, and iliosacral joint gap size for all 5 techniques were measured. RESULTS The construct stiffness (N/mm +/- standard deviation) ranged for model: A, 121 +/- 18; B, 78 +/- 10; C, 168 +/- 13; D, 193 +/- 42; and E, 145 +/- 4. All other parameters exhibited minor variations between the different techniques of fixation: at the 400 N load level, the maximum iliosacral gap globally ranged 0.9-2.8 mm, the maximum mediolateral sacral tilt ranged 1.3-2.4 degrees, and the maximum anteroposterior sacral tilt ranged 0.6-3.0 degrees. CONCLUSIONS The iliosacral fixation with 2 6.5 mm AO-cancellous screws for complete sacroiliac dislocation demonstrated the highest stiffness and the short spinal instrumentation the poorest stiffness. All other fixation techniques could be generally considered of equivalent stability value.
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Affiliation(s)
- Panagiotis G Korovessis
- General Hospital Agios Andreas; A' Orthopaedic Department, 65-67 Haralabi Str., Patras, GR-26224 Greece.
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Anderson DE, Cotton JR. Mechanical analysis of percutaneous sacroplasty using CT image based finite element models. Med Eng Phys 2006; 29:316-25. [PMID: 16730213 DOI: 10.1016/j.medengphy.2006.03.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2005] [Revised: 03/14/2006] [Accepted: 03/22/2006] [Indexed: 10/24/2022]
Abstract
Sacral insufficiency fractures are an under-diagnosed source of acute lower back pain. A polymethylmethacrylate (PMMA) cement injection procedure called sacroplasty has recently been utilized as a treatment for sacral insufficiency fractures. It is believed that injection of cement reduces fracture micromotion, thus relieving pain. In this study, finite element models were used to examine the mechanical effects of sacroplasty. Finite element models were constructed from CT images of two cadavers on which sacroplasties were performed. The images were used to create the mesh geometry, and to apply non-homogeneous material properties to the models. Models were created representing the case with and without cement, thus simulating the pre- and post-sacroplasty situation. The results indicate that the sacrum has a 3D multi-axial state of strain. While compressive strains were the largest, tensile and shear strains were significant as well. Cement in the sacrum reduced strains 40-60% locally around the cement. However, overall model stiffness only increased 1-4%. This indicates that the effects of sacroplasty are primarily local.
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Affiliation(s)
- Dennis E Anderson
- Department of Engineering Science and Mechanics, Virginia Tech-Wake Forest School of Bioengineering and Science, Virginia Tech, Blacksburg, VA 24061, United States
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Hilgert RE, Finn J, Egbers HJ. Technik der perkutanen SI-Verschraubung mit Unterstützung durch konventionellen C-Bogen. Unfallchirurg 2005; 108:954, 956-60. [PMID: 15977007 DOI: 10.1007/s00113-005-0967-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND During percutaneous iliosacral screw fixation, fluoroscopy with a conventional C-arm X-ray unit is still the standard procedure for intraoperative orientation. Lateral sacral images in combination with the inlet and outlet view are always necessary. Nevertheless, the complex pelvic anatomy makes it difficult to prevent malpositioning of screws. OPERATIVE TECHNIQUE Defining the correct entry into the bone is the decisive step for ideal screw placement. The better this is defined, the larger safety margins will be concerning cortical perforation by the screws. In the lateral view, an entry ventral to the sacral canal has to be avoided as well as an entry into the cranial half of the first sacral vertebra. To improve the surgeon's three-dimensional orientation with the help of his personal experience and two-dimensional images, it is recommended to place the tip of the screws in the center of the sacrum (in AP view) whenever possible. Routinely performed postoperative CT imaging of 24 screws, consecutively implanted according to the standards described, revealed no case of malpositioning. CONCLUSION Standard X-ray views in combination with standardized aiming of screw entry position and final screw thread position enable the surgeon to find the "safe zone" for iliosacral screw insertion and to prevent iliosacral screw malpositioning with high accuracy.
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Affiliation(s)
- R E Hilgert
- Klinik für Unfallchirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel.
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Harma A, Inan M. Surgical management of transforaminal sacral fractures. INTERNATIONAL ORTHOPAEDICS 2005; 29:333-7. [PMID: 16047213 PMCID: PMC3456638 DOI: 10.1007/s00264-005-0678-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2005] [Accepted: 05/09/2005] [Indexed: 10/25/2022]
Abstract
Fourteen patients with transforaminal sacral fractures were treated with posterior iliosacral instrumentation. Patients were assessed in terms of surgical technique and functional results. A subjective functional scoring with a five-point scale was performed at the last follow-up. Activity pain, pain at rest, limping and patient satisfaction were evaluated. By considering symptom and satisfaction scores, subjective functional assessment revealed that ten patients had excellent results, two good and two moderate. There were no patients with poor functional outcome. The surgical technique is not a new concept. Combining sacral bar and pediculo-iliac fixation methods, provides vertical as well as horizontal stability and allows early weight bearing, the methods has many advantages. However, vertical and horizontal stabilities achieved by this technique may require further assessment with comparative biomechanical studies.
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Affiliation(s)
- Ahmet Harma
- Department of Orthopaedics and Traumatology, Turgut Ozal Medical Center, Inonu University, Malatya, Turkey.
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Abstract
Eighteen patients with vertically unstable sacral fractures in type C of AO classification, who underwent open reduction and internal fixation, were investigated. Vertically unstable sacral fractures were fixed using a M-Shaped Pelvic Plate prepared by the author with posterior longitudinal incision. The postoperative results were determined by Majeed's functional evaluation and radiography. Excellent in 12 and good in 3. Poor cases were infection and sciatic nerve paralysis. M transiliac plate fixation was achieved by rigid fixation with less invasion for vertically unstable sacral fractures.
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Affiliation(s)
- Masahiro Shirahama
- Department of Orthopaedic Surgery, Kurume University School of Medicine, Kurume 830-0011, Japan.
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van Zwienen CMA, van den Bosch EW, Hoek van Dijke GA, Snijders CJ, van Vugt AB. Cyclic loading of sacroiliac screws in Tile C pelvic fractures. ACTA ACUST UNITED AC 2005; 58:1029-34. [PMID: 15920420 DOI: 10.1097/01.ta.0000158515.58494.11] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND To investigate the stiffness and strength of completely unstable pelvic fractures fixated both anteriorly and posteriorly under cyclic loading conditions, the authors conducted a randomized, comparative, cadaveric study. METHODS In 12 specimens, a Tile C1 pelvic fracture was created. The authors compared the intact situation to anterior plate fixation combined with one or two sacroiliac screws. In 2,000 measurements, each pelvis was loaded with a maximum of 400 N. The translation and rotation stiffness of the fixations were measured using a three-dimensional video system. Furthermore, the load to failure and the number of cycles before failure were determined. RESULTS Both translation and rotation stiffness of the intact pelvis were superior to the fixated pelvis. No difference in stiffness was found between the techniques with one or two sacroiliac screws. However, a significantly higher load to failure and significantly more loading cycles before failure could be achieved using two sacroiliac screws compared with one screw. CONCLUSION Although the combination of anterior plate fixation combined with two sacroiliac screws is not as stable as the intact pelvis, in this study, embalmed aged pelves could be loaded repeatedly with physiologic forces. Given the fact that the average trauma patient is younger and given the fact that the quality (or grip) of the fixation was a significant covariable for longer endurance of the fixation, this suggests that direct postoperative weight bearing could be possible if these results are confirmed in further research.
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Affiliation(s)
- C M A van Zwienen
- Biomedical Physics and Technology, Erasmus University Rotterdam, The Netherlands
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Mouhsine E, Wettstein M, Schizas C, Borens O, Blanc CH, Leyvraz PF, Theumann N, Garofalo R. Modified triangular posterior osteosynthesis of unstable sacrum fracture. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2005; 15:857-63. [PMID: 15843970 PMCID: PMC3489439 DOI: 10.1007/s00586-004-0858-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2004] [Revised: 10/09/2004] [Accepted: 10/27/2004] [Indexed: 11/26/2022]
Abstract
We report preliminary results for unstable sacral fractures treated with a modified posterior triangular osteosynthesis. Seven patients were admitted to our trauma center with an unstable sacral fracture. The average age was 31 years (22-41). There were four vertical shear lesions of the pelvis and three transverse fracture of the upper sacrum. The vertical shear injuries were initially treated with an anterior external fixator inserted at the time of admission. Definitive surgery was performed at a mean time of 9 days after trauma. The operation consisted in a posterior fixation combining a vertebropelvic distraction osteosynthesis with pedicle screws and a rod system, whereby the transverse fixation was obtained using a 6 mm rod as a cross-link between the two main rods. Late displacement of the posterior pelvis or fracture was measured on X-ray films according to the criteria of Henderson. The patients were followed-up for a minimum time of 12 months. Four patients who presented with a pre-operative perineal neurological impairment made a complete recovery. No iatrogenic nerve injury was reported. One case of deep infection was managed successfully with surgical debridement and local antibiotics. All patients complained of symptoms related to the prominence of the iliac screws. The metalwork was removed in all cases after healing of the fracture, at a mean time of 4.3 months after surgery. No loss of reduction of fracture was seen at final radiological follow-up. The preliminary results are promising. The fixation is sufficiently stable to allow an immediate progressive weight-bearing, and safe nursing care in polytrauma cases. The only problem seems to be related to prominent heads of the distal screws.
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Affiliation(s)
- E Mouhsine
- Department of Orthopaedic and Traumatology, University Hospital, OTR-BH 14, CHUV 1011 Lausanne, Switzerland.
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van Zwienen CMA, van den Bosch EW, Snijders CJ, Kleinrensink GJ, van Vugt AB. Biomechanical comparison of sacroiliac screw techniques for unstable pelvic ring fractures. J Orthop Trauma 2004; 18:589-95. [PMID: 15448446 DOI: 10.1097/00005131-200410000-00002] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the stiffness and strength of various sacroiliac screw fixations to compare different sacroiliac screw techniques. DESIGN Randomized comparative study on embalmed human pelvises. MATERIALS AND METHODS In 12 specimens, we created a symphysiolysis and sacral fractures on both sides. Each of these 24 sacral fractures was fixed with 1 of the following methods: 1 sacroiliac screw in the vertebral body of S1, 2 screws convergingly in S1, or 1 screw in S1 and 1 in S2. On the left and right side of a pelvis, different techniques were used. The pubic symphysis was not stabilized. We measured the translation and rotation stiffness of the fixations and the load to failure using a 3-dimensional video system. RESULTS The stiffness of the intact posterior pelvic ring was superior to any screw technique. Significant differences were found for the load to failure and rotation stiffness between the techniques with 2 screws and a single screw in S1. The techniques utilizing 2 screws showed no differences. CONCLUSIONS Based on the results of this study, we can conclude that a second sacroiliac screw in completely unstable pelvic fractures increases rotation stiffness and improves the load to failure.
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Affiliation(s)
- C M A van Zwienen
- Biomedical Physics and Technology, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Sagi HC, Ordway NR, DiPasquale T. Biomechanical analysis of fixation for vertically unstable sacroiliac dislocations with iliosacral screws and symphyseal plating. J Orthop Trauma 2004; 18:138-43. [PMID: 15091266 DOI: 10.1097/00005131-200403000-00002] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To examine the effects of various iliosacral screw configurations with and without symphyseal plating on sacroiliac (SI) motion and hemipelvis stability in the vertically unstable pelvic model. DESIGN Biomechanical, human cadaver. SETTING Level 1 trauma center. INTERVENTION Hemipelvis and SI motion were analyzed on a Materials Testing System before and after creation of a vertically unstable APC III pelvic injury. Posterior fixation constructs consisted of iliosacral screws: (1). one into S1, (2). two into S1, or (3). one into S1 and one into S2. Results were obtained for all posterior constructs with and without a two-hole symphyseal plate. MAIN OUTCOME MEASUREMENT Hemipelvis and SI motion with axial loading. RESULTS There was no statistically significant difference between one or two iliosacral screws when hemipelvis rotational or linear displacement was examined at the SI joint. The two-hole symphyseal plate significantly increased the stability of the fixation construct in resisting linear displacement in all three planes. Without the symphyseal plate, an abnormal loading response was seen at the SI joint, resulting in paradoxical posterior translation and sagittal plane rotation. The addition of the plate restored the normal response, and anterior rotation and translation were observed as in the intact state. CONCLUSIONS Anterior symphyseal plating for the vertically unstable hemipelvis significantly increases the stability of the fixation construct and restores the normal response of the hemipelvis to axial loading. A significant benefit to supplementary iliosacral screws in addition to a properly placed S1 iliosacral screw was not shown.
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Affiliation(s)
- H C Sagi
- UCSF-Fresno Medical Education Program, Fresno, CA 93702, USA.
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Abstract
OBJECTIVE To determine relative stiffness of various methods of posterior pelvic ring internal fixation. DESIGN Simulated single leg stance loading of OTA 61-Cl.2, a2 fracture model (unilateral sacroiliac joint disruption and pubic symphysis diastasis). SETTING Orthopaedic biomechanic laboratory. OUTCOME VARIABLES Pubic symphysis gapping, sacroiliac joint gapping, hemipelvis coronal plane rotation. METHODS Nine different posterior pelvic ring fixation methods were tested on each of six hard plastic pelvic models. Pubic symphysis was plated. The pelvic ring was loaded to 1000N. RESULTS All data were normalized to values obtained with posterior fixation with a single iliosacral screw. The types of fixation could be grouped into three categories based on relative stiffness of fixation: For sacroiliac joint gapping, group 1-fixation stiffness 0.8 and above (least stiff) includes a single iliosacral screw (conditions A and J), an isolated tension band plate (condition F), and two sacral bars (condition H); group 2-fixation stiffness 0.6 to 0.8 (intermediate stiffness) includes a tension band plate and an iliosacral screw (condition E), one or two sacral bars in combination with an iliosacral screw (conditions G and I); group 3-fixation stiffness 0.6 and below (greatest stiffness) includes two anterior sacroiliac plates (condition D), two iliosacral screws (condition B), and two anterior sacroiliac plates and an iliosacral screw (condition C). For sacroiliac joint rotation, group 1-fixation stiffness 0.8 and above includes a single iliosacral screw (conditions A and J), two anterior sacroiliac plates (condition D), a tension band plate in isolation or in combination with an iliosacral screw (conditions E and F), and two sacral bars (condition H); group 2-fixation stiffness 0.6 to 0.8 (intermediate level of instability) includes either one or two sacral bars in combination with an iliosacral screw (conditions G and I); group 3-fixation stiffness 0.6 and below (stiffest fixation) consists of two iliosacral screws (condition B) and two anterior sacroiliac plates and an iliosacral screw (condition C). DISCUSSION Under conditions of maximal instability with similar material properties between specimens, differences in stiffness of posterior pelvic ring fixation can be demonstrated. The choice of which method to use is multifactorial.
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Affiliation(s)
- Kent Yinger
- Santa Monica Group, Santa Monica, California, USA
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Schildhauer TA, Ledoux WR, Chapman JR, Henley MB, Tencer AF, Routt MLC. Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads. J Orthop Trauma 2003; 17:22-31. [PMID: 12499964 DOI: 10.1097/00005131-200301000-00004] [Citation(s) in RCA: 189] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To conduct a biomechanical comparison of a new triangular osteosynthesis and the standard iliosacral screw osteosynthesis for unstable transforaminal sacral fractures in the immediate postoperative situation as well as in the early postoperative weight-bearing period. DESIGN Twelve preserved human cadaveric lumbopelvic specimens were cyclicly tested in a single-limb-stance model. A transforaminal sacral fracture combined with ipsilateral superior and inferior pubic rami fractures were created and stabilized. Loads simulating muscle forces and body weight were applied. Fracture site displacement in three dimensions was evaluated using an electromagnetic motion sensor system. INTERVENTION Specimens were randomly assigned to either an iliosacral and superior pubic ramus screw fixation or to a triangular osteosynthesis consisting of lumbopelvic stabilization (between L5 pedicle and posterior ilium) combined with iliosacral and superior pubic ramus screw fixation. MAIN OUTCOME MEASURES Peak loaded displacement at the fracture site was measured for assessment of initial stability. Macroscopic fracture behavior through 10,000 cycles of loading, simulating the early postoperative weight-bearing period, was classified into type 1 with minimal motion at the fracture site, type 2 with complete displacement of the inferior pubic ramus, or type 3 with catastrophic failure. RESULTS The triangular osteosynthesis had a statistically significantly smaller displacement under initial peak loads (mean +/- standard deviation [SD], 0.163 +/- 0.073 cm) and therefore greater initial stability than specimens with the standard iliosacral screw fixation (mean +/- SD, 0.611 +/- 0.453 cm) ( = 0.0104), independent of specimen age or sex. All specimens with the triangular osteosynthesis demonstrated type 1 fracture behavior, whereas iliosacral screw fixation resulted in one type 1, two type 2, and three type 3 fracture behaviors before or at 10,000 cycles of loading. CONCLUSION Triangular osteosynthesis for unstable transforaminal sacral fractures provides significantly greater stability than iliosacral screw fixation under in vitro cyclic loading conditions. In vitro cyclic loading, as a limited simulation of early stages of patient mobilization in the postoperative period, allows for a time-dependent evaluation of any fracture fixation system.
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Affiliation(s)
- Thomas A Schildhauer
- Department of Orthopaedics & Sports Medicine, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Seattle, WA 98104, USA.
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Abstract
Management of the patient with a high-energy pelvic fracture requires a multidisciplinary team approach with coordination between the general surgery, orthopaedic surgery, neurosurgery, and urology teams. Resuscitation and initial evaluation efforts are critical in stabilization of the patient. An understanding of the complex nature of the pelvic anatomy and injury patterns, the associated injuries, and various treatment fixation constructs are necessary for a successful outcome. This review outlines the initial stabilization and definitive management for the spectrum of pelvic ring disruptions. Case examples illustrate the discussion.
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Affiliation(s)
- P J Kregor
- Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson 39216, USA
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García JM, Doblaré M, Seral B, Seral F, Palanca D, Gracia L. Three-dimensional finite element analysis of several internal and external pelvis fixations. J Biomech Eng 2000; 122:516-22. [PMID: 11091954 DOI: 10.1115/1.1289995] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Finite Element Method (FEM) can be used to analyze very complex geometries, such as the pelvis, and complicated constitutive behaviors, such as the heterogeneous, nonlinear, and anisotropic behavior of bone tissue or the noncompression, nonbending character of ligaments. Here, FEM was used to simulate the mechanical ability of several external and internal fixations that stabilize pelvic ring disruptions. A customized pelvic fracture analysis was performed by computer simulation to determine the best fixation method for each individual treatment. The stability of open-book fractures with external fixations at either the iliac crests or the pelvic equator was similar, and increased greatly when they were used in combination. However, external fixations did not effectively stabilize rotationally and vertically unstable fractures. Adequate stabilization was only achieved using an internal pubis fixation with two sacroiliac screws.
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Affiliation(s)
- J M García
- Department of Mechanical Engineering, University of Zaragoza, Spain
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MacAvoy MC, McClellan RT, Goodman SB, Chien CR, Allen WA, van der Meulen MC. Stability of open-book pelvic fractures using a new biomechanical model of single-limb stance. J Orthop Trauma 1997; 11:590-3. [PMID: 9415866 DOI: 10.1097/00005131-199711000-00008] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE A new biomechanical model of single-limb stance was developed to test the stability of intact, injured, and internally fixed pelves. DESIGN Single-limb stance was simulated by applying muscle forces and body mass loading to cadaver pelves. We created a rotationally unstable "open-book" pelvic injury in nine embalmed pelves by dividing the ligaments of the pubic symphysis, pelvic floor, and anterior and interosseus sacroiliac joint. All pelves were devoid of gross structural abnormalities. INTERVENTION Two methods of internal fixation of the pubis symphysis were compared: (a) a curved six-hole 3.5-millimeter reconstruction plate across the superior pubic symphysis, and (b) the same six-hole 3.5-millimeter reconstruction plate plus a perpendicularly oriented four-hole 3.5-millimeter reconstruction plate placed across the anterior symphysis. MAIN OUTCOME MEASUREMENTS We measured vertical shear displacement at the public symphysis and horizontal displacement at the anterior sacroiliac joint. The results for the injured and fixed specimens were compared with each other and with the results for the intact specimens. RESULTS The injured unfixed specimens showed marked instability that was prevented by both methods of fixation of the pubic symphysis. No significant differences could be demonstrated between single and double plating of the disrupted pubic symphysis when using this single-limb stance model. CONCLUSION This model of single-limb stance suggests that a single symphyseal plate across the pubic symphysis can stabilize the open-book injury under short-term quasi-static loads.
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Affiliation(s)
- M C MacAvoy
- Division of Orthopaedic Surgery, School of Medicine, Stanford University, California, USA
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Abstract
This article reviews a series of biomechanical studies performed in the author's laboratory, evaluating the instabilities produced by the more common and problematic pelvic ring fracture patterns and the increasingly popular and newly developed modes of internal fixation. Topics that are discussed include the following: anteroposterior compression injuries and the disrupted sacroiliac joint; sacral fractures; anteroposterior compression injuries and symphyseal fixation; new symphyseal plate designs; unstable pubic rami fractures; unstable fractures of the iliac wing; and resuscitation fixator biomechanics.
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Affiliation(s)
- P T Simonian
- The Hospital for Special Surgery, Cornell University Medical College, New York, New York, USA
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49
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Abstract
Pelvic ring disruptions are challenging management problems for the orthopedic surgeon. Early hemorrhage, permanent nerve injury, and late pain caused by residual pelvic deformity are some of the many complicating factors. A variety of treatment alternatives are available to stabilize the disrupted pelvic ring. Each technique has inherent advantages and problems.
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Affiliation(s)
- M L Routt
- Harborview Medical Center, Department of Orthopaedic Surgery, University of Washington, Seattle, Washington 98104, USA
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