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Abo-Elsoud M, Awad MI, Abdel Karim M, Khaled S, Abdelmoneim M. Internal fixator vs external fixator in the management of unstable pelvic ring injuries: A prospective comparative cohort study. World J Orthop 2023; 14:562-571. [PMID: 37485427 PMCID: PMC10359749 DOI: 10.5312/wjo.v14.i7.562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/14/2023] [Accepted: 05/19/2023] [Indexed: 07/17/2023] Open
Abstract
BACKGROUND Reconstruction of the pelvic ring anatomy in unstable anterior pelvic ring injuries is a significant step to reduce the mortality rate associated with these injuries efficiently. There is a debate on using either an anterior subcutaneous pelvis internal fixator (INFIX) or an anterior supra-acetabular external fixator (EXFIX) to manage an unstable anterior pelvic ring fracture.
AIM To compare the functional and radiological outcomes and complications of INFIX vs EXFIX in managing unstable pelvic ring injuries.
METHODS A prospective cohort study included 54 patients with unstable pelvic ring fractures. The patients were divided into two groups; the INFIX group, in which 30 cases were fixed by INFIX, and the EXFIX group, in which 24 patients were treated by EXFIX. The average age in the EXFIX group was 31.17 years (16-57 years), while in the INFIX group, it was 34.5 years (17-53 years). The study included 20 (66.7%) males and 10 (33.3%) females in the INFIX group and 10 (41.7%) males and 14 (58.3%) females in the EXFIX group. The radiological outcomes were evaluated using Matta and Tornetta's score, and the functional outcomes using the Majeed score.
RESULTS The results revealed a statistically significant difference between both groups (P = 0.013) regarding radiological outcomes, according to Matta and Tornetta's score in favor of the INFIX group. Sitting, standing, and walking abilities were measured at a 3-mo follow-up visit using Majeed score modules. It was significantly better among the INFIX group than the EXFIX group in all three modules. At the final follow-up, both groups had no statistically significant difference according to the Majeed score; 92.35 in the INFIX group and 90.99 in the EXFIX group (P = 0.513). A lower surgical site infection rate was noticed in the INFIX group (P = 0.007).
CONCLUSION Anterior subcutaneous pelvis INFIX is associated with better radiological outcomes and a lower infection rate than anterior supra-acetabular EXFIX in managing patients with unstable anterior pelvic ring fractures.
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Affiliation(s)
- Mohamed Abo-Elsoud
- Department of Orthopedics and Traumatology, Cairo University Hospitals, Cairo 11562, Egypt
| | - Mostafa I Awad
- Department of Trauma and Orthopedics, Mataria Teaching Hospital, Cairo 4540046, Egypt
| | - Mahmoud Abdel Karim
- Department of Orthopedics and Traumatology, Cairo University Hospitals, Cairo 11562, Egypt
| | - Sherif Khaled
- Department of Orthopedics and Traumatology, Cairo University Hospitals, Cairo 11562, Egypt
| | - Mohamed Abdelmoneim
- Department of Orthopedics and Traumatology, Cairo University Hospitals, Cairo 11562, Egypt
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Berk T, Zderic I, Caspar J, Schwarzenberg P, Pastor T, Halvachizadeh S, Makelov B, Richards G, Pape HC, Gueorguiev B. A Novel Implant for Superior Pubic Ramus Fracture Fixation-Development and a Biomechanical Feasibility Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040740. [PMID: 37109698 PMCID: PMC10142566 DOI: 10.3390/medicina59040740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/10/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Pubic ramus fractures are common in compound pelvic injuries known to have an increased rate of morbidity and mortality along with recurrent and chronic pain, impeding a patient's quality of life. The current standard treatment of these fractures is percutaneous screw fixation due to its reduced risk of blood loss and shorter surgery times. However, this is an intricate surgical technique associated with high failure rates of up to 15%, related to implant failure and loss of reduction. Therefore, the aim of this biomechanical feasibility study was to develop and test a novel intramedullary splinting implant for fixation of superior pubic ramus fractures (SPRF), and to evaluate its biomechanical viability in comparison with established fixation methods using conventional partially or fully threaded cannulated screws. Materials and Methods: A type II superior pubic ramus fracture according to the Nakatani classification was created in 18 composite hemi-pelvises via a vertical osteotomy with an additional osteotomy in the inferior pubic ramus to isolate the testing of three SPRF fixation techniques performed in 6 semi-pelvises each using either (1) a novel ramus intramedullary splint, (2) a partially threaded ramus screw, or (3) a fully threaded ramus screw. Results: No significant differences were detected among the fixation techniques in terms of initial construct stiffness and number of cycles to failure, p ≥ 0.213. Conclusion: The novel ramus intramedullary splint can be used as an alternative option for treatment of pubic ramus fractures and has the potential to decrease the rate of implant failures due to its minimally invasive implantation procedure.
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Affiliation(s)
- Till Berk
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Jan Caspar
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | | | - Torsten Pastor
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Harald-Tscherne Laboratory for Orthopedic and Trauma Research, University of Zurich, Sternwartstrasse 14, 8091 Zurich, Switzerland
| | - Biser Makelov
- University Multiprofile Hospital for Active Treatment 'Prof. Stoyan Kirkovitch', Trakia University, 6003 Stara Zagora, Bulgaria
| | - Geoff Richards
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Department of Orthopaedic and Trauma Surgery, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
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Igei T, Nakasone S, Onaga M, Nishida K. Secure paediatric pelvic fracture external fixation using an intraoperative support device. BMJ Case Rep 2023; 16:16/4/e252365. [PMID: 37011998 PMCID: PMC10083815 DOI: 10.1136/bcr-2022-252365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Secure fixation by inserting a half-pin into the iliac crest as a pelvic external fixator is important. However, the thickness of the iliac bone depends on its location and this makes it difficult to insert a half-pin accurately. The iliac crest is especially narrow in the paediatric pelvis, making it difficult to insert the half-pin accurately compared with an adult pelvis. A case of pelvic external fixation is described for a paediatric pelvic fracture in this report, in which preoperative planning for half-pin insertion was performed accurately using a preoperative three-dimensional CT based on an intraoperative support device that uses the functional pelvic plane as a reference.
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Affiliation(s)
- Takahiro Igei
- Orthopaedic Surgery, University of the Ryukyus Faculty of Medicine, Graduate School of Medicine, Nakagami-gun, Okinawa, Japan
| | - Satoshi Nakasone
- Orthopaedic Surgery, University of the Ryukyus Faculty of Medicine, Graduate School of Medicine, Nakagami-gun, Okinawa, Japan
| | - Masamichi Onaga
- Orthopaedic Surgery, University of the Ryukyus Faculty of Medicine, Graduate School of Medicine, Nakagami-gun, Okinawa, Japan
| | - Kotaro Nishida
- Orthopaedic Surgery, University of the Ryukyus Faculty of Medicine, Graduate School of Medicine, Nakagami-gun, Okinawa, Japan
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Berk T, Zderic I, Schwarzenberg P, Pastor T, Lesche F, Halvachizadeh S, Richards RG, Gueorguiev B, Pape HC. Evaluation of cannulated compression headless screws as an alternative implant for superior pubic ramus fracture fixation: a biomechanical study. INTERNATIONAL ORTHOPAEDICS 2023; 47:1079-1087. [PMID: 36749374 PMCID: PMC10014654 DOI: 10.1007/s00264-023-05710-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/17/2023] [Indexed: 02/08/2023]
Abstract
BACKGROUND/PURPOSE Pubic ramus fractures account for the most common types of pelvic fractures. The standard surgical approach for superior pubic ramus fractures (SPRF) is a minimally invasive percutaneous screw fixation. However, percutaneous closed reduction and internal fixation of anterior pelvic ring injuries have high failure rates of up to 15%. The aim of this biomechanical study was to evaluate the stability of SPRF following stabilization with retrograde placed cannulated compression headless screw (CCHS) versus conventional fully and partially threaded screws in an artificial pelvic bone model. METHODS SPRF type II as described by Nakatani et al. was created by means of osteotomies in eighteen anatomical composite hemi-pelvises. Specimens were stratified into three groups of six specimens each (n = 6) for fixation with either a 7.3 mm partially threaded cannulated screw (group RST), a 7.3 mm fully threaded cannulated screw (group RSV), or a 7.5 mm partially threaded cannulated CCHS (group CCS). Each hemi-pelvic specimen was tested in an inverted upright standing position under progressively increasing cyclic axial loading. The peak load, starting at 200 N, was monotonically increased at a rate of 0.1 N/cycle until 10 mm actuator displacement. RESULTS Total and torsional displacement were associated with higher values for RST versus CCS and RSV, with significant differences between RST and CCS for both these parameters (p ≤ 0.033). The differences between RST and RSV were significant for total displacement (p = 0.020), and a trend toward significance for torsional displacement (p = 0.061) was observed. For both failure criteria 2 mm total displacement and 5° torsional displacement, CCS was associated with significantly higher number of cycles compared to RST (p ≤ 0.040). CONCLUSION CCHS fixation presented predominantly superior stability to the standard surgical treatment and could therefore be a possible alternative implant for retrograde SPRF screw fixation, whereas partially threaded screws in group RST were associated with inferior biomechanical stability.
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Affiliation(s)
- Till Berk
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | | | - Tatjana Pastor
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
- Department of Plastic and Hand Surgery, Inselspital University Hospital Bern, University of Bern, Bern, Switzerland
| | - Felix Lesche
- Department of Gynecology and Obstetrics, Asklepios Clinic Wandsbek, Alphonsstraße 14, 22043 Hamburg, Germany
| | - Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- University of Zurich, Harald-Tscherne Laboratory for Orthopedic and Trauma Research, Sternwartstrasse 14, 8091 Zurich, Switzerland
| | - R. Geoff Richards
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Boyko Gueorguiev
- AO Research Institute Davos, Clavadelerstrasse 8, 7270 Davos, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- University of Zurich, Harald-Tscherne Laboratory for Orthopedic and Trauma Research, Sternwartstrasse 14, 8091 Zurich, Switzerland
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Barrientos-Mendoza C, Brañes J, Wulf R, Kremer A, Barahona M, León S. The role of anterior supra-acetabular external fixator as definitive treatment for anterior ring fixation in unstable pelvic fractures. Eur J Trauma Emerg Surg 2021; 48:3737-3746. [PMID: 34097076 DOI: 10.1007/s00068-021-01711-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Management of anterior ring injuries is still a matter of discussion, and there are only few studies reporting anterior external fixator as definitive treatment for unstable pelvic injuries. This study aimed to describe the clinical and radiological outcomes of a consecutive series of mechanically unstable pelvic injuries that were treated with definitive anterior supra-acetabular external fixator for the anterior ring, and to identify risk factors for failure. METHODS We included a consecutive series of patients with unstable pelvic ring fractures who underwent anterior supra-acetabular external fixation for definitive treatment, between January 2012 and January 2020. All demographics, associated injuries and procedures, injury mechanism, and complications were analysed. Pelvic fracture was classified based on Orthopaedic Trauma Association/Tile AO (OTA/AO) and Young-Burgess classifications. Complications associated with the external fixator were revised. All patients were functionally evaluated at final follow-up and asked to report their clinical outcomes using the Majeed score. RESULTS A total of 47 patients were included, of which 25 were females. The median age was 44 years (interquartile range 23-59). Median follow-up duration was 14 months (interquartile range 6-31). The most frequent aetiology was motor vehicle accident (35), followed by fall from height (8). All fractures required posterior pelvic ring fixation. The median time during which patients had external fixation in situ was 11 weeks (interquartile range 9-13). All patients achieved healing of pelvic fracture at median time of 10 weeks (interquartile range 8-12). At final follow-up, the median displacement of the anterior pelvis was 6 mm (interquartile range 0-11). Superficial infection was the most common complication (n = 7). No washout procedures were needed. No major complication was reported. No patient required reoperation for anterior ring fracture. The median Majeed score was 88 points (range 60-95; interquartile range 80-90) at final follow-up. CONCLUSION Our findings suggest that the use of supra-acetabular external fixator is safe and effective for definitive treatment of the anterior ring in unstable pelvic fractures. It is a method with high proportion of excellent results, regardless of the type of fracture. The rate of complications is low, and it does not compromise functional results.
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Affiliation(s)
- Cristián Barrientos-Mendoza
- Orthopaedics Department, Hospital San José, San Jose 1196, 8380219, Santiago, Region Metropolitana, Chile. .,Orthopaedics Department, Hospital Clínico de La Universidad de Chile, Santiago, Chile. .,Orthopaedics Department, Hip and Pelvis Unit, Clínica Santa María, Santiago, Chile.
| | - Julián Brañes
- Orthopaedics Department, Hospital San José, San Jose 1196, 8380219, Santiago, Region Metropolitana, Chile.,Orthopaedics Department, Hospital Clínico de La Universidad de Chile, Santiago, Chile
| | - Rodrigo Wulf
- Orthopaedics Department, Hospital Clínico de La Universidad de Chile, Santiago, Chile
| | - Alex Kremer
- Orthopaedics Department, Hospital San José, San Jose 1196, 8380219, Santiago, Region Metropolitana, Chile
| | - Maximiliano Barahona
- Orthopaedics Department, Hospital Clínico de La Universidad de Chile, Santiago, Chile
| | - Sebastián León
- Orthopaedics Department, Hospital San José, San Jose 1196, 8380219, Santiago, Region Metropolitana, Chile.,Orthopaedics Department, Hospital Clínico de La Universidad de Chile, Santiago, Chile
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6
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Russ MK, Navarre P, Stevens JP. An Alternative Site for Pin Placement in External Fixation of Pelvic Fractures: Lateral Posterior Pelvic External Fixator Surgical Technique. Front Surg 2021; 7:621125. [PMID: 33585549 PMCID: PMC7876391 DOI: 10.3389/fsurg.2020.621125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction: The application of an external fixator for unstable pelvic fractures is an important component of many resuscitation protocols. Moreover, certain pelvic fractures may be treated with an external fixator without requiring further internal fixation. We report our initial clinical results with an alternate pelvic external fixator site, the lateral posterior external fixator (LPEF), and describe the surgical technique. Methods and Materials: From 2010 to 2013, we identified 27 consecutive patients (mean age 44.6 years, range 18–80 years) treated by the same surgeon (MKR) with an LPEF in a level 1 trauma center. Retrospective data collection included mechanism of injury, surgical interventions, and complications. Results: The LPEF was used in 16 patients as acute pelvic stabilization and converted at a median of 2 days (interquartile range 1–3.5) to internal fixation, whereas in 10 patients, it was used as definitive treatment and removed at a median of 48 days (interquartile range 37–64). One patient died on day 14, secondary to his severe closed head injury. The only surgical complications were two wound infections (20%, 2/10 in the group of definitive LPEFs), which resolved without sequelae after the removal of the LPEF (at 36 and 50 days) and antibiotics, one case of loss of fixation leading to the removal of the LPEF at 71 days, and one patient who had hypergranulating external fixator sites and eventually healed without any cutaneous sequelae. All fractures consolidated in a good position. Discussion: The described techniques of pelvic external fixation include the anterosuperior (iliac wing), supra-acetabular (anteroinferior), and subcristal (anterior superior iliac spine) insertion sites. The reported infection rates in definitive pelvic fracture treatment range from 20 to 40%. Due to the localization of the insertion sites, the lateral femoral cutaneous nerve is potentially at risk with the last two techniques. On the other hand, the LPEF insertion site is quite safe, as it is anatomically far from any nerves and the inguinal region, and allows easy access for laparotomy. The results in this series suggest that the lateral posterior pelvic external fixator technique is an alternative to previous techniques with a low risk of complications.
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Affiliation(s)
- Matthias K Russ
- Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, VIC, Australia.,Cabrini Hospital, Orthopaedic Surgery, Melbourne, VIC, Australia.,Department of Surgery, Monash University, Melbourne, VIC, Australia
| | - Pierre Navarre
- Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, VIC, Australia.,Department of Orthopaedic Surgery, Southland Hospital, Invercargill, New Zealand.,Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Jarrad P Stevens
- Department of Orthopaedic Surgery, Alfred Hospital, Melbourne, VIC, Australia.,Knox Orthopaedic Group, Knox Private Hospital, Melbourne, VIC, Australia
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7
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Ladurner A, Callary SA, Mitra A, Rickman M, Thewlis D, Solomon LB. Radiostereometric Analysis Allows Assessment of the Stability and Inducible Displacement of Pelvic Ring Disruptions during Healing: A Case Series. J Clin Med 2020; 9:jcm9113411. [PMID: 33114372 PMCID: PMC7692147 DOI: 10.3390/jcm9113411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/21/2020] [Accepted: 10/23/2020] [Indexed: 11/18/2022] Open
Abstract
There is currently no accurate data on fracture displacement during the rehabilitation of pelvic ring injuries. This study investigated the use of radiostereometric analysis (RSA) in assessing the stability of C1 pelvic ring injuries stabilised with a posterior plate and an anterior external fixator. Six patients, instructed to weight-bear as tolerated after surgery, were reviewed at 2, 4, 6, 12, 26, 52 and 104 weeks. The external fixators were removed at 6 weeks. Outcomes, including the Iowa Pelvic Score (IPS), and complications were recorded. Fracture stability was assessed using measurements on plain radiographs and RSA. All patients progressed to full weight-bearing without support within 6 weeks. At 104 weeks, the IPS was excellent in four patients, good in one patient and fair in one patient. Plain radiographs showed that all fractures were well reduced, and no loss of reduction occurred over time. By contrast, RSA measurements identified displacement in all cases. The maximum three-dimensional (3D) displacement at any time point in each patient ranged from 2 to 10 mm. Two patients with the largest displacement over time had the lowest IPS. RSA also demonstrated displacements above the currently defined normal threshold through the ‘un-injured’ sacroiliac joint in the same two patients, suggesting a subtle C2 injury, missed at initial assessment. This study demonstrates the limitations of plain radiographs in assessing pelvic fracture stability and displacement during healing, and the potential of RSA to monitor more accurately the effects of stabilisation and weight-bearing on fracture stability.
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Affiliation(s)
- Andreas Ladurner
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (A.L.); (S.A.C.); (M.R.)
| | - Stuart A. Callary
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (A.L.); (S.A.C.); (M.R.)
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA 5000, Australia;
| | - Aniruddha Mitra
- Department of Orthopaedics and Trauma, Warrnambool Hospital, Warrnambool, VIC 3280, Australia;
| | - Mark Rickman
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (A.L.); (S.A.C.); (M.R.)
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA 5000, Australia;
| | - Dominic Thewlis
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA 5000, Australia;
| | - Lucian B. Solomon
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; (A.L.); (S.A.C.); (M.R.)
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, SA 5000, Australia;
- Correspondence:
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Achievable pin spanning angulation in anterosuperior pelvic external fixation. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1163-1170. [PMID: 32358714 DOI: 10.1007/s00590-020-02684-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 04/22/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pelvic external fixation using anterosuperior pins provides a quick method of stabilization without necessitating fluoroscopic guidance. Various locations, depths, and inclinations have been cited for external fixator pins; however, the existing literature lacks clear indications for the angular difference between pins. Thus, we aimed to determine the greatest degree of sagittal pin spanning angulation (SPSA) between two iliac crest pins and how intraosseous depth (ID) affects these angulations. MATERIALS AND METHODS A newly developed computer algorithm produced cross sections of 3D pelvic reconstructions in the sagittal plane in 5° increments. Computer-generated pins with IDs of 60, 75, and 90 mm were positioned in 5° increments transversely. Pins were assessed for cortical containment to define values for SPSA and transverse pin spanning angulation (TPSA). RESULTS A bimodal distribution revealed varying degrees of insertion frequency and SPSA, cranially and caudally. The caudal distribution exhibited greater cortical containment with larger values for SPSA and TPSA. The highest insertion frequency (85.7%) and largest SPSA (155°) were observed for the 60-mm ID. Increasing ID resulted in further bony penetration and smaller values for SPSA and TPSA. CONCLUSIONS Expanding the degree of SPSA between inserted pins in anterosuperior pelvic external fixation can be challenging due to the thinning of the iliac wing, which affords a narrow corridor for intraosseous pin containment. An ID of 60 mm allows larger degrees of SPSA while maintaining higher rates of cortical pin containment when compared to pins with greater IDs.
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9
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Encinas-Ullán CA, Martínez-Diez JM, Rodríguez-Merchán EC. The use of external fixation in the emergency department: applications, common errors, complications and their treatment. EFORT Open Rev 2020; 5:204-214. [PMID: 32377388 PMCID: PMC7202044 DOI: 10.1302/2058-5241.5.190029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The use of an external fixator (EF) in the emergency department (ED) or the emergency theatre in the ED is reserved for critically ill patients in a life-saving attempt. Hence, usually only fixation/stabilization of the pelvis, tibia, femur and humerus are performed. All other external fixation methods are not indicated in an ED and thus should be performed in the operating room with a sterile environment.Anterior EF is used in unstable pelvic lesions due to anterior-posterior compression, and in stable pelvic fractures in haemodynamically unstable patients.Patients with multiple trauma should be stabilized quickly with EF.The C-clamp has been designed to be used in the ED to stabilize fractures of the sacrum or alterations of the sacroiliac joint in patients with circulatory instability.Choose a modular EF that allows for the free placement of the pins, is radiolucent and is compatible with magnetic resonance imaging (MRI).Planning the type of framework to be used is crucial.Avoid mistakes in the placement of EF. Cite this article: EFORT Open Rev 2020;5:204-214. DOI: 10.1302/2058-5241.5.190029.
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10
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Morandi MM, Daily D, Kee C, Barton RS, Solitro GF. Safe Supra-Acetabular Pin Insertion in Relation to Intraosseous Depth. J Orthop Res 2019; 37:1790-1797. [PMID: 31042305 DOI: 10.1002/jor.24323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/04/2019] [Indexed: 02/04/2023]
Abstract
In pelvic fractures, dysfunction of the pelvic ring is often stabilized with supra-acetabular pin insertion. In existing literature, there are heterogeneous indications on proper pins selection and inclinations. Therefore, this study aimed to quantify the narrowing of safe pin corridors in the transverse and sagittal planes with increments of intraosseous screw depths. A computer algorithm created cross-sections over three-dimensional pelvic reconstructions at sagittal inclinations from 45° cranial to 45° caudal in 5° increments. Templates of screw depths spanning 60-120 mm in 15 mm increments were disposed in the transverse plane from 45° medial to 45° lateral. Each intraosseous screw depth and transverse angle were evaluated for intraosseous containment to evaluate ranges narrowing with increasing screw depths. The 60-mm depth resulted in the largest sagittal range (60.9° ± 6.9°) and transverse range (27.5° ± 4.1°) at 30° caudal. Increasing depths by 15 mm resulted in ranges being significantly different from one another (p < 0.01). The sagittal plane of 20° cranial had the highest frequency of insertion for all depths, while transverse ranges were narrowed (p < 0.01). Bisecting angles were similar for sagittal planes 20° cranial to 30° caudal with an average of 27.9° ± 1.2° (p ≥ 0.115). In conclusion, while 60 mm depths can be inserted with the highest discretion, 15 mm increments in depth significantly reduce safe ranges. Screws depths above 90 mm have low frequencies of insertion, should be inserted more cranially and must be considered prone to breaching. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1790-1797, 2019.
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Affiliation(s)
- Massimo Max Morandi
- Department of Orthopaedic Surgery, Louisiana State University Health Science Center, Shreveport, Louisiana
| | - Drayton Daily
- Department of Orthopaedic Surgery, Louisiana State University Health Science Center, Shreveport, Louisiana
| | - Clarence Kee
- Department of Orthopaedic Surgery, Louisiana State University Health Science Center, Shreveport, Louisiana
| | - R Shane Barton
- Department of Orthopaedic Surgery, Louisiana State University Health Science Center, Shreveport, Louisiana
| | - Giovanni F Solitro
- Department of Orthopaedic Surgery, Louisiana State University Health Science Center, Shreveport, Louisiana
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Hua X, Yan SG, Cui Y, Yin Z, Schreiner AJ, Schmidutz F. Minimally invasive internal fixator for unstable pelvic ring injuries with a pedicle screw-rod system: a retrospective study of 23 patients after 13.5 months. Arch Orthop Trauma Surg 2019; 139:489-496. [PMID: 30535810 DOI: 10.1007/s00402-018-3094-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Pelvic ring fractures are challenging injuries and require effective treatment due to the frequently compromised patient condition. The aim of this study was to evaluate the outcome of unstable pelvic ring injuries treated with a minimally invasive pedicle screw-rod system. METHODS Retrospective analysis was performed for patients with an unstable pelvic ring injury that were treated with a minimally invasive anterior internal pelvic fixator (INFIX) with or without a posterior pedicle screw-rod fixator (6/2012-4/2015). The quality of reduction was evaluated by the Tornetta and Matta criteria and the clinical outcome was evaluated by the Majeed scores. Further evaluation included the operation time, intraoperative blood loss, and complication rate. RESULTS A total of 23 patients (12 males and 11 females) with a mean age of 37.6 years (range 10-65 years) and a follow-up of 13.5 months (6-27 months) were evaluated. The Tile classification showed 13 type B (B1 = 6, B2 = 4, and B3 = 3) and 10 type C (C1 = 7 and C2 = 3) fractures. Mean operation time and intraoperative blood loss were 24.8 min (20-30 min) and 20.4 ml (16-29 ml) for an anterior INFIX (n = 13), and 60 min (45-70 min) and 150 ml (115-168 ml) when combined with a posterior pedicle screw-rod fixator (n = 10). Quality of reduction was excellent in 13, good in 6, and fair in 4 patients, with no signs of heterotopic ossification. Clinical results after 6 months were excellent in 14 patients, good in 6, fair in 2, and poor in 1. Unilateral thigh paresthesia was seen in 2 patients which resolved after implant removal. CONCLUSIONS The INFIX appears to be a safe and minimally invasive surgical technique which can effectively be combined with posterior pedicle screw-rod fixation. It also can be applied for the definitive treatment of vertically and/or rotationally unstable pelvic ring injuries, especially in severely compromised patients with a high mortality risk.
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Affiliation(s)
- Xingyi Hua
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Anhui Medical University, No. 1 Baicao Road, Hefei, 230088, China.
| | - Shuang G Yan
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Anhui Medical University, No. 1 Baicao Road, Hefei, 230088, China.,Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany
| | - Yiliang Cui
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Anhui Medical University, No. 1 Baicao Road, Hefei, 230088, China
| | - Zongsheng Yin
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Anhui Medical University, No. 1 Baicao Road, Hefei, 230088, China
| | - Anna J Schreiner
- BG Trauma Center, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Florian Schmidutz
- Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, University of Munich (LMU), Munich, Germany.,BG Trauma Center, Eberhard Karls University Tübingen, Tübingen, Germany
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MacCormick LM, Chen F, Gilbertson J, Khan S, Schroder LK, Bechtold JE, Cole PA. A biomechanical study comparing minimally invasive anterior pelvic ring fixation techniques to external fixation. Injury 2019; 50:251-255. [PMID: 30447984 DOI: 10.1016/j.injury.2018.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/18/2018] [Accepted: 07/17/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION INFIX and Pelvic Bridge are two new minimally invasive surgical techniques for unstable pelvic ring injuries, and they have demonstrated early clinical success in small, single-center case-series. The primary objective of this study is to gather evidence speaking to the biomechanical stability of internal bridging methods relative to external fixation, with the expectation of biomechanical equivalence. METHODS Ten human cadaveric pelvic specimens were dissected free of all skin, fat, organs, and musculature and were prepared with a partially unstable pelvic ring injury (OTA/AO 61-B). The specimens were randomized to two groups and were repaired and tested with anterior pelvic external fixation (APEF) and INFIX sequentially, or APEF and Pelvic Bridge sequentially. Testing was performed with each specimen mounted onto a servo-hydraulic testing frame with axial compression applied to the superior base of the sacrum under five axial loading/unloading sinusoidal cycles between 10 N and 1000 N at 0.1 Hz. Relative translational motion and rotation across the osteotomy site was reported as our primary outcome measures. Outcome measures were further analyzed using a Wilcoxon signed-rank test to determine differences between non-parametric data sets with significance defined as a p value < 0.05. RESULTS We found no statistical difference in translation (p = 0.237, 0.228) or rotation (p = 0.278, 0.873) at the fracture site when comparing both new constructs to external fixation. Under the imposed loading protocol, no episodes of implant failure or failure at the bone-implant interface occurred. DISCUSSION Our study provides the biomechanical foundation necessary to support future clinical trial implementation for pelvic fracture patients. While biomechanical stability of these newer, subcutaneous techniques is equivalent to APEF, the surgeon must take into account their technical abilities and knowledge of pelvic anatomy, patient-specific factors including body habitus, and the potential complications associated with each implant and the ability to avoid them.
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Affiliation(s)
- Lauren M MacCormick
- University of Minnesota, Department of Orthopaedic Surgery, 2512 S. 7th St., R200, Minneapolis, MN 55454, United States
| | - Frank Chen
- Excelen Center for Bone & Joint Research and Education, 700 10th Avenue South, Minneapolis, MN 55415, United States
| | - Jeff Gilbertson
- Regions Hospital, Department of Orthopaedic Surgery, 640 Jackson Street - MS 11503L, Saint Paul, MN 55101-2595, United States
| | - Sikandar Khan
- University of Minnesota, Department of Orthopaedic Surgery, 2512 S. 7th St., R200, Minneapolis, MN 55454, United States
| | - Lisa K Schroder
- Regions Hospital, Department of Orthopaedic Surgery, 640 Jackson Street - MS 11503L, Saint Paul, MN 55101-2595, United States
| | - Joan E Bechtold
- University of Minnesota, Department of Orthopaedic Surgery, 2512 S. 7th St., R200, Minneapolis, MN 55454, United States; Excelen Center for Bone & Joint Research and Education, 700 10th Avenue South, Minneapolis, MN 55415, United States
| | - Peter A Cole
- University of Minnesota, Department of Orthopaedic Surgery, 2512 S. 7th St., R200, Minneapolis, MN 55454, United States; Regions Hospital, Department of Orthopaedic Surgery, 640 Jackson Street - MS 11503L, Saint Paul, MN 55101-2595, United States.
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Yin Y, Zhang R, Li S, Su K, Hou Z, Zhang Y. Complications Following Internal Fixator in the Treatment of Pelvic Fracture. Orthopedics 2019; 42:e7-e13. [PMID: 30403824 DOI: 10.3928/01477447-20181102-06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 03/19/2018] [Indexed: 02/03/2023]
Abstract
The aim of this systematic review was to investigate the incidence of complications of the internal fixator in the treatment of anterior pelvic ring injury. The literature was comprehensively searched from 1980 to January 2017 to identify potential studies. Six studies involving 272 cases of anterior pelvic ring injury treated with the internal fixator were included in this meta-analysis. The rates of wound infection, heterotopic ossification, nerve paresthesia, pain, and fracture dislocation were 5.7%, 35.1%, 28.2%, 3.7%, and 3.0%, respectively. This new technique should be prudently used to treat pelvic fractures. [Orthopedics. 2019; 42(1):e7-e13.].
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Abstract
The objective of this article was to highlight the indications and various methods of external fixation for management of the unstable anterior pelvic ring. Although most often used temporarily in the setting of significant hemorrhage from a pelvic ring fracture, external fixation remains an option for definitive stabilization of select pelvic ring injuries. Classically, the iliac crest frame has been used, although use of the supra-acetabular frame has gained favor due to its superior bone purchase and improved biomechanics. Common complications from external fixation include pin site infections, loss of reduction, and the "external fixator deformity."
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Abstract
INTRODUCTION The purpose of this article is to review the available literature on anterior subcutaneous internal pelvic fixation (ASIPF) to identify indications, clinical and radiographic outcomes, and compare these with alternative fixation methods. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic search on PubMed and Google Scholar was performed. Articles included were in the English language or English translations and published between 2007 and 2018. Studies included were appraised with narrative data synthesis. RESULTS Twenty-five articles with 496 patients were included. These included 17 case series, with 3 case reports reporting adverse events. CONCLUSIONS ASIPF and the appropriate posterior fixation resulted in healing of pelvic ring injuries in 99.5% of cases. Indications include unstable pelvic ring injuries with the appropriate posterior fixation. Radiographic parameters and outcome measures were infrequently reported. ASIPF is a valuable tool for reduction and fixation in unstable pelvic ring injuries. Complications include lateral femoral cutaneous nerve irritation (26.3%); heterotopic ossification (36%); infection (3%); and femoral nerve palsy (1%), which is likely related to placing the bar and screws too deep.
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Çavuşoğlu AT, Erbay FK, Özsoy MH, Demir T. Biomechanical comparison of supraacetabular external fixation and anterior pelvic bridge plating. Proc Inst Mech Eng H 2017; 231:931-937. [PMID: 28689459 DOI: 10.1177/0954411917718223] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Unstable pelvic ring injuries are complex and risky injuries due to high morbidity and mortality. Although anterior pelvic external fixator is a suitable method for rapid stabilization of an injured pelvic ring, due to some disadvantages such as high complication rate, nerve damage, and difficulties of patient's mobility and comfort, there has recently been increased searching for alternative methods for stabilization of the pelvic ring. Pubic symphysis zone freely moves in pelvic models. This study aims to evaluate the biomechanical stability of anterior pelvic bridge plating and compare it with supraacetabular external fixators in an untreated unstable pelvic fracture model. Samples were loaded statically with 2-mm/min loading rate in single leg standing position. Maximum load was 2.3 kN. When loading the samples, photographs were taken continuously. Stiffness values were calculated from the load displacement curves. Some reference parameters were described and were measured from unloaded and 2.3-kN-loaded photographs of the test. The mean stiffness values were 491.14 ± 52.22, 478.55 ± 41.44, and 470.25 ± 44.51 N/mm for anterior pelvic bridge plating group, supraacetabular external fixator group, and Control group, respectively. According to the measured parameters from photographs, the mean displacement at the pubic symphysis was 4.7 ± 0.32, 15.8 ± 2.01, and 18.2 ± 0.47 mm for anterior pelvic bridge plating, supraacetabular external fixator, and Control group, respectively. The highest displacement in the pubic symphysis was found in Control group, and minimum displacement was observed in anterior pelvic bridge plating group. When the perpendicular distance between the right and left lower end of ischium was examined, it was observed that displacement was minimum in anterior pelvic bridge plating group compared to other two groups, regarding to the high stability of pubic symphysis. In conclusion, this study revealed superiority of anterior subcutaneous plate fixation with biomechanical results.
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Affiliation(s)
- Ali Turgay Çavuşoğlu
- 1 Department of Orthopedics, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Fatma Kübra Erbay
- 2 Department of Micro and Nanotechnology, TOBB University of Economics and Technology, Ankara, Turkey
| | - Mehmet Hakan Özsoy
- 3 Department of Orthopedics and Traumatology, Memorial Hospital, Ankara, Turkey
| | - Teyfik Demir
- 4 Department of Mechanical Engineering, TOBB University of Economics and Technology, Ankara, Turkey
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Tosounidis TH, Sheikh HQ, Kanakaris NK, Giannoudis PV. The use of external fixators in the definitive stabilisation of the pelvis in polytrauma patients: Safety, efficacy and clinical outcomes. Injury 2017; 48:1139-1146. [PMID: 28363753 DOI: 10.1016/j.injury.2017.03.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/22/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To analyse the complications and outcomes (functional/radiographic) of Pelvic External Fixators applied as part of the definitive fixation in polytrauma patients. DESIGN A single center retrospective chart review. SETTING A level-1 trauma center. PATIENTS AND METHODS We reviewed all the polytrauma patients (ISS>16) between 2007 and 2012 that had a PEF applied more than 30days. Complications including infection, aseptic loosening, neurological injury, loss of reduction, non-union and mal-union were recorded. Pelvic asymmetry and Deformity Index (DI) were measured at the immediate postoperative radiographs and final follow-up. The functional outcome at final follow up was estimated using a scale previously reported by Chiou et al. RESULTS 59 patients with mean age of 38.4 (16 - 81) years and mean ISS score 28 (16- 66) were included. The PEFs were applied for mean duration of 56 (30-104) days. The average follow-up was 403days. 22 injuries were type B and 37 type C (AO/OTA). The most common symptomatic complications were pin site infection in 11 (18.6%) and loosening in 5 (8.5%) cases. 44 (74.5%) patients had satisfactory functional outcome. The immediate post-operative and final asymmetry and DI were compared between the two pelvic injury groups (type B and C fractures). The difference in displacement progression was more for type C injuries (p=0.034) but no correlation to the functional outcome was evident. CONCLUSION PEF can be used as definitive alternative stabilization method in specific situations at polytrauma setting. Radiological displacement occurred in both type B and C injuries but the clinical outcome was not correlated to this displacement. Complications related to PEF do not affect the final clinical outcome. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Theodoros H Tosounidis
- Academic Department of Trauma & Orthopaedic Surgery, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA West Yorkshire, Leeds, UK.
| | - Hassaan Qaiser Sheikh
- Academic Department of Trauma & Orthopaedic Surgery, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK.
| | - Nikolaos K Kanakaris
- Academic Department of Trauma & Orthopaedic Surgery, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK.
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA West Yorkshire, Leeds, UK.
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Midterm Radiographic and Functional Outcomes of the Anterior Subcutaneous Internal Pelvic Fixator (INFIX) for Pelvic Ring Injuries. J Orthop Trauma 2017; 31:252-259. [PMID: 28079731 PMCID: PMC5402711 DOI: 10.1097/bot.0000000000000781] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe our experience using the anterior internal pelvic fixator (INFIX) for treating pelvic ring injuries. DESIGN Case Series. SETTING Level 1 Trauma Center. PATIENTS Eighty-three patients with pelvic ring injuries were treated with INFIX. Follow-up average was 35 months (range 12-80.33). INTERVENTION Surgical treatment of pelvic ring injuries included reduction, appropriate posterior fixation, and INFIX placement. OUTCOME MEASUREMENTS Reduction using the pelvic deformity index and pubic symphysis widening, Majeed functional scores, complications; infection, implant failure, heterotopic ossification (HO), nerve injury, and pain. RESULTS All patients healed in an appropriate time frame (full weight bearing 12 weeks postoperation). The average pelvic deformity index reduction (injury = 0.0420 ± 0.0412, latest FU = 0.0254 ± 0.0243) was 39.58%. The average reduction of pubic symphysis injuries was 56.92%. The average Majeed score of patients at latest follow-up was 78.77 (range 47-100). Complications were 3 infections, 1 case of implant failure, 2 cases implantation too deep, 7 cases of lateral femoral cutaneous nerve irritation, and 3 cases of pain associated with the device. HO was seen in >50% of the patients, correlated with increased age (P < 0.007), injury severity score (P < 0.05) but only 1 case was symptomatic. CONCLUSIONS The pelvic injuries had good functional and radiological outcomes with INFIX and the appropriate posterior fixation. The downside is removal requiring a second anesthetic, there is a learning curve, HO often occurs, the lateral femoral cutaneous nerve may get irritated which often resolves once the implants are removed. Surgery-specific implants need to be developed. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Abstract
Traumatic disruptions of the pelvic ring are high energy life threatening injuries. Management represents a significant challenge, particularly in the acute setting in the presence of severe haemorrhage. Initial management is focused on preserving life by controlling haemorrhage and associated injuries. Advances in prehospital care, surgery, interventional radiology and the introduction of treatment algorithms to streamline decision making have improved patient survival. As more patients with unstable pelvic injuries survive, the poor results associated with nonoperative management and increasing patient expectations of outcome are making surgical management of these fractures increasingly common. The aim of operative fracture fixation is to correct deformity and restore function. The advent of percutaneous fixation techniques has reduced the morbidity previously associated with large operative exposures and internal fixation.
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Affiliation(s)
- James Min-Leong Wong
- The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria 3050, Australia.
| | - Andrew Bucknill
- The Royal Melbourne Hospital, Grattan Street, Parkville, Victoria 3050, Australia
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Apivatthakakul T, Rujiwattanapong N. "Anterior subcutaneous pelvic internal fixator (INFIX), Is it safe?" A cadaveric study. Injury 2016; 47:2077-2080. [PMID: 27546721 DOI: 10.1016/j.injury.2016.08.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 08/12/2016] [Accepted: 08/12/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Anterior pelvic internal fixator (INFIX) is used to treat unstable pelvic ring injuries. Nerve injury complications with this procedure have been reported. OBJECTIVES This anatomic study attempted to identify structures at risk after application of INFIX. MATERIALS AND METHODS INFIX was applied in fifteen fresh, frozen, anatomical specimens using polyaxial pedicular screws and subcutaneous rods. Surgical dissection was done to identify the structures at risk including the femoral nerve (FN), femoral artery (FA), femoral vein (FV) and the lateral femoral cutaneous nerve (LFCN) related to which are potentially affected by the implant. RESULTS All structures at risk were closer to the rod than to the pedicular screw. Measurements were made between the rod and the structures at risk. The LFCN was an average of 13.49±1.65mm (95% CI 12.871-14.103) from the lateral end of the rod. The FN was an average of 12.43±3.42mm (95% CI 11.151-13.709), the FA was an average of 12.80±3.67 (95% CI 11.430-14.173) and the FV was an average of 13.48±3.73 (95% CI 12.082-14.871) below the rod. No direct compression of the rod to the structure at risk was observed. CONCLUSIONS The femoral nerve is the structure most at risk of compression by the INFIX rod. Careful surgical technique is required in every step of this surgery. We suggest using polyaxial screws and recommend that during screw insertion the surgeon should leave some space between the screw and rectus fascia. The the rod should be trimmed as short as possible to reduce LFCN irritation.
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Affiliation(s)
- T Apivatthakakul
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand; Excellence Center in Osteology Research and Training Center (ORTC), Chiang Mai University, Thailand.
| | - N Rujiwattanapong
- Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Guimarães RP, de Góes Ribeiro A, Ulson O, de Ávila RB, Ono NK, Polesello GC. Supra-acetabular fixation and sacroiliac screws for treating unstable pelvic ring injuries: preliminary results from 20 patients. Rev Bras Ortop 2016; 51:132-7. [PMID: 27069879 PMCID: PMC4811994 DOI: 10.1016/j.rboe.2016.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 04/06/2015] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To analyze the treatment results from 20 patients who underwent an alternative osteosynthesis method as definitive treatment for pelvic ring fractures. METHODS A retrospective analysis was conducted on a series of 20 patients with pelvic ring fractures (Tile type C) and a high risk of postoperative infection, who were treated at Santa Casa de Misericórdia de São Paulo between August 2004 and December 2012. The patients underwent percutaneous supra-acetabular external fixation in association with cannulated 7.0 mm iliosacral screws. RESULTS The patients' mean age was 40 years (range 22-77 years) and the mean length of follow-up was 18.5 months (range 3-69 months). At the end of the treatment, ten patients (50%) were classified as having good results, nine patients (45%) had fair results and one patient (5%) did not have any improvement. Six patients presented complications, and paresthesia of the lateral femoral cutaneous nerve was the most frequent of these (two patients). CONCLUSION Supra-acetabular external fixation in association with iliosacral percutaneous osteosynthesis is a good definitive treatment method for patients with a high risk of postoperative infection.
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Affiliation(s)
| | - Arthur de Góes Ribeiro
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil
| | - Oliver Ulson
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil
| | | | - Nelson Keiske Ono
- Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil
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Abstract
The modularity and ease of application of modern external fixation has expanded its potential use in the management of fractures and other musculoskeletal conditions. In fracture care, it can be used for provisional and definitive fixation. Short-term provisional applications include "damage control" and periarticular fracture fixation. The risk:benefit ratio of added stability needs to be assessed with each fixator. Soft-tissue management is critical during pin insertion to lessen the risk of loosening and infection. Although provisional fixation is safe for early conversion to definitive fixation, several factors affect the timing of definitive surgery, including the initial injury, external fixator stability, infection, and the physiologic state of the patient.
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Hesse D, Kandmir U, Solberg B, Stroh A, Osgood G, Sems SA, Collinge CA. Femoral nerve palsy after pelvic fracture treated with INFIX: a case series. J Orthop Trauma 2015; 29:138-43. [PMID: 24983430 DOI: 10.1097/bot.0000000000000193] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The treatment of some pelvic injuries has evolved recently to include the use of a subcutaneous anterior pelvic fixator (INFIX). We present 8 cases of femoral nerve palsy in 6 patients after application of an INFIX to highlight this potentially devastating complication to pelvic surgeons using this technique and discuss how it might be avoided in the future. DESIGN Retrospective chart review. Case series. SETTING Five level 1 and 2 trauma centers, tertiary referral hospitals. PATIENTS/PARTICIPANTS Six patients with anterior pelvic ring injury treated with an INFIX who experienced 8 femoral nerve palsies (2 bilateral). INTERVENTION Removal of internal fixator, treatment for femoral nerve palsy. MAIN OUTCOME MEASUREMENTS Clinical and electromyographic evaluation of patients. RESULTS All 6 patients with a total of 8 femoral nerve palsies had their INFIX removed. Variable resolution of the nerve injuries was observed. CONCLUSIONS Application of an INFIX for the treatment of pelvic ring injury carries a potentially devastating risk to the femoral nerve(s). Despite early implant removal after detection of nerve injury, some patients had residual quadriceps weakness, disturbance of the thigh's skin sensation, and/or gait disturbance attributable to femoral nerve palsy at the time of early final follow-up. LEVEL OF EVIDENCE Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Daniel Hesse
- *Department of Orthopaedic Surgery, Queens University, Kingston, Ontario, Canada; †Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA; ‡Los Angeles Orthopaedic Specialists, Los Angeles, CA; §Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, MD; ‖Department of Orthopaedic Surgery, Mayo Clinic, Rochester, MN; and ¶Harris Methodist Fort Worth Hospital, Fort Worth, TX
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Mitchell PM, Corrigan CM, Patel NA, Silverberg AJ, Greenberg SE, Thakore RV, Obremskey WT, Ehrenfeld JM, Evans JM, Sethi MK. 13-Year experience in external fixation of the pelvis: complications, reduction and removal. Eur J Trauma Emerg Surg 2015; 42:91-6. [DOI: 10.1007/s00068-015-0499-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 02/06/2015] [Indexed: 10/24/2022]
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Eagan M, Kim H, Manson TT, Gary JL, Russell JP, Hsieh AH, O'Toole RV, Boulton CL. Internal anterior fixators for pelvic ring injuries: Do monaxial pedicle screws provide more stiffness than polyaxial pedicle screws? Injury 2015; 46:996-1000. [PMID: 25697857 DOI: 10.1016/j.injury.2015.01.040] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/23/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Little is known about the mechanical properties of internal anterior fixators (known as INFIX), which have been proposed as subcutaneous alternatives to traditional anterior external fixators for pelvic ring disruptions. We hypothesised that INFIX has superior biomechanical performance compared with traditional external fixators because the distance from the bar to the bone is reduced. METHODS Using a commercially available synthetic bone model, 15 unstable pelvic ring injuries were simulated by excising the pubic bone through the bilateral superior and inferior rami anteriorly and the sacrum through the bilateral sacral foramen posteriorly. Three test groups were established: (1) traditional supra-acetabular external fixation, (2) INFIX with polyaxial screws, (3) INFIX with monaxial screws. Load was applied, simulating lateral compression force. Outcome measure was construct stiffness. RESULTS The traditional external fixator constructs had an average stiffness of 6.21 N/mm ± 0.40 standard deviation (SD). INFIX with monaxial screws was 23% stiffer than the traditional external fixator (mean stiffness, 7.66 N/mm ± 0.86 SD; p = .01). INFIX with polyaxial screws was 26% less stiff than INFIX with monaxial screws (mean stiffness, 5.69 N/mm ± 1.24 SD; p = .05). No significant difference was noted between polyaxial INFIX and external fixators (mean stiffness, 6.21 N/mm ± 0.40 SD; p=.65). CONCLUSIONS The performance of INFIX depends on the type of screw used, with monaxial screws providing significantly more stiffness than polyaxial screws. Despite the mechanical advantage of being closer to the bone, polyaxial INFIX was not stiffer than traditional external fixation.
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Affiliation(s)
- Michael Eagan
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, United States
| | - Hyunchul Kim
- Fischell Department of Bioengineering, University of Maryland Orthopaedic Mechanobiology Laboratory, College Park, MD, United States
| | - Theodore T Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, United States
| | - Joshua L Gary
- University of Texas Health Science Center at Houston, Department of Orthopaedic Surgery, Houston, TX, United States
| | - Joseph P Russell
- Fischell Department of Bioengineering, University of Maryland Orthopaedic Mechanobiology Laboratory, College Park, MD, United States
| | - Adam H Hsieh
- Fischell Department of Bioengineering, University of Maryland Orthopaedic Mechanobiology Laboratory, College Park, MD, United States
| | - Robert V O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, United States
| | - Christina L Boulton
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, United States.
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Sellei RM, Dienstknecht T, Brücken D, Pfeifer R, Pape HC. Percutaneous Anterior Internal Pelvic Fixator. ACTA ACUST UNITED AC 2013. [DOI: 10.1053/j.oto.2013.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Vaidya R, Oliphant B, Jain R, Nasr K, Siwiec R, Onwudiwe N, Sethi A. The bikini area and bikini line as a location for anterior subcutaneous pelvic fixation: An anatomic and clinical investigation. Clin Anat 2012; 26:392-9. [DOI: 10.1002/ca.22149] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 06/25/2012] [Accepted: 07/23/2012] [Indexed: 11/11/2022]
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Vaidya R, Kubiak EN, Bergin PF, Dombroski DG, Critchlow RJ, Sethi A, Starr AJ. Complications of anterior subcutaneous internal fixation for unstable pelvis fractures: a multicenter study. Clin Orthop Relat Res 2012; 470:2124-31. [PMID: 22219004 PMCID: PMC3392373 DOI: 10.1007/s11999-011-2233-z] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Stabilization after a pelvic fracture can be accomplished with an anterior external fixator. These devices are uncomfortable for patients and are at risk for infection and loosening, especially in obese patients. As an alternative, we recently developed an anterior subcutaneous pelvic internal fixation technique (ASPIF). QUESTIONS/PURPOSES We asked if the ASPIF (1) allows for definitive anterior pelvic stabilization of unstable pelvic injuries; (2) is well tolerated by patients for mobility and comfort; and (3) has an acceptable complication rate. METHODS We retrospectively reviewed 91 patients who incurred an unstable pelvic injury treated with an anterior internal fixator and posterior fixation at four Level I trauma centers. We assessed (1) healing by callous formation on radiographs and the ability to weightbear comfortably; (2) patient function by their ability to sit, stand, lie on their sides, and how well they tolerated the implants; and (3) complications during the observation period. The minimum followup was 6 months (mean, 15 months; range, 6-40 months). RESULTS All 91 patients were able to sit, stand, and lie on their sides. Injuries healed without loss of reduction in 89 of 91 patients. Complications included six early revisions resulting from technical error and three infections. Irritation of the lateral femoral cutaneous nerve was reported in 27 of 91 patients and resolved in all but one. Heterotopic ossification around the implants, which was asymptomatic in all cases, occurred in 32 of 91 patients. CONCLUSIONS The anterior internal fixator provided high rates of union for the anterior injury in unstable pelvic fractures. Patients were able to sit, stand and ambulate without difficulty. Infections and aseptic loosening were reduced but heterotopic ossification and irritation of the LFCN are common. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Rahul Vaidya
- Detroit Medical Center, Wayne State University, 4D-4 University Health Center, Detroit Receiving Hospital, Detroit, MI 48201, USA.
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Treatment of unstable pelvic ring injuries with an internal anterior fixator and posterior fixation: initial clinical series. J Orthop Trauma 2012; 26:1-8. [PMID: 22048183 DOI: 10.1097/bot.0b013e318233b8a7] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To present a novel internal fixation device for stabilizing unstable pelvic fractures using supra-acetabular spinal pedicle screws and a subcutaneous connecting rod (INFIX). SETTING Level I trauma center. DESIGN Case series. PATIENTS Twenty-four patients with rotational or vertically unstable pelvic fractures that reported to a level I trauma center. METHODS/INTERVENTION: Surgical treatment of unstable pelvic fractures included reduction, appropriate posterior fixation where indicated, and an anterior subcutaneous internal fixator. MAIN OUTCOME MEASUREMENT Healing time, quality and loss of reduction, ease of nursing, incidence of complications, including nonunion, infection, and patient mobility and comfort. RESULTS In the present clinical series, all fractures healed without significant loss of reduction. There were no infections, delayed unions or nonunions. Nursing care was observed to be easier especially in the intensive care unit setting. Complications included unilateral anterior thigh paresthesias in 2 patients, and 1 patient each required repositioning of the pedicle screw and readjustment of screw rod junction. Patients tolerated the procedure well and were fairly mobile after the procedure. CONCLUSIONS The reported technique allows for a definitive and stable anterior fixation of vertically and rotationally unstable pelvic fractures when combined with the appropriate posterior fixation if indicated. The potential complications are acceptable with this technique and good outcomes were achieved. A second operative procedure is required for removal of the device. It is our view that its best indication is in obese individuals, in whom other options have shortcomings.
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