Advertisement

Clinical utility of minimally invasive posterior internal fixation within the pelvic ring using S2 alar iliac screws for unstable pelvic ring fracture

      Highlights

      • Internal fixation for unstable pelvic ring fractures is associated with complications, including bleeding, invasion of soft tissues, and a weak fixation force.
      • This study compared surgical outcomes of internal fixation within the pelvic ring using the S2 alar iliac screw with trans-iliac plate fixation.
      • Internal fixation in the pelvic ring using the S2 alar iliac screw is a less invasive technique, with less intraoperative bleeding, than trans-iliac plate fixation.

      Abstract

      Introduction

      Posterior internal fixation for unstable pelvic ring fractures is often associated with complications, including pelvic hemorrhage and gluteal necrosis. Pelvic ring fixation using the S2 alar iliac screw (SAIS) without fixation of the lumbosacral vertebrae may have potential as a novel, minimally invasive technique for treating unstable pelvic ring fractures. The present study compared clinical outcomes in patients who underwent SAIS fixation within the pelvic ring with a historical control group of patients who underwent conventional trans-iliac plate fixation for the treatment of unstable pelvic ring fractures.

      Materials and methods

      Thirty-two patients diagnosed with unstable pelvic fractures with sacral fracture or sacroiliac joint fracture dislocation were retrospectively evaluated. Eight consecutive patients underwent trans-iliac plate fixation from April 2012 to March 2015, and 24 consecutive patients underwent SAIS fixation from April 2015 to February 2020. Rates of soft tissue complications, intraoperative blood loss, and intraoperative blood transfusion volume were compared in these two groups.

      Results

      Mean intraoperative blood loss was significantly lower in patients who underwent SAIS fixation than in those who underwent trans-iliac plate fixation (141.0 ml vs 315.0 ml; P = 0.027), although there were no between-group differences in intraoperative blood transfusion volume (0.0 ml vs 140 ml; P = 0.105), incidence rate of soft tissue complications (4.2% vs 0%; P = 1.000), and operation time (88.5 min vs 93.0 min; P = 0.862). Bone healing was confirmed in all patients who underwent SAIS fixation without dislocation of the fracture site, whereas one patient who underwent trans-iliac plate fixation experienced a dislocation of the fracture site during follow-up (0% vs 12.5%; P = 0.250).

      Conclusions

      SAIS fixation reduces intraoperative blood loss and ensures bone healing without major complications, including dislocation of the fracture site. SAIS fixation may therefore be an alternative, minimally invasive method of treating unstable pelvic fractures.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Yasumura K.
        • Ikegami K.
        • Kamohara T.
        • Nohara Y.
        High incidence of ischemic necrosis of the gluteal muscle after transcatheter angiographic embolization for severe pelvic fracture.
        J Trauma Inj Infect Crit Care. 2005; 58: 985-990
        • Routt M.L.C.
        • Kregor P.J.
        • Simonian P.T.
        • Mayo K.A.
        Early results of percutaneous iliosacral screws placed with the patient in the supine position.
        J Orthop Trauma. 1995; 9: 207-214
        • Gardner M.J.
        • Routt M.L.C.
        Transiliac-transsacral screws for posterior pelvic stabilization.
        J Orthop Trauma. 2011; 25: 378-384
        • Shirahama M.
        Surgical treatment of vertically unstable sacral fractures using a new plate.
        Kurume Med J. 2005; 52: 857-863
        • Mouhsine E.
        • Wettstein M.
        • Schizas C.
        • Borens O.
        • Blanc C.H.
        • Leyvraz P.F.
        • et al.
        Modified triangular posterior osteosynthesis of unstable sacrum fracture.
        Eur Spine J. 2006; 15: 857-863
        • Kim J.W.
        • Oh C.W.
        • Oh J.K.
        • Kyung H.S.
        • Park K.H.
        • Yoon S.D.
        • et al.
        The incidence of and factors affecting iliosacral screw loosening in pelvic ring injury.
        Arch Orthop Trauma Surg. 2016; 136: 921-927
        • Allen B.L.
        • Ferguson R.L.
        The galveston technique of pelvic fixation with L-rod instrumentation of the spine.
        Spine. 1984; 9: 388-394
        • Pearcy M.
        • Portek I.F.
        • Shepherd J.
        Three-dimensional X-ray analysis of normal movement in the lumbar spine.
        Spine. 1984; 9: 294-297
        • Keel M.J.B.
        • Benneker L.M.
        • Siebenrock K.A.
        • Bastian J.D.
        Less invasive lumbopelvic stabilization of posterior pelvic ring instability: technique and preliminary results.
        J Trauma Inj Infect Crit Care. 2011; 71: E62-E70
        • Toogood P.
        • McDonald E.
        • Pekmezci M.
        A biomechanical comparison of ipsilateral and contralateral pedicle screw placement for modified triangular osteosynthesis in unstable pelvic fractures.
        J Orthop Trauma. 2013; 27: 515-520
        • Kebaish K.M.
        Sacropelvic fixation: Techniques and complications.
        Spine (Phila Pa 1976). 2010; 35: 2245-2251
        • O'Brien J.R.
        • Yu W.
        • Kaufman B.E.
        • Bucklen B.
        • Salloum K.
        • Khalil S.
        • et al.
        Biomechanical evaluation of S2 alar-iliac screws: effect of length and quad-cortical purchase as compared with iliac fixation.
        Spine (Phila Pa 1976). 2013; 38: E1250-E1255
        • Burns C.B.
        • Dua K.
        • Trasolini N.A.
        • Komatsu D.E.
        • Barsi J.M.
        Biomechanical comparison of spinopelvic fixation constructs: iliac screw versus S2-Alar-Iliac screw.
        Spine Deform. 2016; 4: 10-15
        • Martin C.T.
        • Witham T.F.
        • Kebaish K.M.
        Sacropelvic fixation: two case reports of a new percutaneous technique.
        Spine (Phila. Pa. 1976). 2011; 36: 618-621
        • Lee H.D.
        • Jeon C.H.
        • Chung N.S.
        • Jeong S.
        • Song H.K.
        Triangular osteosynthesis using an S1 pedicle screw and S2 alar iliac screw for a unilateral vertically displaced sacral fracture.
        World Neurosurg. 2020; 142: 57-61
        • El Dafrawy M.H.
        • Kebaish K.M.
        Percutaneous S2 alar iliac fixation for pelvic insufficiency fracture.
        Orthopedics. 2014; 37: e1033-e1035
        • EL Dafrawy M.H.
        • Shafiq B.
        • Vaswani R.
        • Osgood G.M.
        • Hasenboehler E.A.
        • Kebaish K.M.
        • et al.
        Minimally invasive fixation for spinopelvic dissociation: percutaneous triangular osteosynthesis with S2 alar-iliac and iliosacral screws.
        JBJS Case Connect. 2019; 9: 9-12
        • Wiltse L.L.
        • Bateman J.G.
        • Hutchinson R.H.
        • Nelson W.E.
        The paraspinal sacrospinalis-splitting approach to the lumbar spine.
        J Bone Jt Surg. 1968; 50: 919-926
        • Bellabarba C.
        • Schildhauer T.A.
        • Vaccaro A.R.
        • Chapman J.R.
        Complications associated with surgical stabilization of high-grade sacral fracture dislocations with spino-pelvic instability.
        Spine (Phila Pa 1976). 2006; 31: 80-88
        • Sagi H.C.
        • Militano U.
        • Caron T.
        • Lindvall E.A.
        Comprehensive analysis with minimum 1-year follow-up of vertically unstable transforaminal sacral fractures treated with triangular osteosynthesis.
        J Orthop Trauma. 2009; 23: 313-319
        • Liuzza F.
        • Silluzio N.
        • Florio M.
        • Ezzo O.E.
        • Cazzato G.
        • Ciolli G.
        • et al.
        Comparison between posterior sacral plate stabilization versus minimally invasive transiliac-transsacral lag-screw fixation in fractures of sacrum: a single-centre experience.
        Int Orthop. 2019; 43: 177-185
        • Pearson J.M.
        • Niemeier T.E.
        • McGwin G.
        • Manoharan S.R.
        Spinopelvic dissociation: comparison of outcomes of percutaneous versus open fixation strategies.
        Adv Orthop. 2018; 20185023908
        • Kelly M.
        • Zhang J.
        • Humphrey C.A.
        • Gorczyca J.T.
        • Mesfin A.
        Surgical management of U/H type sacral fractures: outcomes following iliosacral and lumbopelvic fixation.
        J Spine Surg. 2018; 4: 361-367
        • Okuda A.
        • Maegawa N.
        • Matsumori H.
        • Kura T.
        • Mizutani Y.
        • Shigematsu H.
        • et al.
        Minimally invasive spinopelvic ‘crab-shaped fixation’ for unstable pelvic ring fractures: technical note and 16 case series.
        J Orthop Surg Res. 2019; 14: 1-7
        • Abumi K.
        • Saita M.
        • Iida T.
        • Kaneda K.
        Reduction and fixation of sacroiliac joint dislocation by the combined use of S1 pedicle screws and the Galveston technique.
        Spine (Phila. Pa. 1976). 2000; 25: 1977-1983
        • Toda K.
        • Yagata Y.
        • Kikuchi T.
        • Takigawa T.
        • Ito Y.
        Minimally invasive surgery for unstable pelvic ring fractures: transiliac rod and screw fixation.
        Acta Med Okayama. 2020; 74: 27-32
        • Kanezaki S.
        • Miyazaki M.
        • Notani N.
        • Ishihara T.
        • Sakamoto T.
        • Sone T.
        • et al.
        Minimally invasive triangular osteosynthesis for highly unstable sacral fractures: technical notes and preliminary clinical outcomes.
        Medicine (U S). 2019; 98: e16004
        • Tian W.
        • Chen W.H.
        • Jia J.
        Traumatic spino-pelvic dissociation with bilateral triangular fixation.
        Orthop Surg. 2018; 10: 205-211
        • Futamura K.
        • Baba T.
        • Mogami A.
        • Kanda A.
        • Obayashi O.
        • Iwase H.
        • et al.
        Within ring”-based sacroiliac rod fixation may overcome the weakness of spinopelvic fixation for unstable pelvic ring injuries: technical notes and clinical outcomes.
        Int Orthop. 2018; 42: 1405-1411
        • Yu B.S.
        • Zhuang X.M.
        • Zheng Z.M.
        • Li Z.M.
        • Wang T.P.
        • Lu W.W.
        • et al.
        Biomechanical advantages of dual over single iliac screws in lumbo-iliac fixation construct.
        Eur Spine J. 2010; 19 (1121-8)
        • Shin J.K.
        • Lim B.Y.
        • Goh T.S.
        • Son S.M.
        • Kim H.S.
        • Lee J.S.
        • et al.
        Effect of the screw type (S2-alar-iliac and iliac), screw length, and screw head angle on the risk of screw and adjacent bone failures after a spinopelvic fixation technique: a finite element analysis.
        PLoS One. 2018; 13: 1-21