TS5: A NEW TECHNIQUE FOR REDUCTION AND FIXATION OF POSTERIOR PELVIC RING INJURIES – INTRODUCTION OF THE TECHNIQUE AND FIRST EXPERIENCE

Abstract

Introduction: Unilateral posterior Pelvic Ring injuries but especially bilateral sacral fractures or bilateral sacroiliac joint (SI) ruptures as well as lumbosacral dislocations and fracture dislocations remains a significant surgical challenge.^1,2,3 despite advances in surgical techniques. Although the true incidence of these fractures are unknown, 30% are identified late.⁴

The treatment of those fractures varies from conservative treatment, posterior plate fixation, anterior plating as well as percutaneous and open Sacroiliac (SI) joint screws.

However, screw pull-outs and loss of fixation in those methods are well described In the Alfred Hospital, Melbourne (Australia) a Level 1 Trauma Center a series of 14 patients were treated from 10/2006 to date with a multiaxial spinal system.

Methods: Patients with posterior pelvic injuries separation were identified prospectively since October 2006. Data was extracted from the trauma registry database and medical record and diagnostic imaging. Since Ocober 2006, 10 patients with bilateral posterior pelvic ring injuries and 4 with unilateral injuries were identified for fixation.

Technique: The patients were put supine and a incision medial/distalto the posterior iliac spine was made. The placement for the incision gives the surgeon the opportunity to estend the approach to an open reduction of the sacral fracture or SI Joint disruption if a closed reduction cannot be achieved.

A pedicel screw from a multiaxial spinal system (Xia, Stryker or Pangea, Synthes) is placed percutaneously in the posterior iliac crest on both sides and the reduction is performed with the screws attached to the screw handles and with Image Intensifier.

After the reduction the multiaxial screwheads are bent and transfixed with a bar which is tunneled epifacial.

All patients underwent a multislice pelvic and lumbar spine CT and these patients were assessed clinically for neurovascular symptoms and stability. The follow-up included clinical assessment and CT imaging.

Results: Since October 2006 14 patients (10 male, 4 female) with an average age of 32.4 years (range: 20–44 years, median 33 years) and an average ISS (Injury Severity Score) of 37 (range: 14–66, median 34). The mechanism of injury for these patients included: pedestrians versus car; motorcylce; paragliding and motor car collision. All patients had associated anterior pelvic ring injuries which were internally fixed in all but one case.

The follow up time was one to 18 month. The patients were assessed clinically and with CT imaging. No complications or loss of fixation have been observed in this patient group in this short follow up time.

Discussion: The fixation system is highly versaitle and the whole posterior iliac crest can be used for fixation. The posterior instrumentation provides also a good control of the reduction of anterior pelvic ring fractures which should be fixed when associated. In all cases but 3 the nature of the comminuted sacral fractures did not allow the use of SI-Joint screws or anterior SI-Joint plating.

The construct provides initial stability and allows mobilization of the patient. It can be used in cases with sacral comminution and may offer advantages over posterior plate fixation, by reducing complications with prominent metalware.