Title: Evaluation of the results of the treatment of fracture of pelvis and acetabulum using Percutaneous, minimally invasive internal fixation technique
Author(s): Hamid Reza Seyyed Hosseinzadeh MD, Mohammad Reza Bigdeli MD, Mohammad Qoreishi MD*
Affiliattion(s): Shahid Beheshti University of Medical Sciences, Tehran, Iran
* Corresponding Author
Vol 1, Num 1, July 2014
Introduction: The unstable pelvic ring fractures are major orthopaedic injuries associated with high rates of morbidity and mortality. Open surgical stabilization is the standard treatment for the majority of them. Percutaneous minimally invasive surgical stabilization of the fractures has become an accepted treatment method in the past several years. We report our experience with this relatively new technique in our patients with unstable pelvic fractures.
Materials and Methods: This is a descriptive study on 36 patients (23 male and 13 female) with the mean age of 29+7 years. All the operations were performed by a single surgeon (HRSH) in supine position and under C-arm fluoroscopy control. All the patients have at least 6 month clinical and radiographic control.
Results: All the fractures in all 36 patients healed in the follow-up study and the patients could bear weight completely on both lower limbs. 31 patients could get back to their preoperative abilities, but 5 cases had to change their jobs. We had one screw breakage and one deep infection. There was no neurologic deficit following screw insertion. The average blood loss was 20 cc.
Conclusion: Closed reduction and percutaneous iliosacral and iliopubic minimally invasive screw fixation for, respectively, posterior pelvic ring or anterior column acetabular fractures are useful surgical treatment options with low complication rates.
Keywords: Pelvis, Acetabulum, Fracture, Internal fixation
Unstable pelvic ring fractures are associated with high morbidity and mortality, and usually occur in multiple trauma patients. Treatment of these fractures commonly is a challenge facing most orthopaedic surgeons. Treating these injuries by non-surgical methods is associated with poor clinical results and high morbidity. On the other hand it has been shown that surgical treatment of these injuries has reduced the morbidity and mortality of them.(1, 2, 3, 4 and 5) The standard treatment method for the fractures of anterior column of acetabulum is now open reduction and internal fixation (ORIF) with anterior surgical approach. (6 and 7) Pelvic fracture treatment by closed screw insertion was first reported in 1995 by Routt and was compared to routine open methods. The overall advantages of this method are less soft tissue injury, less blood loss and lower rate of infection. But this technique has some drawbacks such as inappropriate screw placement, neurovascular injury and poor reduction.(2,3,5) There is only one previous report of this technique in Iran by the same group and this is the second and more extensive report.
Materials and Methods
This is a descriptive study. 36 patients (23 male and 13 female) with pelvic and acetabular fractures amenable to percutaneous fixation entered our study. The average age of the patients was 29±7 years (16-65). The definitive diagnosis of acetabular or pelvis fractures was based on clinical suspicion and confirmation by radiography and CT scan. All of these patients were operated on by a single surgeon (HRSH) with closed reduction and percutaneous iliosacral or iliopubic screw fixation under the fluoroscopy control. Inclusion criteria were all unstable pelvic fractures amenable to this type of fixation which includes fractures of the pubic rami, vertical fractures of sacrum, crescent fractures and sacroiliac fracture ± dislocation and all anterior column, transverse and both column fractures of acetabulum. Those patients who needed temporary external fixation due to hemodynamic instability and those who needed open reduction were excluded from the study. The screws used for fixation were partial or full threaded 7.3 or 6.5 mm cannulated screws. After fixation, all the fractures were controlled by fluoroscopy under stress. All the patients received postoperative IV antibiotic for 48 hours and LMWH for at least one week. Postoperatively, all classic radiographic views (AP, obturator and iliac oblique and inlet and outlet pelvic views) were obtained. Then these views were repeated after 6 weeks, 3 and 6 months postoperatively. The patient data including injury mechanism, type of the fracture, type of the surgery, size of the incision, duration of the surgery, duration of admission, time from surgery to first walking, quantity of pain in the follow-ups, union quality, amount of blood loss and presence of nerve injury were recorded. These data were analyzed by Wilcoxon Sign test.
The research was carried out on the 36 patients. Of these, 13 (36.1%) were females and 23 were males (63.9%). The mean age of the patients was 29+7 years with the youngest patient being 16 and the oldest 65 years old. The injury mechanism was car accident in 22 patients (61.1%) and falling from height in the rest (38.9%). The mechanisms of pelvic fractures were lateral compression in 17 (47.7%) patients, which was associated with the fracture of the anterior column of the acetabulum in 6 patients. In 2 patients (5%) the mechanism was combined lateral compression and vertical shear and in 9 patients (25%) this mechanism was anteroposterior compression, which was associated with the fracture of the anterior column of the acetabulum in 2 patients. 8 patients (22.2%) had isolated acetabular fractures, 7 of them were transverse and 1 was both column fracture. We used iliosacral screw fixation in 28 and iliopubic screw fixation in 19 patients (some patients needed both kinds of fixation). Six patients needed simultaneous open reduction and internal fixation for symphysis pubis diastheses and iliac wing fractures. We performed all the operations in supine position for both iliosacral and iliopubic screw insertion. Our first experience with iliopubic screw insertion was with retrograde technique, which proved to be difficult in the hands of our surgeon (HRSH). Since then, all iliopubic screws were inserted by antegrade technique. In 4 patients we inserted bilateral iliopubic and in 1 patient bilateral iliosacral screws. Operation time in our patients was on average 32±8 minutes (22 – 72 minutes). The operation time was measured from the first flouroscopic exposure after patient positioning till the last suture. Since we used multiple stab incisions to insert multiple screws, we measured the length of the incision by summation the length of all incisions. This length was on average 3±1 cm (1 – 6 cm). In 7 patients we needed to perform a manipulation to reduce the fracture by a closed method via a small incision. 28 of our patients were out of bed the day after surgery and could walk with partial weight bearing with the aid of a walker. The rest of our patients had to stay in bed for at most 48 hours postoperatively due to other comorbidities or fractures. The average duration of admission for our patients was 4±2 (the maximum was 10 days). We followed the patients for at least 6 months (average 14±3.5 month) and in each follow up, we assessed the union, pain quantity, walking ability and return to preoperative activities. According to X-rays, all the fractures went to union and all the patients could walk fully without any significant pain. Those who had pain all felt it in the sacroiliac area. 31 of patients got back to their preoperative activities while 5 patients had to change their job, due to the quality of their job. During the operation, the measured blood loss was less than 20 ml in all patients except those who needed percutaneous manipulation, in whom blood loss was near 100 ml. Our major complications were one screw breakage and one deep wound infection. The infection was treated by wound debridement and IV antibiotics and the broken screw was left in place and the fracture continued to union by weight bearing restriction. We had no postoperative neural injury.
Currently the standard treatment of the fractures of the anterior column of the acetabulum is open reduction and internal fixation (ORIF) with anterior surgical approach (6,7), but recently, most authorities prefer to treat these fractures by closed methods using percutaneous screw fixation (2,3,5,8). Since this method of pelvic and acetabular fracture fixation has not got popularity in our orthopaedic surgeons, we introduce our patients to underscore this method as a versatile and practical technique without significant complications. Since this technique uses intramedullary screw, the rigidity of the fixation would be so high that the patient can bear weight completely on the day after surgery.(8) This early walking and weight bearing in addition to less soft tissue damage result in more rapid rehabilitation. In the study by Lin YC et al, 3 patients with anterior column fractures treated by iliopubic screws began weight bearing the day after surgery.(9) All our patients were allowed to walk and bear weight after 48 hours postoperatively. This is a major advantage of his method in comparison to open methods and plate fixation, which usually need prolonged duration of limitation in weight bearing. (1-3) Schweritz D et al reported the results of percutaneous iliosacral screw insertion in 71 patients with unstable pelvic fractures.(1) In a 31-month follow-up, 61 patients (86%) could return to their preoperative activities and job, which is consistent with our result (86.1%). They also reported neurologic deficit in two patients postoperatively, a significant complication which we did not see in our patients. In long-term follow-up, they found osteoarthritis in the sacroiliac joint of 15 patients. We did not perform long-term follow-up as Schweritz et al performed, so we cannot deduce on the presence of osteoarthritis in our patients. In their last follow-up, Schweritz et al reported excellent results in 66 patients. Crowl AC et al (10) reported on 23 patients with anterior column fractures who were treated by closed reduction and percutaneous iliopubic fixation. 8 of these patients had associated posterior hemitransverse fractures which were treated by percutaneous intramedullary screw fixation. None of the 23 patients showed signs of loss of reduction. They reported no infection, visceral injury nor neurologic injury. They had no ectopic bone formation around the pelvis. Their results show this method as a reliable and reproducible technique for treating certain pelvic fractures. Griffin DR et al (11) in a study on 62 patients treated by percutaneous iliosacral screws, reported excellent results. 32 of these patients had iliosacral fracture-dislocation and 30 patients had vertical sacral fractures. 4 patients showed loss of reduction, all of who had vertical sacral fracture and this complication occurred the first 3 months postoperatively. Our study has some limitations. The number of our cases is limited. We have included all cases with pelvic and acetabular fractures amenable to this method of fixation. We assessed the reduction postoperatively by radiography and did not performed CT scan in our patients.
Closed reduction and percutaneous minimally invasive iliosacral or iliopubic screw fixation is a reliable treatment method for unstable pelvic ring and anterior column acetabular fractures with minimal morbidity and complication rate. This intramedullary fixation is the most rigid fixation method in pelvic ring and following it, the patient can bear weight early postoperatively.
Hamid Reza Seyyed Hosseinzadeh MD Orthopaedic surgeon, Associate professor, Shahid Beheshti Medical Univerity, Tehran, Iran email@example.com
Mohammad Qoreishi MD Orthopaedic surgeon, Assistant professor, Shahid Beheshti Medical University, Tehran, Iran firstname.lastname@example.org
Mohammad Reza Bigdeli MD Orthopaedic surgeon, Tehran, Iran email@example.com
Acknowledgements: None declared.
Financial disclosure: None declared.
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