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Clinical Orthopaedics and Related Research®

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01-08-2012 | Symposium: Disruptions of the Pelvic Ring: An Update

Can Lumbopelvic Fixation Salvage Unstable Complex Sacral Fractures?

Authors: Clifford B. Jones, MD, Debra L. Sietsema, RN, PhD, Martin F. Hoffmann, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 8/2012

Abstract

Background

Traditional screw or plate fixation options can be used to fix the majority of sacral fractures. However, these techniques are unreliable with dysmorphic upper sacral segments, U-fractures, osseous compression of neural elements, and previously failed fixation. Lumbopelvic fixation can potentially address these injuries but is a technically demanding procedure requiring spinal and pelvic fixation and it is unclear whether it reliably corrects the deformity and restores function.

Questions/purposes

We therefore assessed reduction quality and loss of fixation, pain related to prominent hardware, subjective dysfunction measured by the Short Musculoskeletal Function Assessment (SMFA), and complications.

Methods

We retrospectively reviewed 15 patients with unstable sacral fractures treated with lumbopelvic fixation between 2002 and 2010. Patients had radiographic monitoring regarding reduction quality and loss of fixation and clinical followup using the SMFA. The minimum followup was 12 months (mean, 23 months; range, 12–41 months).

Results

Posterior reduction quality was 11 of 15 with less than 5 mm persistent displacement and four of 15 with 5 to 10 mm displacement. Loss of fixation was observed in one patient as a result of a technical error. Prominent hardware resulted in greater pain. Despite daily activity and bother subscores improving over time, we found long-term dysfunction in the SMFA. Eleven of the 15 patients were able to return to previous work or activities.

Conclusion

Complex posterior pelvic ring injuries of the sacrum not amenable to traditional fixation options can be salvaged with adherence to the technical details of lumbopelvic fixation. Hardware prominence and pain are markedly reduced with screw head recession. Long-term impairment is noted in patients with complex pelvic ring injuries requiring lumbopelvic fixation compared with normative data.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Collinge C, Tornetta P 3rd. Soft tissue injuries associated with pelvic fractures. Orthop Clin North Am. 2004;35:451–456, v.PubMed

Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;227:67–81.PubMed

Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213.PubMedCrossRef

Ellison M, Timberlake GA, Kerstein MD. Impotence following pelvic fracture. J Trauma. 1988;28:695–696.PubMedCrossRef

Gansslen A, Pape HC, Lehmann U, Lange U, Krettek C, Pohlemann T. [Open reduction and internal fixation of unstable sacral fractures] [in German]. Zentralblatt fur Chirurgie. 2003;128:40–45.PubMedCrossRef

Gibbons KJ, Soloniuk DS, Razack N. Neurological injury and patterns of sacral fractures. J Neurosurg. 1990;72:889–893.PubMedCrossRef

Goldstein A, Phillips T, Sclafani SJ, Scalea T, Duncan A, Goldstein J, Panetta T, Shaftan G. Early open reduction and internal fixation of the disrupted pelvic ring. J Trauma. 1986;26:325–333.PubMedCrossRef

Gribnau AJ, van Hensbroek PB, Haverlag R, Ponsen KJ, Been HD, Goslings JC. U-shaped sacral fractures: surgical treatment and quality of life. Injury. 2009;40:1040–1048.PubMedCrossRef

Griffin DR, Starr AJ, Reinert CM, Jones AL, Whitlock S. Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure? J Orthop Trauma. 2003;17:399–405.PubMedCrossRef

10.

Gruen GS, Leit ME, Gruen RJ, Garrison HG, Auble TE, Peitzman AB. Functional outcome of patients with unstable pelvic ring fractures stabilized with open reduction and internal fixation. J Trauma. 1995;39:838–844; discussion 844–845.PubMedCrossRef

11.

Harris I, Dao AT, Young J, Solomon M, Jalaludin BB, Rae H. Factors predicting patient satisfaction following major trauma. Injury. 2007;38:1102–1108.PubMedCrossRef

12.

Harris IA, Dao AT, Young JM, Solomon MJ, Jalaludin BB. Predictors of patient and surgeon satisfaction after orthopaedic trauma. Injury. 2009;40:377–384.PubMedCrossRef

13.

Henderson RC. The long-term results of nonoperatively treated major pelvic disruptions. J Orthop Trauma. 1989;3:41–47.PubMedCrossRef

14.

Hunsaker FG, Cioffi DA, Amadio PC, Wright JG, Caughlin B. The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am. 2002;84:208–215.PubMed

15.

Hunt N, Jennings A, Smith M. Current management of U-shaped sacral fractures or spino-pelvic dissociation. Injury. 2002;33:123–126.PubMedCrossRef

16.

Isler B. Lumbosacral lesions associated with pelvic ring injuries. J Orthop Trauma. 1990;4:1–6.PubMedCrossRef

17.

Kaech K, Trenz O. Distraction spondylodesis of the sacrum in ‘vertical shear lesions’ of the pelvis. Der Unfallchirurg. 1994;97:28–38.

18.

Keel MJ, Benneker LM, Siebenrock KA, Bastian JD. Less invasive lumbopelvic stabilization of posterior pelvic ring instability: technique and preliminary results. J Trauma. 2011;71:E62–E70.PubMedCrossRef

19.

Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audige L. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21:S1–S133.PubMedCrossRef

20.

Matta JM, Tornetta P 3rd. Internal fixation of unstable pelvic ring injuries. Clin Orthop Relat Res. 1996;329:129–140.PubMedCrossRef

21.

Moshirfar A, Rand FF, Sponseller PD, Parazin SJ, Khanna AJ, Kebaish KM, Stinson JT, Riley LH 3rd. Pelvic fixation in spine surgery. Historical overview, indications, biomechanical relevance, and current techniques. J Bone Joint Surg Am. 2005;87(Suppl 2):89–106.PubMedCrossRef

22.

Mouhsine E, Wettstein M, Schizas C, Borens O, Blanc CH, Leyvraz PF, Theumann N, Garofalo R. Modified triangular posterior osteosynthesis of unstable sacrum fracture. Eur Spine J. 2006;15:857–863.PubMedCrossRef

23.

Mullis BH, Sagi HC. Minimum 1-year follow-up for patients with vertical shear sacroiliac joint dislocations treated with iliosacral screws: does joint ankylosis or anatomic reduction contribute to functional outcome? J Orthop Trauma. 2008;22:293–298.PubMedCrossRef

24.

Papakostidis C, Kanakaris NK, Kontakis G, Giannoudis PV. Pelvic ring disruptions: treatment modalities and analysis of outcomes. Int Orthop. 2009;33:329–338.PubMedCrossRef

25.

Powers ML, Hatem SF, Sundaram M. Morel-Lavallee lesion. Orthopedics. 2007;30:250, 322–353.

26.

Reilly MC, Bono CM, Litkouhi B, Sirkin M, Behrens FF. The effect of sacral fracture malreduction on the safe placement of iliosacral screws. J Orthop Trauma. 2003;17:88–94.PubMedCrossRef

27.

Routt ML Jr, Kregor PJ, Simonian PT, Mayo KA. Early results of percutaneous iliosacral screws placed with the patient in the supine position. J Orthop Trauma. 1995;9:207–214.PubMedCrossRef

28.

Roy-Camille R, Saillant G, Gagna G, Mazel C. Transverse fracture of the upper sacrum. Suicidal jumper’s fracture. Spine. 1985;10:838–845.

29.

Sagi HC. Technical aspects and recommended treatment algorithms in triangular osteosynthesis and spinopelvic fixation for vertical shear transforaminal sacral fractures. J Orthop Trauma. 2009;23:354–360.PubMedCrossRef

30.

Sagi HC, Lindvall EM. Inadvertent intraforaminal iliosacral screw placement despite apparent appropriate positioning on intraoperative fluoroscopy. J Orthop Trauma. 2005;19:130–133.PubMedCrossRef

31.

Sagi HC, 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; discussion 319–321.PubMedCrossRef

32.

Schildhauer TA, Bellabarba C, Nork SE, Barei DP, Routt ML Jr, Chapman JR. Decompression and lumbopelvic fixation for sacral fracture-dislocations with spino-pelvic dissociation. J Orthop Trauma. 2006;20:447–457.PubMedCrossRef

33.

Schildhauer TA, Chapman JR, Mayo KA. Multisegmental open sacral fracture due to impalement: a case report. J Orthop Trauma. 2005;19:134–139.PubMedCrossRef

34.

Schildhauer TA, Josten C, Muhr G. Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weight-bearing. J Orthop Trauma. 1998;12:307–314.PubMedCrossRef

35.

Schildhauer TA, Ledoux WR, Chapman JR, Henley MB, Tencer AF, Routt ML Jr. Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads. J Orthop Trauma. 2003;17:22–31.PubMedCrossRef

36.

Selby R, Geerts W. Prevention of venous thromboembolism: consensus, controversies, and challenges. Hematology Am Soc Hematol Educ Program. 2009:286–292.

37.

Stambough JL, Dolan D, Werner R, Godfrey E. Ophthalmologic complications associated with prone positioning in spine surgery. J Am Acad Orthop Surg. 2007;15:156–165.PubMed

38.

Stannard JP, Singhania AK, Lopez-Ben RR, Anderson ER, Farris RC, Volgas DA, McGwin GR Jr, Alonso JE. Deep-vein thrombosis in high-energy skeletal trauma despite thromboprophylaxis. J Bone Joint Surg Br. 2005;87:965–968.PubMedCrossRef

39.

Strange-Vognsen HH, Lebech A. An unusual type of fracture in the upper sacrum. J Orthop Trauma. 1991;5:200–203.PubMedCrossRef

40.

Suzuki K, Mochida J. Operative treatment of a transverse fracture-dislocation at the S1–S2 level. J Orthop Trauma. 2001;15:363–367.PubMedCrossRef

41.

Swiontkowski MF, Engelberg R, Martin DP, Agel J. Short musculoskeletal function assessment questionnaire: validity, reliability, and responsiveness. J Bone Joint Surg Am. 1999;81:1245–1260.PubMedCrossRef

42.

Tile M. Fractures of the Pelvis and Acetabulum. Baltimore, MD, USA: Lippincott Williams & Wilkins; 1984.

43.

Tornetta P 3rd, Matta JM. Outcome of operatively treated unstable posterior pelvic ring disruptions. Clin Orthop Relat Res. 1996;329:186–193.PubMedCrossRef

44.

Vanderschot P, Meuleman C, Lefevre A, Broos P. Trans iliac-sacral-iliac bar stabilisation to treat bilateral lesions of the sacro-iliac joint or sacrum: anatomical considerations and clinical experience. Injury. 2001;32:587–592.PubMedCrossRef

45.

White RH, Goulet JA, Bray TJ, Daschbach MM, McGahan JP, Hartling RP. Deep-vein thrombosis after fracture of the pelvis: assessment with serial duplex-ultrasound screening. J Bone Joint Surg Am. 1990;72:495–500.PubMed

46.

Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment. Radiology. 1986;160:445–451.PubMed

Title: Can Lumbopelvic Fixation Salvage Unstable Complex Sacral Fractures?
Authors: Clifford B. Jones, MD
Debra L. Sietsema, RN, PhD
Martin F. Hoffmann, MD
Publication date: 01-08-2012
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 8/2012
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-012-2273-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Can Lumbopelvic Fixation Salvage Unstable Complex Sacral Fractures?

Abstract

Background

Questions/purposes

Methods

Results

Conclusion

Level of Evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Questions/purposes

Methods

Results

Conclusion

Level of Evidence

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