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European Journal of Trauma and Emergency Surgery

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Open Access 01-12-2021 | Original Article

Safety and efficacy of 2D-fluoroscopy-based iliosacral screw osteosynthesis: results of a retrospective monocentric study

Authors: Pol Maria Rommens, Eva Mareike Nolte, Johannes Hopf, Daniel Wagner, Alexander Hofmann, Martin Hessmann

Published in: European Journal of Trauma and Emergency Surgery | Issue 6/2021

Abstract

Introduction

Iliosacral screw osteosynthesis is a well-accepted procedure for stabilization of sacral fractures and iliosacral (fracture) dislocations.

Materials and Methods

In this monocentric study, safety and efficacy of conventional 2D-fluoroscopic-guided iliosacral screw insertion were evaluated.

Results

During a 10-year period (2005–2014), 98 patients between the age of 18 and 65 years received 207 iliosacral screws in 101 procedures. Average patient age was 43.2 years. There were 46 Type B and 40 Type C injuries in the AO/OTA classification, nine patients had a fragility fracture of the pelvis. In three patients, primary radiological data were missing. The indication for surgical treatment was a sacral fracture in 97 patients, a pure iliosacral dislocation in 37 patients and a fracture-dislocation in 31 patients. 70 procedures were performed with the patient in supine position, 31 with the patient in prone position. Surgery was done in a minimal-invasive technique in 76 patients, in 22 patients an open reduction was necessary before screw insertion. 81 patients received a unilateral, 17 patients a bilateral screw osteosynthesis. 199 screws were inserted in S1, only eight screws in S2. 65 patients received two screws unilaterally, ten patients two screws bilaterally. There were no vascular or neurologic complications. During in-hospital stay, there were seven complications, which needed 12 operative revisions: three wound infections, two hematomas, one screw malalignment and one early screw loosening. In 28 patients with 56 iliosacral screws, a pelvic CT-scan was performed during follow-up. A penetration of a cortical layer was diagnosed in 20 of these screws. All penetrations were seen in double screw osteosynthesis of S1. In none of the patients, complaints could be explained by the malalignment of these screws. Five operative revisions were performed during follow-up: two for screw loosening, two for fracture healing problems and one for screw malalignment. Metal removal was performed in 39 patients with 75 screws. 2D-fluoroscopic-guided iliosacral screw osteosynthesis is a safe and efficient procedure in clinical practice.

Discussion

A thorough preoperative evaluation of the morphology of the upper sacrum and careful operative procedure are indispensable. Fluoroscopic views in AP, lateral, inlet and outlet must allow recognition of all anatomical landmarks. The indication for double screw osteosynthesis in S1 should be taken with caution. Screw malalignments do not inevitably correlate with complaints.

Tile M. Acute pelvic fractures: I. Causation and classification. J Am Acad Orthop Surg. 1996;4(3):143–51.PubMed

Spiegel PG. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma. 1996;10:1–154.

Dalal SA, Burgess AR, Siegel JH, Young JW, Brumback RJ, Poka A, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma. 1989;29(7):981–1000.PubMed

Rommens PM, Hofmann A, Hessmann MH. Management of acute hemorrhage in pelvic trauma: an overview. Eur J Trauma Emerg Surg. 2010;36(2):91–9.PubMed

Marzi I, Lustenberger T. Management of bleeding pelvic fractures. Scand J Surg. 2014;103(2):104–11.PubMed

Pohlemann T, Stengel D, Tosounidis G, Reilmann H, Stuby F, et al. Survival trends and predictors of mortality in severe pelvic trauma: estimates from the German Pelvic Trauma Registry Initiative. Injury. 2011;42(10):997–1002.PubMed

Ward EF, Tomasin J, Vander Griend RA. Open reduction and internal fixation of vertical shear pelvic fractures. J Trauma. 1987;27(3):291–5.PubMed

Matta JM, Saucedo T. Internal fixation of pelvic ring fractures. Clin Orthop Relat Res. 1989;242:83–97.

Keating JF, Werier J, Blachut P, Broekhuyse H, Meek RN, et al. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma. 1999;13(2):107–13.PubMed

10.

Hopf JC, Krieglstein CF, Müller LP, Koslowsky TC. Percutaneous iliosacral screw fixation after osteoporotic posterior ring fractures of the pelvis reduces pain significantly in elderly patients. Injury. 2015;46(8):1631–6.PubMed

11.

Rommens PM, Arand C, Hofmann A, Wagner D. When and how to operate fragility fractures of the pelvis? Ind J Orthop. 2019;53(1):128–37.

12.

Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: recommendations for surgical treatment. Injury. 2013;44(12):1733–44.PubMed

13.

Zwingmann J, Konrad G, Mehlhorn AT, Südkamp NP, Oberst M. Percutaneous iliosacral screw insertion: malpositioning and revision rate of screws with regards to application technique (navigated vs. conventional). J Trauma. 2010;69(6):1501–6.PubMed

14.

Zwingmann J, Hauschild O, Bode G, Südkamp NP, Schmal H. Malposition and revision rates of different imaging modalities for percutaneous iliosacral screw fixation following pelvic fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2013;133(9):1257–65.PubMed

15.

Krappinger D, Lindtner RA, Benedikt S. Preoperative planning and safe intraoperative placement of iliosacral screws under fluoroscopic control. Oper Orthop Traumatol. 2019;31(6):465–73.PubMedPubMedCentral

16.

Rommens PM, Wagner D, Hofmann A. Iliosacral screw osteosynthesis. In: Rommens PM, Hofmann A, editors. Fragility fractures of the pelvis. Berlin: Springer International Publishing; 2018. p. 121–138.

17.

Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Percutaneous iliosacral screw fixation in S1 and S2 for posterior pelvic ring injuries: technique and perioperative complications. Arch Orthop Trauma Surg. 2011;131(6):809–13.PubMed

18.

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(3):207–14.PubMed

19.

Gras F, Marintschev I, Wilharm A, Klos K, Mückley T, Hofmann GO. 2D-fluoroscopic navigated percutaneous screw fixation of pelvic ring injuries - a case series. BMC Musculoskelet Disord. 2010;7(11):153.

20.

Gorczyca JT, Varga E, Woodside T, Hearn T, Powell J, Tile M. The strength of iliosacral lag screws and transiliac bars in the fixation of vertically unstable pelvic injuries with sacral fractures. Injury. 1996;27(8):561–4.PubMed

21.

van Zwienen CM, van den Bosch EW, Snijders CJ, Kleinrensink GJ, van Vugt AB. Biomechanical comparison of sacroiliac screw techniques for unstable pelvic ring fractures. J Orthop Trauma. 2004;18(9):589–95.PubMed

22.

Kraemer W, Hearn T, Tile M, Powell J. The effect of thread length and location on extraction strengths of iliosacral lag screws. Injury. 1994;25(1):5–9.PubMed

23.

Carlson DA, Scheid DK, Maar DC, Baele JR, Kaehr DM. Safe placement of S1 and S2 iliosacral screws: the "vestibule" concept. J Orthop Trauma. 2000;14(4):264–9.PubMed

24.

Kaiser SP, Gardner MJ, Liu J, Routt ML Jr, Morshed S. Anatomic determinants of sacral dysmorphism and implications for safe iliosacral screw placement. J Bone Jt Surg Am. 2014;96(14):e120.

25.

Wagner D, Kamer L, Sawaguchi T, Richards GR, Noser H, et al. Critical dimensions of trans-sacral corridors assessed by 3D CT models: Relevance for implant positioning in fractures of the sacrum. J Orthop Res. 2017;35(11):2577–84.PubMed

26.

Wagner D, Kamer L, Sawaguchi T, Noser H, Uesugi M, et al. Space available for trans-sacral implants to treat fractures of the pelvis assessed by virtual implant positioning. Arch Orthop Trauma Surg. 2019;139(10):1385–91.PubMed

27.

Wendt H, Gottschling H, Schröder M, Marintschev I, Hofmann GO, et al. Recommendations for iliosacral screw placement in dysmorphic sacrum based on modified in-out-in corridors. J Orthop Res. 2019;37(3):689–96.PubMed

28.

Wagner D, Hofmann A, Kamer L, Sawaguchi T, Richards RG, et al. Fragility fractures of the sacrum occur in elderly patients with severe loss of sacral bone mass. Arch Orthop Trauma Surg. 2018;138(7):971–7.PubMed

29.

Simonian PT, Routt ML, Harrington RM, Mayo KA, Tencer AF. Biomechanical simulation of the anteroposterior compression injury of the pelvis. An understanding of instability and fixation. Clin Orthop Relat Res. 1994;309:245–56.

30.

Dujardin FH, Roussignol X, Hossenbaccus M, Thomine JM. Experimental study of the sacroiliac joint micromotion in pelvic disruption. J Orthop Trauma. 2002;16(2):99–103.PubMed

31.

Schep NW, Haverlag R, van Vugt AB. Computer-assisted versus conventional surgery for insertion of 96 cannulated iliosacral screws in patients with postpartum pelvic pain. J Trauma. 2004;57(6):1299–302.PubMed

32.

Ecker TM, Jost J, Cullmann JL, Zech WD, Djonov V, et al. Percutaneous screw fixation of the iliosacral joint: a case-based preoperative planning approach reduces operating time and radiation exposure. Injury. 2017;48(8):1825–30.PubMed

33.

Gusic N, Grgorinic I, Fedel I, Lemac D, Bukvic N, et al. Fluoroscopic iliosacral screw placement made safe. Injury. 2017;48(Suppl 5):S70–S7272.PubMed

34.

Takao M, Hamada H, Sakai T, Sugano N. Factors influencing the accuracy of iliosacral screw insertion using 3D fluoroscopic navigation. Arch Orthop Trauma Surg. 2019;139(2):189–95.PubMed

35.

Pieske O, Landersdorfer C, Trumm C, Greiner A, Wallmichrath J, et al. CT-guided sacroiliac percutaneous screw placement in unstable posterior pelvic ring injuries: accuracy of screw position, injury reduction and complications in 71 patients with 136 screws. Injury. 2015;46(2):333–9.PubMed

36.

Matityahu A, Kahler D, Krettek C, Stöckle U, Grutzner PA, et al. Three-dimensional navigation is more accurate than two-dimensional navigation or conventional fluoroscopy for percutaneous sacroiliac screw fixation in the dysmorphic sacrum: a randomized multicenter study. J Orthop Trauma. 2014;28(12):707–10.PubMed

37.

Wang JQ, Wang Y, Feng Y, Han W, Su YG, et al. Percutaneous sacroiliac screw placement: a prospective randomized comparison of robot-assisted navigation procedures with a conventional technique. Chin Med J. 2017;130(21):2527–34.PubMedPubMedCentral

38.

Kim JW, Oh CW, Oh JK, Lee HJ, Min WK, et al. Percutaneous iliosacral screwing in pelvic ring injury using three-dimensional fluoroscopy. J Orthop Sci. 2013;18(1):87–92.PubMed

39.

Berger-Groch J, Lueers M, Rueger JM, Lehmann W, Thiesen D, Kolb JP, Hartel MJ, Grossterlinden LG. Accuracy of navigated and conventional iliosacral screw placement in B- and C-type pelvic ring fractures. Eur J Trauma Emerg Surg. 2020;46(1):107–13.PubMed

40.

Fischer S, Vogl TJ, Marzi I, Zangos S, Wichmann JL, et al. Percutaneous cannulated screw fixation of sacral fractures and sacroiliac joint disruptions with CT-controlled guidewires performed by interventionalists: single center experience in treating posterior pelvic instability. Eur J Radiol. 2015;84(2):290–4.PubMed

41.

Theologis AA, Burch S, Pekmezci M. Placement of iliosacral screws using 3D image-guided (O-Arm) technology and Stealth Navigation: comparison with traditional fluoroscopy. Bone Jt J. 2016;98(5):696–702.

42.

Zwingmann J, Südkamp NP, König B, Culemann U, Pohlemann T, et al. Intra- and postoperative complications of navigated and conventional techniques in percutaneous iliosacral screw fixation after pelvic fractures: Results from the German Pelvic Trauma Registry. Injury. 2013;44(12):1765–72.PubMed

43.

Rommens PM, Hessmann MH. Staged reconstruction of pelvic ring disruption: differences in morbidity, mortality, radiologic results, and functional outcomes between B1, B2/B3, and C-type lesions. J Orthop Trauma. 2002;16(2):92–8.PubMed

44.

Ebraheim NA, Xu R, Biyani A, Nadaud MC. Morphologic considerations of the first sacral pedicle for iliosacral screw placement. Spine. 1997;22(8):841–6.PubMed

45.

Grossterlinden L, Rueger J, Catala-Lehnen P, Rupprecht M, Lehmann W, Rücker A, Briem D. Factors influencing the accuracy of iliosacral screw placement in trauma patients. Int Orthop. 2011;35(9):1391–6.PubMed

46.

Khaled SA, Soliman O, Wahed MA. Functional outcome of unstable pelvic ring injuries after iliosacral screw fixation: single versus two screw fixation. Eur J Trauma Emerg Surg. 2015;41(4):387–92.PubMed

47.

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(6):399–405.PubMed

48.

Quade J, Busel G, Beebe M, Auston D, Shah AR, et al. Symptomatic iliosacral screw removal after pelvic trauma-incidence and clinical impact. J Orthop Trauma. 2019;33(7):351–3.PubMed

49.

Hessmann MH, Rickert M, Hofmann A, Rommens PM, Buhl M. Outcome in pelvic ring fractures. Eur J Trauma Emerg Surg. 2010;36(2):124–30.PubMed

Title: Safety and efficacy of 2D-fluoroscopy-based iliosacral screw osteosynthesis: results of a retrospective monocentric study
Authors: Pol Maria Rommens
Eva Mareike Nolte
Johannes Hopf
Daniel Wagner
Alexander Hofmann
Martin Hessmann
Publication date: 01-12-2021
Publisher: Springer Berlin Heidelberg
Published in: European Journal of Trauma and Emergency Surgery / Issue 6/2021
Print ISSN: 1863-9933
Electronic ISSN: 1863-9941
DOI: https://doi.org/10.1007/s00068-020-01362-9

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Safety and efficacy of 2D-fluoroscopy-based iliosacral screw osteosynthesis: results of a retrospective monocentric study

Abstract

Introduction

Materials and Methods

Results

Discussion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Materials and Methods

Results

Discussion

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