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Archives of Orthopaedic and Trauma Surgery

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01-10-2019 | Computed Tomography | Trauma Surgery

Space available for trans-sacral implants to treat fractures of the pelvis assessed by virtual implant positioning

Authors: Daniel Wagner, Lukas Kamer, Takeshi Sawaguchi, Hansrudi Noser, Masafumi Uesugi, Andreas Baranowski, Dominik Gruszka, Pol M. Rommens

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 10/2019

Abstract

Introduction

The use of trans-sacral implants to treat fractures of the sacrum is limited by the variable pelvic anatomy. We were interested in how many trans-sacral implants can be placed per pelvis? If a trans-sacral implant cannot be placed in S1, where is the cortex perforated, and is the use of sacroiliac screws safe in these pelves?

Materials and methods

3D pelvic models were created from CT scans of 156 individuals without fractures (92 European and 64 Japanese, 79 male and 77 female, mean age 66.7 ± 13.7 years). Trans-sacral implants with a diameter of 7.3 mm were positioned virtually with and without a surrounding safe zone of 12 mm diameter.

Results

Fifty-one percent of pelves accommodated trans-sacral implants in S1 with a safe zone. Twenty-two percent did not offer enough space in S1 for an implant even when ignoring the safe zone. Every pelvis had sufficient space for a trans-sacral implant in S2, in 78% including a safe zone as well. In S1, implant perforation was observed in the sacral ala and iliac fossa in 69%, isolated iliac fossa perforation in 23% and perforation of the sacral ala in 8%. Bilateral sacroiliac screw placement was always possible in S1.

Conclusions

The use of trans-sacral implants in S1 requires meticulous preoperative planning to avoid injury of neurovascular structures. S2 more consistently offers space for trans-sacral implants.

Andrich S, Haastert B, Neuhaus E, Neidert K, Arend W, Ohmann C, Grebe J, Vogt A, Jungbluth P, Rösler G, Windolf J, Icks A (2015) Epidemiology of pelvic fractures in germany: considerably high incidence rates among older people. PLoS ONE 10:e0139078. https://doi.org/10.1371/journal.pone.0139078 CrossRefPubMedPubMedCentral

Kannus P, Parkkari J, Niemi S, Sievänen H (2015) Low-trauma pelvic fractures in elderly finns in 1970–2013. Calcif Tissue Int 97:577–580. https://doi.org/10.1007/s00223-015-0056-8 CrossRefPubMed

Rommens PM, Wagner D, Hofmann A (2017) Fragility fractures of the pelvis. JBJS Rev. https://doi.org/10.2106/JBJS.RVW.16.00057 CrossRefPubMed

Routt ML Jr, Simonian PT, Mills WJ (1997) Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma 11:584–589CrossRef

Reuther G, Röhner U, Will T, Dehne I, Petereit U (2014) CT-guided screw fixation of vertical sacral fractures in local anaesthesia using a standard CT. RöFo Fortschritte Auf Dem Geb Röntgenstrahlen Nukl 186:1134–1139. https://doi.org/10.1055/s-0034-1366605 CrossRef

Eckardt H, Egger A, Hasler RM, Zech CJ, Vach W, Suhm N, Morgenstern M, Saxer F (2017) Good functional outcome in patients suffering fragility fractures of the pelvis treated with percutaneous screw stabilisation: assessment of complications and factors influencing failure. Injury 48:2717–2723. https://doi.org/10.1016/j.injury.2017.11.002 CrossRefPubMed

Wagner D, Ossendorf C, Gruszka D, Hofmann A, Rommens PM (2015) Fragility fractures of the sacrum: how to identify and when to treat surgically? Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc 41:349–362. https://doi.org/10.1007/s00068-015-0530-z CrossRef

Kim J-W, Oh C-W, Oh J-K, Kyung H-S, Park K-H, Yoon S-D, Yoon S-H (2016) The incidence of and factors affecting iliosacral screw loosening in pelvic ring injury. Arch Orthop Trauma Surg 136:921–927. https://doi.org/10.1007/s00402-016-2471-3 CrossRefPubMed

Mehling I, Hessmann MH, Rommens PM (2012) Stabilization of fatigue fractures of the dorsal pelvis with a trans-sacral bar. Operative technique and outcome. Injury 43:446–451. https://doi.org/10.1016/j.injury.2011.08.005 CrossRefPubMed

10.

Rommens PM, Wagner D, Hofmann A (2012) Surgical management of osteoporotic pelvic fractures: a new challenge. Eur J Trauma Emerg Surg Off Publ Eur Trauma Soc 38:499–509. https://doi.org/10.1007/s00068-012-0224-8 CrossRef

11.

Balling H (2019) Additional sacroplasty does not improve clinical outcome in minimally invasive navigation-assisted screw fixation procedures for nondisplaced insufficiency fractures of the sacrum. Spine (Phila Pa 1976) 44(8):534–542. https://doi.org/10.1097/BRS.0000000000002899 CrossRef

12.

Wagner D, Hofmann A, Kamer L, Sawaguchi T, Richards RG, Noser H, Gruszka D, Rommens PM (2018) Fragility fractures of the sacrum occur in elderly patients with severe loss of sacral bone mass. Arch Orthop Trauma Surg 138:971–977. https://doi.org/10.1007/s00402-018-2938-5 CrossRefPubMed

13.

Wagner D, Kamer L, Sawaguchi T, Richards RG, Noser H, Rommens PM (2016) Sacral bone mass distribution assessed by averaged three-dimensional CT models: implications for pathogenesis and treatment of fragility fractures of the sacrum. J Bone Jt Surg Am 98:584–590. https://doi.org/10.2106/JBJS.15.00726 CrossRef

14.

Lattauschke A, Klauke F, Ullrich BW, Hofmann GO, Mendel T (2017) Course of operative treatment of a sacral insufficiency fracture: successful or serious treatment? Unfallchirurg 120:890–895. https://doi.org/10.1007/s00113-017-0403-5 CrossRefPubMed

15.

Ricci P-L, Maas S, Kelm J, Gerich T (2018) Finite element analysis of the pelvis including gait muscle forces: an investigation into the effect of rami fractures on load transmission. J Exp Orthop. https://doi.org/10.1186/s40634-018-0151-7 CrossRefPubMedPubMedCentral

16.

Zhao Y, Li J, Wang D, Liu Y, Tan J, Zhang S (2012) Comparison of stability of two kinds of sacro-iliac screws in the fixation of bilateral sacral fractures in a finite element model. Injury 43:490–494. https://doi.org/10.1016/j.injury.2011.12.023 CrossRefPubMed

17.

Tabaie SA, Bledsoe JG, Moed BR (2013) Biomechanical comparison of standard iliosacral screw fixation to transsacral locked screw fixation in a type C zone II pelvic fracture model. J Orthop Trauma 27:521–526. https://doi.org/10.1097/BOT.0b013e3182781102 CrossRefPubMed

18.

Heydemann J, Hartline B, Gibson ME, Ambrose CG, Munz JW, Galpin M, Achor TS, Gary JL (2016) Do transsacral–transiliac screws across uninjured sacroiliac joints affect pain and functional outcomes in trauma patients? Clin Orthop Relat Res 474:1417–1421. https://doi.org/10.1007/s11999-015-4596-z CrossRefPubMed

19.

Höch A, Pieroh P, Henkelmann R, Josten C, Böhme J (2017) In-screw polymethylmethacrylate-augmented sacroiliac screw for the treatment of fragility fractures of the pelvis: a prospective, observational study with 1-year follow-up. BMC Surg 17:132. https://doi.org/10.1186/s12893-017-0330-y CrossRefPubMedPubMedCentral

20.

Wagner D, Kamer L, Rommens PM, Sawaguchi T, Richards RG, Noser H (2014) 3D statistical modeling techniques to investigate the anatomy of the sacrum, its bone mass distribution, and the trans-sacral corridors. J Orthop Res Off Publ Orthop Res Soc 32:1543–1548. https://doi.org/10.1002/jor.22667 CrossRef

21.

Wagner D, Kamer L, Sawaguchi T, Richards RG, Noser H, Hofmann A, Rommens PM (2017) Morphometry of the sacrum and its implication on trans-sacral corridors using a CT data-based 3D statistical model. Spine J Off J N Am Spine Soc 17:1141–1147. https://doi.org/10.1016/j.spinee.2017.03.023 CrossRef

22.

Day CS, Prayson MJ, Shuler TE, Towers J, Gruen GS (2000) Transsacral versus modified pelvic landmarks for percutaneous iliosacral screw placement—a computed tomographic analysis and cadaveric study. Am J Orthop Belle Mead NJ 29:16–21PubMed

23.

Hasenboehler EA, Stahel PF, Williams A, Smith WR, Newman JT, Symonds DL, Morgan SJ (2011) Prevalence of sacral dysmorphia in a prospective trauma population: Implications for a “safe” surgical corridor for sacro-iliac screw placement. Patient Saf Surg 5:8. https://doi.org/10.1186/1754-9493-5-8 CrossRefPubMedPubMedCentral

24.

Gras F, Hillmann S, Rausch S, Klos K, Hofmann GO, Marintschev I (2015) Biomorphometric analysis of ilio-sacro-iliacal corridors for an intra-osseous implant to fix posterior pelvic ring fractures. J Orthop Res Off Publ Orthop Res Soc 33:254–260. https://doi.org/10.1002/jor.22754 CrossRef

25.

Lee JJ, Rosenbaum SL, Martusiewicz A, Holcombe SA, Wang SC, Goulet JA (2015) Transsacral screw safe zone size by sacral segmentation variations. J Orthop Res Off Publ Orthop Res Soc 33:277–282. https://doi.org/10.1002/jor.22739 CrossRef

26.

Kaiser SP, Gardner MJ, Liu J, Routt MLC, Morshed S (2014) Anatomic determinants of sacral dysmorphism and implications for safe iliosacral screw placement. J Bone Jt Surg Am 96:e120. https://doi.org/10.2106/JBJS.M.00895 CrossRef

27.

Mendel T, Noser H, Kuervers J, Goehre F, Hofmann GO, Radetzki F (2013) The influence of sacral morphology on the existence of secure S1 and S2 transverse bone corridors for iliosacroiliac screw fixation. Injury 44:1773–1779. https://doi.org/10.1016/j.injury.2013.08.006 CrossRefPubMed

28.

Radetzki F, Wohlrab D, Goehre F, Noser H, Delank KS, Mendel T (2014) Anatomical conditions of the posterior pelvic ring regarding bisegmental transverse sacroiliac screw fixation: a 3D morphometric study of 125 pelvic CT datasets. Arch Orthop Trauma Surg 134:1115–1120. https://doi.org/10.1007/s00402-014-2022-8 CrossRefPubMed

29.

Wagner D, Kamer L, Sawaguchi T, Richards RG, Noser H, Uesugi M, Ossendorf C, Rommens PM (2017) Critical dimensions of trans-sacral corridors assessed by 3D CT models. Relevance for implant positioning in fractures of the sacrum. J Orthop Res Off Publ Orthop Res Soc 35:2577–2584. https://doi.org/10.1002/jor.23554 CrossRef

30.

Conflitti JM, Graves ML, Chip Routt ML Jr (2010) Radiographic quantification and analysis of dysmorphic upper sacral osseous anatomy and associated iliosacral screw insertions. J Orthop Trauma 24:630–636. https://doi.org/10.1097/BOT.0b013e3181dc50cd CrossRefPubMed

31.

Eastman JG, Adams MR, Frisoli K, Chip Routt ML (2018) Is S3 a viable osseous fixation pathway. J Orthop Trauma 32:93–99. https://doi.org/10.1097/BOT.0000000000001036 CrossRefPubMed

32.

Zhang L, Peng Y, Du C, Tang P (2014) Biomechanical study of four kinds of percutaneous screw fixation in two types of unilateral sacroiliac joint dislocation: a finite element analysis. Injury 45:2055–2059. https://doi.org/10.1016/j.injury.2014.10.052 CrossRefPubMed

33.

Jazini E, Klocke N, Tannous O, Johal HS, Hao J, Salloum K, Gelb DE, Nascone JW, Belin E, Hoshino CM, Hussain M, OʼToole RV, Bucklen B, Ludwig SC (2017) Does lumbopelvic fixation add stability? A cadaveric biomechanical analysis of an unstable pelvic fracture model. J Orthop Trauma 31:37–46. https://doi.org/10.1097/BOT.0000000000000703 CrossRefPubMed

34.

Gras F, Gottschling H, Schröder M, Marintschev I, Hofmann GO, Burgkart R (2016) Transsacral osseous corridor anatomy is more amenable to screw insertion in males: a biomorphometric analysis of 280 pelves. Clin Orthop 474:2304–2311. https://doi.org/10.1007/s11999-016-4954-5 CrossRefPubMed

35.

Routt ML Jr, Simonian PT, Agnew SG, Mann FA (1996) Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study. J Orthop Trauma 10:171–177CrossRef

36.

Miller AN, Routt MLC Jr (2012) Variations in sacral morphology and implications for iliosacral screw fixation. J Am Acad Orthop Surg 20:8–16. https://doi.org/10.5435/JAAOS-20-01-008 CrossRefPubMed

37.

Mendel T, Noser H, Wohlrab D, Stock K, Radetzki F (2011) The lateral sacral triangle—a decision support for secure transverse sacroiliac screw insertion. Injury 42:1164–1170CrossRef

38.

Kim JW, Quispe JC, Hao J, Herbert B, Hake M, Mauffrey C (2016) Fluoroscopic views for a more accurate placement of iliosacral screws: an experimental study. J Orthop Trauma 30:34–40. https://doi.org/10.1097/BOT.0000000000000426 CrossRefPubMed

39.

Graves ML, Routt MLC Jr (2011) Iliosacral screw placement: are uniplanar changes realistic based on standard fluoroscopic imaging? J Trauma 71:204–208. https://doi.org/10.1097/TA.0b013e31821e842a (discussion 208) CrossRefPubMed

40.

Gardner MJ, Morshed S, Nork SE, Ricci WM, Chip Routt ML Jr (2010) Quantification of the upper and second sacral segment safe zones in normal and dysmorphic sacra. J Orthop Trauma 24:622–629. https://doi.org/10.1097/BOT.0b013e3181cf0404 CrossRefPubMed

41.

Carlson DA, Scheid DK, Maar DC, Baele JR, Kaehr DM (2000) Safe placement of S1 and S2 iliosacral screws: the “vestibule” concept. J Orthop Trauma 14:264–269CrossRef

42.

Hammer N, Steinke H, Lingslebe U, Bechmann I, Josten C, Slowik V, Böhme J (2013) Ligamentous influence in pelvic load distribution. Spine J Off J N Am Spine Soc 13:1321–1330. https://doi.org/10.1016/j.spinee.2013.03.050 CrossRef

43.

Linstrom NJ, Heiserman JE, Kortman KE, Crawford NR, Baek S, Anderson RL, Pitt AM, Karis JP, Ross JS, Lekovic GP, Dean BL (2009) Anatomical and biomechanical analyses of the unique and consistent locations of sacral insufficiency fractures. Spine 34:309–315. https://doi.org/10.1097/BRS.0b013e318191ea01 CrossRefPubMedPubMedCentral

44.

Wong-Chung J, Jamsheer N, Nabar U, Aradi AJ (1997) Two parallel linear densities on lateral radiographs of the lumbosacral spine: neither iliopectineal lines nor basis ossis sacri. Br J Radiol 70:58–61CrossRef

45.

Day AC, Stott PM, Boden RA (2007) The accuracy of computer-assisted percutaneous iliosacral screw placement. Clin Orthop 463:179–186PubMed

46.

Takao M, Hamada H, Sakai T, Sugano N (2019) Factors influencing the accuracy of iliosacral screw insertion using 3D fluoroscopic navigation. Arch Orthop Trauma Surg 139(2):189–195. https://doi.org/10.1007/s00402-018-3055-1 CrossRefPubMed

47.

Zwingmann J, Hauschild O, Bode G, Südkamp NP, Schmal H (2013) 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 133:1257–1265. https://doi.org/10.1007/s00402-013-1788-4 CrossRefPubMed

48.

Teo AQA, Yik JH, Jin Keat SN, Murphy DP, O’Neill GK (2018) Accuracy of sacroiliac screw placement with and without intraoperative navigation and clinical application of the sacral dysmorphism score. Injury. https://doi.org/10.1016/j.injury.2018.05.027 CrossRefPubMed

49.

Richter PH, Gebhard F, Dehner C, Scola A (2016) Accuracy of computer-assisted iliosacral screw placement using a hybrid operating room. Injury 47:402–407. https://doi.org/10.1016/j.injury.2015.11.023 CrossRefPubMed

50.

Matityahu A, Kahler D, Krettek C, Stöckle U, Grutzner PA (2014) 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 28:4CrossRef

51.

Morshed S, Choo K, Kandemir U, Kaiser SP (2015) Internal fixation of posterior pelvic ring injuries using iliosacral screws in the dysmorphic upper sacrum. JBJS Essent Surg Tech 5:e3. https://doi.org/10.2106/JBJS.ST.N.00006 CrossRefPubMedPubMedCentral

52.

Bastian JD, Jost J, Cullmann JL, Aghayev E, Keel MJB, Benneker LM (2015) Percutaneous screw fixation of the iliosacral joint: optimal screw pathways are frequently not completely intraosseous. Injury 46:2003–2009. https://doi.org/10.1016/j.injury.2015.06.044 CrossRefPubMed

53.

Mendel T, Appelt K, Kuhn P, Suhm N (2008) Bony sacroiliac corridor. A virtual volume model for the accurate insertion of transarticular screws. Unfallchirurg 111:19–26. https://doi.org/10.1007/s00113-007-1386-4 CrossRefPubMed

54.

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

Title: Space available for trans-sacral implants to treat fractures of the pelvis assessed by virtual implant positioning
Authors: Daniel Wagner
Lukas Kamer
Takeshi Sawaguchi
Hansrudi Noser
Masafumi Uesugi
Andreas Baranowski
Dominik Gruszka
Pol M. Rommens
Publication date: 01-10-2019
Publisher: Springer Berlin Heidelberg
Keywords: Computed Tomography
Computed Tomography
Published in: Archives of Orthopaedic and Trauma Surgery / Issue 10/2019
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI: https://doi.org/10.1007/s00402-019-03204-9

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Space available for trans-sacral implants to treat fractures of the pelvis assessed by virtual implant positioning

Abstract

Introduction

Materials and methods

Results

Conclusions

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Introduction

Materials and methods

Results

Conclusions

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