Single cannulated screws for stabilisation of pelvic ring and acetabular fractures

PURPOSE OF THE STUDY: Current trends in minimally invasive surgery together with advances in computed tomography and fluoroscopic guidance allow us to perform close reduction and percutaneous fixation also in non-displaced or minimally displaced fractures of the pelvic ring and acetabulum. Authors report the method of percutaneous screw fixation. MATERIAL AND METHODS: During the period from 1998 to 2010, a total of 568 patients were surgically treated for fractures of the pelvic ring and acetabulum. The patient series included 132 men and 46 women with an average age of 41.6 years (from 15 to 88 years). In this cohort, 225 single screws were placed at various sites of the pelvis. Of the screws, 197 were applied percutaneously and 28 in open procedures. A definition of six screw categories is proposed as well as the list of indications for their use. A detailed description of the techniques for screw placement, including the associated risks, is also presented. A novel method of minimally invasive stabilisation of the ruptured symphysis by means of two pubic screws and a two-hole plate is reported. A total of 157 patients were followed for the average period of 11.9 months (from 3 to 144 months). The navigation methods used in pelvic fracture stabilisation are described. RESULTS: It is difficult to provide an overall evaluation of the results in such a heterogeneous group of patients and therefore the outcome was assessed according to the placement of single screws. The types of injury with the use of appropriate screws are described in detail. Complications and the final graphical and clinical outcomes are reported. As the pelvic ring and acetabular injuries vary too much, it was not easy to assess the clinical outcome for each screw category. DISCUSSION: Percutaneous screw fixation is indicated in non-displaced fractures having a potential for displacement as well as in minimally displaced fractures that can be fixed with precisely placed screws. Dislocated fractures have to be reduced before surgery. Percutaneous screw placement can be performed as a single surgical procedure and this technique can also be part of a limited open approach. Percutaneous or open placement of cannulated screws facilitates stabilisation of individual fragments and allows for low surgical invasivity. This type of screw fixation in pelvic surgery provides all benefits of minimally invasive procedures. In this respect, some authors' view that the advantages outweigh a less successful result of fracture reduction can be accepted. A relatively high risk of iatrogenic complications is a disadvantage of this technique. The correct placement of screws has the highest priority because all percutaneous pelvic screws described here are inserted into the sites known as "narrow safe zones". CONCLUSIONS: In specific localisations, the percutaneous fixation of pelvic ring and acetabular fractures using single screws presents a new surgical technique for which the indications have not been exactly defined yet. The procedure should be performed by an experienced surgeon ready to convert surgery from a minimally invasive procedure to an open one, if the navigation technique used does not provide a reliable guidance or when the fracture reduction or stabilisation fails.