Locked plate fixation for traumatic pubic symphysis diastasis:a report of 17 patients
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Objective To investigate the clinical and radiographic outcome of traumatic pubic symphyseal diastases fixed with the locked plate. Methods From December 2007 to December 2009,17 patients(11 males,6 females,at mean age of 45.3 years)with pubic symphysis diastasis of unstable pelvic ring injuries were treated with open reduction and fixation with the locked plate.According to Tile classification system,five patients were with type B1 fractures,one with type B2,one with type B3,six with type C1,three with type C2 and one with type C3.All operations were performed under general anesthesia.Pubic symphyseal diastasis was treated by open reduction and fixation with the locked plate.There were 13 patients with associated posterior pelvic disruption,of which seven patients were treated by open reduction via anterior approach and fixed wich the reconstruction plates,three by close reduction and fixed with percutaneoua sacroiliac cannulated screws and three by posterior approach and fixed with M type plates. Results Of all the patients,16 patients were followed up for a mean time of 16 months(6-30months),which showed mean blood loss of 200 ml(50-600 ml)and mean hospital stay of 21 days (14-62 days).The clinical outcome was measured according to Majeed scores system,which showed excellent results in seven patients,good in seven and fair in two. Conclusions The locked plate fixation takes advantages of sailsfactory clinical outcomes with less operative trauma and a lower implant failure and wound infection rate in treatment of traumatic pubis symphysis diastasis.Locked plate fixation of symphysis call be performed alone when the posterior pelvic ring is only partially disrupted (Tile B).Posterior fixation construction should be used if the pelvic ring is under complete instability(Tile C).
Key words:
Pelvis; Pubic symphyseal diastasis; Frature fixation,internalKeywords:
Diastasis
Pubic symphysis
Objective
To evaluate the clinical treatment of unstable pelvic fractures by posterior ring fixation using percutaneous minimally invasive pedicle screws following anterior ring fixation.
Methods
From January 2010 to January 2016, 31 patients with unstable pelvic fracture were treated at our department. They were 20 males and 11 females, with an average age of 44.4 years (range, from 18 to 65 years). According to the Tile classification, 6 cases were type B2, 8 cases type B3, 12 cases type C1, and 5 cases type C2. The anterior pelvic ring was fixated in supine position first, and the posterior pelvic ring was fixated next using percutaneous minimally invasive pedicle screws. The operation time, intraoperative bleeding, and frequency of fluoroscopy needed for the posterior ring fixation were recorded. Reduction quality, complications like loss of reduction and pelvic function at the final follow-up were also assessed.
Results
For the posterior ring fixation in the 31 patients, the operation time ranged from 40 to 60 minutes (average, 50.7 minutes), blood loss from 30 to 80 mL (average, 42.9 mL), and fluoroscopic frequency from 7 to 12 times (average, 9.7 times). By the Tornetta evaluation, the reduction was rated postoperatively as excellent in 15 cases and as good in 16 ones, yielding an excellent and good rate of 100%. Twenty-nine patients obtained complete follow-up for 12 to 83 months (average, 34.7 months), and they achieved bone union after an average of 14.5 weeks (range, from 12 to 16 weeks). According to the Majeed criteria for pelvic function at the final follow-up, 10 cases were rated as excellent, 16 cases as good, and 3 cases as fair, giving an excellent and good rate of 89.7%. No reduction loss, incision infection, vascular or nerve injury, screw loosening or breakage, or fracture displacement was observed during follow-up.
Conclusion
In the treatment of unstable pelvic fractures, posterior ring fixation using percutaneous minimally invasive pedicle screws following anterior ring fixation can lead to less operation time, intraoperative bleeding and fluoroscopic radiation, and satisfactory fracture reduction and functional recovery of the pelvis as well.
Key words:
Pelvis; Fractures, bone; Fracture fixation, internal; Internal fixators; Surgical procedures, minimally invasive
Supine position
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Objective To evaluate the effectiveness of unstable pelvic fractures treated by cannulated screw internal fixation with the assistance of three-dimensional (3D) printing insertion template. Methods The clinical data of 10 patients who underwent surgical treatment for unstable pelvic fractures by cannulated screw internal fixation with the assistance of 3D printing insertion template between May 2015 and June 2016 were retrospectively analysed. There were 7 males and 3 females with an average age of 37.5 years (range, 20-58 years). The causes of injury included falling from height in 5 cases, crushing from heavy load in 1 case, and traffic accidents in 4 cases. The interval from injury to admission was 1-5 hours (mean, 3.1 hours). The fracture situation included 6 cases of sacral fracture, 1 case of right sacroiliac joint dislocation, and 3 cases of iliac bone fracture. There were 10 cases of superior and inferior pubic rami fracture, including 3 cases on the left side (2 cases of suprapubic fracture adjacent to symphysis pubis), 2 cases on the right side, and 5 cases on the bilateral. All fractures were classified according to the Tile system, there were 4 cases of type B2, 1 of type B3, 4 of type C1, and 1 of type C2. The radiological outcome was evaluated by Matta scale, and the positions of the iliosacral screw and superior pubic ramus screw were evaluated according to 3D reconstruction of CT postoperatively. The functional outcome was evaluated by Majeed function scale. Results The average time of each screw implantation was 30 minutes, and the average blood loss per screw incision was 50 mL. The time of implantation of each sacroiliac screw was 24-96 seconds (mean, 62 seconds), and the time of implantation of each suprapubic screw was 42-80 seconds (mean, 63.2 seconds). The hospitalization duration was 17-90 days (mean, 43.7 days). All incisions healed by first intention. All patients were followed up 12-22 months (mean, 15.6 months). The radiological outcome was excellent in 8 cases and good in 2 cases according to Matta scale; and 3D reconstruction of CT demonstrated that all the 9 iliosacral screws were placed as type Ⅰ, and all the 13 suprapubic ramus screws were placed as grade 0 on the first postoperative day. No complication such as neurovascular injury, screw back out or rupture, or secondary fracture displacement was observed during the follow-up. At 6 months after operation, the X-ray films showed good fracture healing in all the 10 patients. The functional outcome was excellent in 9 cases and good in 1 case according to Majeed scale at 1 year after operation. One patient sustained Tile C2 pelvic disruption complicated with L 5 nerve root injury achieved complete nervous functional recovery at last follow-up. Conclusion It has advantages of precise screw insertion and lower risk of neurovascular injury to treat unstable pelvic fractures by cannulated screw internal fixation with the assistance of 3D printing insertion template, which can be a good alternative for the treatment of unstable pelvic fractures.
Pelvic fracture
Pubic symphysis
Sacroiliac joint
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OBJECTIVE To evaluate the safety and reliability of percutaneous internal fixation for pelvic ring injuries with cannulated screws. METHODS Forty-eight patients (21 male and 27 female, aged from 17 to 61 years with an average age of 38 years) with unstable pelvic ring injuries were treated with closed reduction and percutaneous cannulated screws fixation under C-arm fluoroscopic guidance. According to Tile's classification, the patients were classified into type B1 in 4 cases, B2.1 in 8, B2.2 in 10, B3 in 4, C1 in 11, C2 in 7 and C3 in 4. Among them, 39 patients were treated with anterior and posterior fixation, 4 were treated with anterior fixation, and 5 were treated with posterior fixation alone. Anteroposterior, inlet and outlet X-ray radiographs and CT scans of the pelvis were taken preoperatively to evaluate the stability and deformities, and after surgery the plain radiographs and CT scans were taken to evaluate the reduction and the location of screws. RESULTS The average operative time was 55 minutes (range, 15 to 95 minutes), and the average intraoperative blood loss was 60 ml (range, 15 to 150 ml), no patient accepted blood transfusion during or after operation. All 48 patients were inserted 157 cannulated screws (mean 3.3, range 2 to 8 per patient). Forty-two patients (135 screws) underwent postoperative pelvic CT scan and 91.11% (123 screws) of them was considered in optimal location; 7 screws penetrated the wall of pelvis and acetabulam because of overlength (<0.5 cm) or deviation, 5 screws interfered with the sacral canal or foramen. Fortunately, these 12 screws did not cause any symptom to the patients. The average follow-up period was 13 months (range 8 to 49 months), the displacement of injured pelvis was satisfactorily corrected in 45 patients (93.75%) and the fractures were healed at one stage. Among all patients, 40 cases (83.33%) had returned to their original works, 4 were still in the process of recovery at the last follow-up and the other 4 were unemployed as sciatic nerve injury or amputation. According to Lindahl improved standard of functional assessment of pelvic injury, the result was excellent in 35 cases, good 10 and fair 3, the average score was 78.7. CONCLUSION With better understanding of the pelvic anatomy, and under C-arm fluoroscopic guidance, treatment of closed reduction and percutaneous cannulated screw internal fixation for unstable pelvic ring injuries is a safe, reliable and feasible method. The clinical outcome is satisfactory.
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Objective To study the clinical efficacy of a locking reconstruction titanium plate plus a titanium cable in the treatment of traumatic pubic symphyseolysis.Methods From March 2008 to February 2011,14 patients with pubic symphyseolysis were treated in our department.They were 13 men and one woman,18 to 46 years old (average,32.4 years old).By Tile classification,11 cases were type B1,one case was type B2.1 and 2 cases were type C1.1.The injury was fresh in 11 cases and obsolete in 3 cases.The time from injury to surgery ranged from 4 days to 6 weeks,averaging 16 days.All the patients were treated by open reduction of the separated pubic symphysis through Pfannenstiel approach,the reconstruction plate locked on the upper edge of the pubic symphysis and the titanium cable anteriorly fastened through 2 bilateral obturator foramens.Results All cases were followed up for 12 to 24 months (average,16.8 months).All the incisions got primary healing and the separated pubic symphysis got anatomic reduction and healed at 10 to 18 weeks (average,13.8 weeks) postsurgery.No plate breakage,bolt loosening,cable loosening,cable breakage,or neural or vascular injury occurred.According to the Matta evaluation system,9cases were rated as excellent,3 as good and 2 as fair at the last follow-up,with a good to excellent rate of 85.7％.Conclusion Internal fixation with a locking reconstruction titanium plate and a titanium cable is effective and safe to treat traumatic pubic symphysis diastasis,because the anatomic integrity and stability of the injured pelvis can be restored.
Key words:
Pubic symphysis diastasis; Fracture fixation, internal; Bone plates
Pubic symphysis
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To study the clinical results of surgical treatment for Tile C type pelvis fractures with internal fixation by posterior approach.From January 2005 to June 2009, 12 patients with Tile C type pelvis fracture were treated by open reduction through posterior approach. There were 8 males and 4 females, with an average age of 39.5 years ranging from 25 to 58 years. The time from injury to operation was ranged from 7 to 10 days with an average of 9.5 days. All the patients were given X-ray, 3-D CT examinations before operation. The fracture were classified by Tile classification: Type C1 in 5 cases, Type C2 in 2 cases, Type C1 and Type C2 in 4 cases, Type C3 in 1 case. All the posterior rings were fixed by re-establishing steel board without anterior ring fixation after stabilization of body condition. All the patients were treated with skin traction for 3 weeks after operation.All 12 patients were followed up for 6 months to 24 months with an average of 12.6 months. All the incisions healed well, and the fractures got union. No pelvic malunion, low back pain or leg length discrepancy was found. According to Majeed criteria for the evaluation of therapeutic effect, 10 patients were excellent, and 2 were good.In the management of the Tile C type pelvis fractures, a stable pelvis can be reconstructed by fixing posterior ring simply through the posterior approach, so that further sequelae can be reduced.
Malunion
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Objective To explore the effect of staged compression by external fixation combined with internal fixation in treatment of type Ⅱ and Ⅲ of old Young-Burgess APC pelvic fracture.Methods A total of 5 patients with type Ⅱ or Ⅲ of Young-Burgess APC during August 2011 and July 2012 were treated with external fixation compression which could reduce rotation of pelvic ring in onestage operation,among them 2 patients with type Ⅲ of APC underwent skeletal traction for reducing vertical displacement,and internal fixation in second stage operation.Results In the group patients' the distances of pubic symphysis separation obviously improved after treatment,Matta score showed the postoperative fracture reduction: 3 patients were excellent,1 patient was good,and 1 patient was common.Review of x ray picture after operation for 6 months showed fracture healing.There were 3 patients with excellent and 2 patients with good by Majieed score method with 6-18 months of follow-up.Conclusion Old Young-Burgess APC Type Ⅱ and Ⅲ of pelvic fracture with pubic symphysis separation can be treated with external fixation compression which can reduce rotation of pelvic ring,and internal fixation in second stage.The method can get better reduction and satisfied function.
Pelvic fracture
Pubic symphysis
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To investigate the application and effect of minimally invasive percutaneous anterior pelvic pubic ramus screw fixation in Tile B fractures.A retrospective review was conducted on 56 patients with posterior pelvic ring injury combined with fractures of anterior pubic and ischiadic ramus treated between May 2010 and August 2015, including 31 males and 25 females with an average age of 36.8 years old ranging from 35 to 65 years old. Based on the Tile classification, there were 13 cases of Tile B1 type, 28 cases of Tile B2 type and 15 cases of Tile B3 type. Among them, 26 patients were treated with sacroiliac screws combined with external fixation (external fixator group) and the other 30 patients underwent sacroiliac screw fixation combined with anterior screw fixation (pubic ramus screw group). Postoperative complications, postoperative ambulation time, fracture healing, blood loss, Majeed pelvic function score and visual analogue scale(VAS) were compared between two groups.Fifty-four patients were followed up from 3 to 24 months with a mean of 12 months. There were no significant difference in the peri-operative bleeding and operation time between two groups(P>0.05). The postoperative activity time and fracture healing time of pubic ramus screw group were shorter than those of the external fixator group, the differences were statistically significant(P<0.05). The Majeed score, VAS score of pubic ramus screw group were higher than those of the external fixator group, the differences were statistically significant(P<0.05). The incidence of postoperative complications of pubic ramus screw was lower than that of the external fixator group, the difference was statistically significant (P<0.05).Percutaneous iliosacral screws fixation combined with the pubic ramus screw is an effective and safty treatment method to the Tile B pelvic fracture. It has advantages of early ambulation, relief of the pain and few complications.
Pelvic fracture
Sacroiliac joint
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Objective
To study the clinical efficacy of external fixator and combined screwing at iliac crests and pubic symphysis for the treatment of unstable pelvic fractures.
Methods
From January 2013 to February 2014, 12 cases of unstable pelvic fracture were treated at our department. They were 8 men and 4 women, from 32 to 57 years of age (average, 42.5 years) . Seven cases were caused by a traffic accident, and 5 by falling from a height. By Tile classification, 8 cases were type B (including type B1 in 3 cases, type B2 in 3 and type B3 in 2) , and 4 cases type C1. Associated injury included shock in 7 cases, bladder injury in one, limb long bone fracture in 6, joint injury in 3, and thoracic and lumbar injury in 4. The interval from injury to operation averaged 4 days, ranging from 12 hours to 7 days. The type B fractures were treated with an external fixator and combined screwing at iliac crests and pubic symphysis while the type C1 fractures with internal fixation with percutaneous S1 sacroiliac screws in addition to what was used for the type B fractures.
Results
The 12 patients were followed up for 5 to 12 months (average, 9 months) . No one died in this group. The fractures healed after 8 to 13 weeks (average, 11.3 weeks) . All the patients recovered normal walking. Superficial infection at the pin hole occurred in 7 cases, but there was no deep infection. Screw loosening was observed in only one case, and no reduction loss, injury to nerves or urinary canal was observed. According to the Majeed criteria, the efficacy was evaluated as excellent in 10 cases, good in one, and moderate in one.
Conclusion
External fixator and combined screwing at iliac crests and pubic symphysis can restore the stability of anterior pelvic ring, leading to good clinical outcomes.
Key words:
Pelvis; Fractures, bone; Fracture fixation; External fixator
Pelvic fracture
Pubic symphysis
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Objective To summarize the curative effect of staged treatment with combined internal and external fixation for type CⅠandⅡpelvic fracture. Methods From Mar. 2013 to Jul. 2011,there were 6 cases of type CⅠ,Ⅱpelvic fracture,including 4 males and 2 females( age ranged from 24 to 62 years,mean 55 years). There were 4 cases of traffic accident injury,and 2 cases of falling injury. The injury time ranged from 3 weeks to 2 months. All cases were complicated with other organ injuries. X-ray and CT examination showed 2 cases of pubic symphysis separation,with the separation distance 2. 5cm. There were 4 cases of type CⅠ( sacral fracture without sacroiliac joint dislocation) and 2 cases of CⅡ( sacral fracture with sacroiliac joint dislocation). In the first stage,external fixator was gradually pressurized to reset the anterior ring,correct the rotational instability,and simultaneously correct the vertical instability. In the second stage we used internal fixation for final treatment for both anterior and posterior pelvic ring.Results All incisions healed in the primary stage. Six cases were followed up,ranging from 5 to 26 months,with an average of 15. 5 months. The Matta score indicated excellent in 4 cases,good in 1 case,and fair in 1 case. The Majeed score for functional recovery indicated excellent in 4 cases,good in 1 case,and fair in 1 case. Conclusion The combined use of external and internal fixation for type CⅠ,Ⅱ pelvic fracture has advantages of minimal trauma,less bleeding,and fast postoperative recovery. It can obtain a good treatment effect.
Pelvic fracture
Sacroiliac joint
Pubic symphysis
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