[Treatment of unstable pelvic fractures by cannulated screw internal fixation with the assistance of three-dimensional printing insertion template].
Hongqi YangQing LeiLihong CaiFeng LiuWeili ZhouSong ChenLi ChenTangyou LiuMinghui JiangKang WangSishun XiaoWenqian Liu
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Abstract:
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.Keywords:
Pelvic fracture
Pubic symphysis
Sacroiliac joint
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 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 determine the curative effect of stabilizing unstable pelvic ring fracture using the anterior subcutaneous internal fixator (INFIX).
Methods
From July 2013 to June 2014, 15 cases who suffered from anterior pelvic ring fracture were treated with the device. There were 11 males and 4 females, with mean age of 38. 5 years (range, 23-65 years). Eight cases sustained fracture in traffic accidents, 4 in high falls, and 3 in crush injury. According to the Young-Burgess and AO/OTA classification systems, type APC2 or 61-B1 was noted in one case, LC1 or 61-B2.1 in 4 cases, LC2 or 61-B2. 2/61-B2. 3 in 6 cases, and VS or 61-C1/61-C2 in 4 cases. Basic method in anterior ring fixation was one pedicle screw was respectively inserted into the area between the anterior superior iliac spine and anterior inferior iliac spine of both sides. The precontoured rod was then tunneled subcutaneously from one screw to the other. For the stable posterior injury in pelvic ring fracture, the anterior pelvic ring was stabilized only using the technique. For the unstable posterior injury in pelvic ring fracture, the anterior and posterior ring were both fixed using the technique.During follow-up visits, patients' tolerance to the device, wound infection, myositis ossificans, internal fixation lessening, and lateral femoral cutaneous nerve injury were evaluated.
Results
Follow-up ranged from 6-12 months (mean, 7. 5 months). The device was well tolerated by the patients for comfort. None had surgical site infection and internal fixation loosening. Injuries healed without loss of reduction at the 3-month follow-up. Injury of the lateral femoral cutaneous nerve at the both side was reported in 4 cases and at one side in 2 cases, but all restored 3 month after operation.
Conclusion
The reported technique is minimally invasive with few complications and reliable results, hinting an ideal method to stabilize the anterior pelvic ring fracture.
Key words:
Pelvis; Fracture fixation, internal; Surgical procedures, minimally invasive
Pelvic fracture
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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 evaluate the clinical efficacy of our self-made minimally invasive pelvic channel instrument in the treatment of pelvic ring fracture-dislocation.
Methods
A retrospective study was conducted of the 35 patients who had been treated for pelvic ring fracture-dislocation from December 2015 to November 2017 and fully followed up at Department I of Orthopaedis, Beijing Chaoyang Emergency Rescue Center. They were 25 males and 10 females, aged from 20 to 73 years (average, 41.3 years). According to the Tile classification for pelvic fractures, there were 26 cases of type B (type B1 in 8, type B2 in 12 and type B3 in 6) and 9 cases of type C(type C1 in 5, type C2 in 3 and type C3 in 1). Infix or anterior plate combined with percutaneous internal fixation with sacroiliac cannulated screws was used in 11 patients, sacroiliac triangle fixation combined with percutaneous internal fixation with anterior ring cannulated screws in 5 ones, and internal fixation with cannulated screws for anterior and posterior rings in 19 ones. All the channels were established using our self-made minimally invasive pelvic channel instrument for internal fixation with cannulated screws. The time for each screw placement and the number of X-ray projection were recorded. Postoperative reduction, pelvic function at the final follows-ups and complications were recorded.
Results
A total of 84 cannulated screws were inserted in the 35 patients. The time for each cannulated screw placement ranged from 5 to 13 minutes (average, 8.1 minutes); the number of X-ray projection for each screw placement ranged from 7 to 15 times (average, 10.3 times). Postoperative CT showed that all the cannulated screws were located in the preset channels. According to the Matta radiological criteria, postoperative reduction quality was excellent in 29, good in 4 and fair in 2, giving a good to excellent rate of 94.3%. The follow-up time for the 35 patients ranged from 6 to 15 months (average, 12.3 months). At the final follow-ups, all the patients showed fine fracture union. There was no loosening or breakage of screws in all but one patient in whom one sacroiliac screw became loose 3 months after surgery. By the Majeed criteria, the pelvic function was excellent in 27 cases, good in 5, fair in 3 and poor in one, giving a good to excellent rate of 91.4%.
Conclusion
Our self-made minimally invasive pelvic channel instrument can be used to establish pelvic channels, leading to more accurate placement, shorter operative time and less X-ray projection.
Key words:
Pelvis; Fractures, bone; Fracture fixation, internal; Internal fixator; Surgical procedures, minimally invasive
Pelvic fracture
Sacroiliac joint
Trauma Center
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To evaluate the clinical feasibility and safety of percutaneous screw fixation in the management of vertically unstable pelvic fractures.Forty S1 CT films of orthopedic patients aged 18 - 73, were analyzed so as to provide the best screw entrance point and angle for screw entrance. The data thus obtained were used on 14 patients with unequivocally vertical unstable pelvic fractures, 11 cases being of Tile C(1) type, 2 of C(2) type, and 1 of C type, 9 males and 5 females, aged 19 to 68. All the patients received heavy traction to reduce displacement before the surgery. Percutaneous pelvic screw fixation of the disrupted pelvic ring was performed when the patients were in the supine position, and then fixation of sacroiliac joint was performed when the patients were in the prone position.S1 CT scanning showed an average distance from the standard screw entrance point to the backbone of 10.78 cm (9.80 - 12.00 cm), and a standard screw entrance angle of 61.24 degrees (52.18 - 68.20 degrees). Anatomic reduction was achieved in all 14 patients. One patient had neurological deficit due to the screw penetrating into 1/2 of the intervertebral foramen, but the side-effect was released when the screw was removed 21 days after operation. A 6-24 months postoperative follow-up revealed that all the patients had recovered from fracture and resumed their previous work.With advantages including simple procedures, better bony stability, minimal invasion of compromised soft tissue and limited blood loss, percutaneous screw fixation is a practical technique which can be widely used to treat vertical unstable pelvic fracture.
Supine position
Sacroiliac joint
Pelvic fracture
Prone position
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To investigate the effectiveness of anterior subcutaneous internal fixator combined with posterior plate in the treatment of unstable pelvic fractures.
Pelvic fracture
Nerve Injury
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Internal fixation with percutaneous screws for crescent fracture-dislocation of the sacroiliac joint
Objective
To investigate the clinical outcomes of closed reduction and internal fixation with percutaneous screws for crescent fracture-dislocation of the sacroiliac joint.
Methods
We reviewed 78 consecutive patients treated operatively for crescent fracture-dislocation of the sacroiliac joint from June 2003 to October 2014. They were 41 males and 37 females, with a mean age of 37.9 years (range, from 18 to 68 years). By Day classification, there were 18 cases of Type Ⅰ, 35 ones of Type Ⅱ, and 25 ones of Type Ⅲ. Closed reduction and percutaneous fixation was performed in 72 patients. For Type Ⅰ fractures, perpendicular to fracture line fixation was performed with 1-2 parallel iliac screws. For Type Ⅱ, crossed fixation was performed with 1-2 posterior iliac screws and 1-2 SIJ screws. For Type Ⅲ, fixation was performed with SIJ screws. Open reduction and internal fixation was performed in the 6 patients whose closed reduction failed.
Results
Time for closed reduction and internal fixation for posterior crescent fracture-dislocation averaged 38 minutes in the 72 patients; their intraoperative blood loss was 23 mL; their incision length was 1.9 cm; their hospitalization time averaged 5.2 days. Of them, 70 were followed up for an average time of 14 months (from 6 to 24 months). By Matta scoring criteria, the reduction was excellent in 24 cases, good in 30, fair in 14, and poor in 2, giving an excellent to good rate of 77.1% . The average fracture healing time was 12.0 weeks. By Majeed system, functional outcome at the last follow-up was excellent in 34 cases, good in 26, fair in 8, and poor in 2, giving an excellent to good rate of 85.7% . No complications like redislocation, nonunion and implant failure occurred during the follow-ups.
Conclusion
Based on the Day classification, closed reduction and percutaneous screw fixation is an effective treatment for the majority of crescent fracture-dislocations of the sacroiliac joint.
Key words:
Pelvis; Fractures, bone; Fracture fixation, internal; Surgical procedures, minimally invasive
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 evaluate the effectiveness of lumbopelvic fixation using the combination of closed multi-axial screws (CMAS) iliosacral fixation system and the posterior segmental spinal fixation for unstable sacral fractures. Methods Between January 2013 and November 2014, 25 patients (39 sides) with unstable sacral fractures were treated with lumbopelvic fixation using the combination of CMAS iliosacral fixation system and the posterior segmental spinal fixation. There were 17 males and 8 females, aged 19-55 years (mean, 33.9 years). The causes were traffic accident injury in 15 cases, falling injury from height in 8 cases, and crushing injury in 2 cases. The interval of injury and operation was 1-13 days (mean, 3.5 days). Fracture was classified as Denis type I in 2 sides, type II in 20 sides, and type III in 17 sides; nerve injury was rated as Gibbons grade I in 2 cases, grade II in 2 cases, grade III in 7 cases, and grade IV in 9 cases. The reduction quality was evaluated by Matta criterion, the clinical function outcome by Majeed, and nerve function by Gibbons criterion. Results The average operation time was 110 minutes (range, 80-150 minutes). The average blood loss was 570 mL (range, 250-1 400 mL). Superficial wound infection occurred in 2 patients, and was cured after debridement and antibiotic therapy. All patients were followed up for an average of 18 months (range, 15-22 months). Postoperative X-ray and CT examination showed clinical healing of sacral fractures at 8-12 weeks after operation (mean, 10 weeks). The mean removal time of internal fixation was 13 months (range, 12-20 months). No screw loosening and fracture, adhesion of internal fixation to surrounding tissue, and obvious electrolysis phenomenon occurred. According to Matta criterion, reduction was rated as excellent in 32 sides, good in 6 sides, fair in 1 side, and the excellent and good rate was 97.5%. According to Majeed functional scoring at last follow-up, the mean score was 84.7 (range, 64-98); the results were excellent in 18 cases, good in 5 cases, and fair in 2 cases, and the excellent and good rate was 92.0%. The nerve function was significantly improved when compared with preoperative one; nerve injury was rated as Gibbons grade I in 8 cases, grade II in 8 cases, grade III in 3 cases, and grade IV in 1 case. Conclusion Lumbopelvic fixation using the combination of CMAS iliosacral fixation system and the posterior segmental spinal fixation is a relatively effective fixation for unstable sacral fractures. Not only is the fracture fixation rigid for early full weight-bearing, but also nerve decompression can be performed which facilitates nerve function recovery.
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