Surgical technique: a percutaneous method of subcutaneous fixation for the anterior pelvic ring: the pelvic bridge.
ABSTRACT Management of pelvic ring injuries using minimally invasive techniques may be desirable if reduction and stability can be achieved. We present a new technique, the anterior pelvic bridge, which is a percutaneous method of fixing the anterior pelvis through limited incisions over the iliac crest(s) and pubic symphysis.
An incision is made over each anterior iliac crest and a 6- to 8-cm incision is centered over the symphysis. Either a locking reconstruction plate or a spinal rod is placed through a subcutaneous tunnel overlying the external oblique fascia in the subcutaneous tissue, and fixation into the iliac crest and pubis is achieved to effect stability.
A randomized controlled trial comparing anterior pelvic external fixation (APEF) versus anterior pelvic internal fixation (APIF) for unstable pelvic ring injuries was begun in October 2010. Patients with unstable pelvic ring injuries were enrolled and followed with respect to fracture reduction, surgical pain, complications, and functional outcome scores.
As of January 2012, 23 patients met inclusion; however, 12 patients refused participation because of the possibility of external fixation, leaving 11 patients (four male, seven female) enrolled. At 6-month followup, there was a single pin tract infection in the APEF cohort and no complications or pain in the APIF cohort.
This clinical experience lends support to the use of a new minimally invasive technique to stabilize the anterior pelvis, particularly given the resistance on the part of patients to consider external fixation.
Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
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ABSTRACT: Objective: The treatment of some pelvic injuries has evolved recently to include the use of a subcutaneous anterior pelvic fixator (INFIX). We present eight cases of femoral nerve palsy in six patients after application of an INFIX to highlight this potentially devastating complication to pelvic surgeons using this technique and discuss how it might be avoided in the future. Design: Retrospective chart review. Case Series. Setting: Five level 1 and 2 trauma centers, tertiary referral hospitals. Patients/Participants: Six patients with anterior pelvic ring injury treated with an INFIX that experienced eight femoral nerve palsies (two bilateral). Intervention: Removal of internal fixator, treatment for femoral nerve palsy Main Outcome Measurements: Clinical and electromyographic (EMG) evaluation of patients. Results: All six patients with a total of eight femoral nerve palsies had their INFIX removed. Variable resolution of the nerve injuries was observed. Conclusions: Application of an INFIX for the treatment of pelvic ring injury carries a potentially devastating risk to the femoral nerve(s). Despite early implant removal after detection of nerve injury, some patients had residual quadriceps weakness, disturbance of the thigh's skin sensation, and/or gait disturbance attributable to femoral nerve palsy at the time of early final follow-up. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. CopyrightJournal of Orthopaedic Trauma 06/2014; 29(3). DOI:10.1097/BOT.0000000000000193 · 1.54 Impact Factor
Article: Fractures of the pelvic ring[Show abstract] [Hide abstract]
ABSTRACT: Traumatic disruptions of the pelvic ring are high energy life threatening injuries. Management represents a significant challenge, particularly in the acute setting in the presence of severe haemorrhage. Initial management is focused on preserving life by controlling haemorrhage and associated injuries. Advances in prehospital care, surgery, interventional radiology and the introduction of treatment algorithms to streamline decision making have improved patient survival. As more patients with unstable pelvic injuries survive, the poor results associated with nonoperative management and increasing patient expectations of outcome are making surgical management of these fractures increasingly common. The aim of operative fracture fixation is to correct deformity and restore function. The advent of percutaneous fixation techniques has reduced the morbidity previously associated with large operative exposures and internal fixation.Injury 12/2013; 46. DOI:10.1016/j.injury.2013.11.021 · 2.46 Impact Factor
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ABSTRACT: Tibial plateau fractures (TPFs) are an independent, non-modifiable risk factor for surgical site infections (SSIs). Current antero-lateral approaches to the knee dissect through the anterior tibial angiosome (ATA), which may contribute to a higher rate of SSIs. The aim of this study was to develop an angiosome-sparing antero-lateral approach to allow reduction and fixation of lateral TPFs and to investigate its feasibility in a consecutive cohort. Twenty cadaveric knees were dissected to define the position of the vessels supplying the ATA from the lateral tibial condyle to the skin perforators. Based on these results, an angiosome-sparing surgical approach to treat lateral TPFs was developed. Fifteen consecutive patients were subsequently treated through this approach. Clinical outcomes included assessment of SSI and Lysholm score. Fracture healing and stability were assessed using the Rasmussen score and radiostereometric analysis (RSA). At the latest follow-up between 1 and 4 years, there was no report of SSI. Nine patients (60%) had good or excellent Lysholm scores. The mean Rasmussen score at final follow-up was 17 (median 18, range 14-18) with 10 patients (66%) graded as excellent. Fracture fragment migration measured using RSA was below 2mm in all cases. This study has demonstrated that an angiosome-sparing antero-lateral approach to the lateral tibial plateau is feasible. Adequate stability of these fracture types was achieved by positioning a buttress plate away from the bone and superficial to the regional fascial layer as an 'internal-external fixator'. The angiosome-sparing approach developed was able to be used in a prospective cohort and the clinical results to date are encouraging. Future clinical studies need to investigate the potential benefits of this surgical approach when compared with the previously described antero-lateral approaches.Injury 12/2013; DOI:10.1016/j.injury.2013.11.035 · 2.46 Impact Factor