A comprehensive analysis with minimum 1-year follow-up of vertically unstable transforaminal sacral fractures treated with triangular osteosynthesis.

Orthopaedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL 33606, USA.
Journal of orthopaedic trauma (Impact Factor: 1.54). 01/2009; 23(5):313-9; discussion 319-21. DOI: 10.1097/BOT.0b013e3181a32b91
Source: PubMed

ABSTRACT To analyze the radiographic, clinical, and functional results of triangular osteosynthesis constructs for the treatment of vertically unstable comminuted transforaminal sacral fractures.
Level I trauma center.
During a 3-year period (July 1, 2003 to June 30, 2006), 58 patients with vertically unstable pelvic injuries were treated with triangular osteosynthesis fixation by a single surgeon at a single institution. Patients were followed-up prospectively as a single cohort, with institutional review board approval. Inclusion criteria for this study were skeletally mature patients with a vertically unstable pelvic ring injury associated with a comminuted transforaminal sacral fracture. Minimum follow-up, both clinically and radiographically, was 1 year. Computed tomography scan was performed on all patients at 6 months to assess healing of the fracture. If the fracture healed, the fixation was removed. Functional outcome was assessed using the Short Form 36, version 2, and short version of Musculoskeletal Functional Assessment questionnaires at 6 months (before fixation removal) and 12 months.
Forty of 58 patients with an average age of 39 years were available for a minimum of 1-year follow-up. Wound complications requiring surgical debridement occurred in 5 patients (13%), all of whom had severe soft tissue wounds with internal degloving. Two patients required removal of infected fixation. Iatrogenic L5 nerve injury occurred in 5 patients (13%). Ten patients (25%) had a delayed union on computed tomography scans, and 3 patients had a nonunion as a result of residual fracture gap and incomplete reduction. Six patients (15%) were found to have pronounced tilting of the L5 vertebral body (scoliosis) and distraction of the L5/S1 facet joint ipsilateral to the fixation. This did not correct with removal of the fixation. Failure of the triangular osteosynthesis construct resulting in malunion occurred in 2 patients (5%). All but 2 patients (95%) complained of painful and prominent implants. Functional outcome scoring showed that patients continued to function below the population mean at 1 year but continued to improve, particularly with function and daily activity. Ninety-seven percent of patients returned to some form of work or schooling.
Triangular osteosynthesis fixation is a reliable form of fixation that allows early full weight-bearing at 6 weeks while preventing loss of reduction in comminuted vertical shear transforaminal sacral fractures. For this study group, operative reduction was maintained until healing in 95% of patients. However, the 1-year follow-up shows a substantial rate of potential technical problems and complications. Of primary concern were the asymmetric L5 tilting with L5-S1 facet joint distraction and the need for a second surgery in all patients to remove painful fixation. Iatrogenic nerve injury occurred in 5 patients (13%) and is thought to arise secondary to fracture manipulation and reduction. We recommend selective use of this technique for comminuted transforaminal sacral fractures in situations only where reliable iliosacral or trans-sacral screw fixation is not obtainable.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Die operative Versorgung instabiler Sakrumfrakturen wird als Standard erachtet. Die Verwendung von iliosakralen Schrauben führt zu Redislokationsraten in bis zu 15 %. Vertikale Sakrumfrakturen mit Beteiligung des kranialen S1-Facettengelenks (Isler Typ 2 und 3) führen zu einer multidirektionalen Instabilität. Eine lumbopelvine trianguläre Stabilisierung des hinteren Beckenrings überträgt die axialen Kräfte der Wirbelsäule unter Umgehung der sakroiliakalen Gelenke auf das Os ilium durch Kombination einer lumbalen pedikulären Verankerung mit einer Iliumschraubenverankerung, welche von der Spina iliaca posterior superior zur Spina iliaca anterior inferior verläuft und mit einer horizontal stabilisierenden sakroiliakalen Schraube kombiniert wird. Diese Versorgung ist belastungsstabil und erlaubt eine frühzeitige Mobilisation des Patienten. Sie ist jedoch ein komplexer chirurgischer Eingriff und erfordert eine gute Vorbereitung und operative Logistik. Insbesondere lokale Komplikationen werden beschrieben. Vorbestehende Weichteilschädigungen (Morell-Lavallée) erhöhen das Risiko von Infekten. Prominente Schraubenköpfe der Iliumschraube führen zu lokalen Problemen und sollten durch konsequentes knöchernes Versenken vermieden werden.
    Der Unfallchirurg 01/2013; 116(11). DOI:10.1007/s00113-012-2337-2 · 0.61 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND:: The literature in pelvic ring disruptions is based largely on non-standardized, and non-validated radiographic outcomes. A thorough review of the literature revealed only three described methods for measuring radiographic displacement, and one frequently used grading system for displacement. We aimed to test the reliability of these previously published radiographic measurement methods and grading system. METHODS:: Five separate observers measured radiographic displacement on the standardized pre and post-operative antero-posterior, inlet and outlet views of 25 patients with surgically treated Tile B and C pelvic fractures. The readers measured their initial impression based on the Tornetta and Matta grading system (Excellent, Good, Fair and Poor). Next, they measured displacement using the Inlet and Outlet Ratio as described by Sagi, The Cross Measurement technique as described by Keshishyan, and The Absolute Displacement Method (ADM) as described by Lefaivre. The millimeter measurement obtained by the ADM was converted using the Tornetta and Matta grading system. Each continuous measure was compared for inter-observer reliability using intra-class correlations, and the categorical outcomes were compared using a kappa statistic. Finally, the relationship of the initial impression to the grade as determined by the ADM was compared using kappa agreement. RESULTS:: The agreement among observers based on initial impression was poor (kappa statistic 0.306), but was fair among those reductions that were excellent (k = 0.495). Using the Sagi method the reliability ICC was moderate for the post-operative inlet (0.515, 95% CI 0.338-0.702) and outlet ratios (0.594, 95%CI 0.423-0.760), but almost perfect in pre-operative radiographs (Inlet: 0.814, 95% CI 0.703-0.901, Outlet: 0.863, 95% CI 0.775-0.929). The ICC for all interpretations of the Keshishyan technique were excellent, but were highest when considered as a ratio (Pre-op: 0.938, 95% CI 0.894-0.969, Post-op: 0.912, 95% CI 0.850-0.955). Using the ADM, the location and film used for measurement had poor agreement, and the ICC for the measurement in mm was moderate (pre-op: 0.522, 95% CI 0.342-0.708, post-op: 0.432, 95% CI 0.255-0.634), and the Kappa agreement poor when converted using the Tornetta and Matta scale (k=0.2190). The agreement between the impression and the converted grade from the ADM was poor (k=0.2520) CONCLUSIONS:: Radiographic measurement in pelvic xrays to date has been non-validated, and we found the inter-observer reliability on common methods, including overall impression and absolute displacement in mm, to be poor. The inlet/outlet ratio as described by Sagi was reliable only with wide displacement. The cross measurement technique allows least observer choice, and had excellent reliability, but does not give a measurement that we can easily interpret based on convention in pelvic fracture description.
    Journal of orthopaedic trauma 06/2013; 28(3). DOI:10.1097/BOT.0b013e31829efcc5 · 1.54 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Operative fixation has become treatment of choice for unstable sacral fractures. Osteosynthesis for these fractures results in loss of reduction in up to 15%. Vertical sacral fractures involving the S1 facet joint (Isler 2 and 3) may lead to multidirectional instability. Multidirectional instability of the posterior pelvic ring and lumbopelvic junction may be stabilized and forces balanced by a so-called lumbopelvic triangular fixation. Lumbopelvic triangular fixation combines vertical fixation between the lumbar vertebral pedicle and the ilium, with horizontal fixation, as an iliosacral screw or a transiliacal plate osteosynthesis. The iliac screw is directed from the posterior superior iliac spine (PSIS) to the anterior inferior iliac spine (AIIS). Thereby, lumbopelvic fixation decreases the load to the sacrum and SI joint and transfers axial loads from the lumbar spine directly onto the ilium. Triangular lumbopelvic fixation allows early full weight bearing and therefore reduces prolonged immobilization. The placement of iliac screws may be a complex surgical procedure. Thus, the technique requires thorough surgical preparation and operative logistics. Wound-related complications may occur. Preexisting Morell-Lavalée lesions increase the risk for infection. Prominent implants cause local irritation and pain. Hardware prominence and pain are markedly reduced with screw head recession into the PSIS.
    Der Unfallchirurg 11/2013; 116(11):985-990. · 0.61 Impact Factor