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ABSTRACT: Obesity can complicate surgical procedures by both adding to difficulty intraoperatively and increasing post-operative complications. Intraoperative imaging can be difficult on morbidly obese patients. We have noted specifically that in morbidly obese patients where the lateral sacrum cannot be visualized on the pre-operative scout CT image, the lateral sacrum will not be able to be seen on intraoperative fluoroscopy. This is an important component of preoperative planning in morbidly obese patients with pelvic ring injuries.
Journal of orthopaedic trauma 05/2012; · 1.78 Impact Factor
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ABSTRACT: Posterior pelvic percutaneous fixation following either closed or open reduction is a popular procedure. Knowledge of the posterior pelvic anatomy, its variations, and related imaging is critical to performing reproducibly safe surgery. The dysmorphic sacrum has several key characteristics. The upper portion of the sacrum is relatively colinear with the iliac crests on the outlet radiographic view. Other characteristics include the presence of mammillary bodies (ie, underdeveloped transverse processes) at the sacral mid-alar area, anterior upper sacral foramina that are not circular, residual upper sacral disks, an acute alar slope oriented from cranial-posterior-central to caudal-anterior-lateral on the outlet and lateral views of the sacrum, a tongue-in-groove sacroiliac joint surface visualized on CT, and cortical indentation of the anterior ala on the inlet radiographic view. The surgeon must be knowledgeable about individual patient anatomy to ensure safe iliosacral screw placement.
The Journal of the American Academy of Orthopaedic Surgeons 01/2012; 20(1):8-16. · 2.66 Impact Factor
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ABSTRACT: To quantify the obliquity and dimensions of the upper and second sacral segment iliosacral screw safe zones and to determine the differences between normal and dysmorphic sacral morphology.
Retrospective cohort.
University Level I trauma center.
Fifty patients with pelvic computed tomography scans.
All sacra were characterized as normal or dysmorphic based on plain pelvic radiographs and previously described criteria. Multiple computed tomography scan reconstructions were viewed and manipulated simultaneously with 6 degrees of freedom to allow for custom visualization in any plane.
In each patient, a unique reconstruction plane was created perpendicular to the safe zone axis. The narrowest safe zone cross-sectional area was measured. Next, on simulated pelvic outlet and inlet views, safe zone obliquity and width were measured. Finally, the space available for a transverse screw was assessed. Measurements were performed for both upper and second sacral segment. Values for normal and dysmorphic safe zones were compared.
Sacral dysmorphism was identified in 22 patients. In these sacra, the upper sacral segment safe zone cross-section was 36% smaller than in normal sacra (P < 0.001). No transverse screws could be placed, but accommodating for the caudal to cranial obliquity (30° versus 21° in normals, P < 0.001) and posterior to anterior obliquity (15% versus 4% in normals, P < 0.001) of the safe zone, an iliosacral screw at least 75 mm in length could be placed safely in 91% of patients. A transverse screw could be placed in 75% of normal sacra. In the second segment safe zone, the cross-sectional area was more than twice as large in dysmorphic sacra compared to normals (220 mm versus 109 mm, P < 0.001). The obliquity was not different on either the inlet or outlet views between groups. A transverse screw could be placed at this level in 95% of those with dysmorphic sacra and in only 50% of normal sacra.
Sacral dysmorphism occurred in 44% of patients in this consecutive series. Many anatomic differences were consistently found between the two morphologies with clinical relevance to iliosacral screw placement. Specifically, the dysmorphic upper sacral segment safe zone is significantly smaller and more obliquely oriented but is still large enough to accommodate an iliosacral screw in nearly all patients. The second sacral segment safe zone is approximately transversely oriented in both sacral types but is more than twice as large in dysmorphic sacra. This segment may be a primary fixation opportunity in patients with sacral dysmorphism.
Journal of orthopaedic trauma 10/2010; 24(10):622-9. · 1.78 Impact Factor
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ABSTRACT: Unstable pelvic ring injuries are associated with an increased mortality rate, most commonly from severe hemorrhage. Circumferential pelvic antishock sheeting has proven effective for rapidly stabilizing the pelvic ring and has become an integral part of resuscitation protocols. Acute antishock sheet placement frequently results in patient hemodynamic stabilization and an accurate pelvic reduction. In these situations, we describe a technique of maintaining the pelvic sheet position for continued use as a reduction aid and using working portals to insert definitive percutaneous pelvic implants.
Journal of orthopaedic trauma 10/2009; 23(9):668-74. · 1.78 Impact Factor
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ABSTRACT: Sciatic nerve injury associated with acetabular fractures has been reported in most series. Typically, sciatic neuropraxia occurs from traumatic impaction or compression due to posterior hip fracture-dislocation. We report 2 patients with sciatic nerve entrapment within the posterior column components of their associated both-column acetabular fractures. Following neuroplasty through a Kocher-Langenbeck surgical approach, both patients' neurologic function improved. This unlikely cause of neurologic compromise should be considered in all patients with symptoms of sciatic nerve injury or irritation and particularly in the presence of a mechanical block during posterior column reduction through an ilioinguinal approach.
Journal of orthopaedic trauma 02/2009; 23(1):80-3. · 1.78 Impact Factor
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ABSTRACT: To report results of sacral decompression and lumbopelvic fixation in neurologically impaired patients with highly displaced, comminuted sacral fracture-dislocations resulting in spino-pelvic dissociation.
Retrospective clinical study.
Regional level one trauma center.
Nineteen patients with highly displaced, comminuted, irreducible Roy-Camille type 2-4 sacral fractures with spino-pelvic instability patterns and cauda equina deficits were identified over a 6-year period, 18 of which met the 12-month minimum follow-up criterion.
All were treated with open reduction, sacral decompression, and lumbopelvic fixation. Radiographic and clinical results were evaluated. Neurological outcome was measured by Gibbons' criteria.
Radiographic evaluation with computed tomography scan and antero-posterior, lateral, and oblique views of the pelvis to assess alignment, hardware position and decompression. Clinical evaluation emphasizing neurological outcome as described by Gibbons' criteria.
Sacral fractures healed in all 18 patients without loss of reduction. Average sacral kyphosis improved from 43 to 21 degrees. Fifteen patients (83%) had full or partial recovery of bowel and bladder deficits, although only 10 patients (56%) had improved Gibbons scores. Average Gibbons score improved from 4 to 2.8 at 31-month average follow-up (range: 12 to 57 mo). Wound infection (16%) was the most common complication. Complete recovery of cauda equina function was more likely in patients with continuity of all sacral roots (86% vs. 0%, P = 0.00037) and incomplete deficits (100% vs. 20%, P = 0.024). Although not statistically significant, recovery of bowel and bladder function specifically was more closely associated with absence of any sacral root discontinuity (86% vs. 36%, P = 0.066) than on completeness of the injury (100% vs. 47%, P = 0.21).
Lumbopelvic fixation provided reliable fracture stability and allowed consistent fracture union without loss of alignment. Neurological outcome was, in part, influenced by completeness of injury and presence of sacral root disruption.
Journal of Orthopaedic Trauma 08/2006; 20(7):447-57. · 2.13 Impact Factor
