Surgical Technique: A Percutaneous Method of Subcutaneous Fixation for the Anterior Pelvic Ring: The Pelvic Bridge
Department of Orthopaedic Surgery, University of Minnesota, Regions Hospital, St Paul, MN 55101-2595, USA. Clinical Orthopaedics and Related Research
(Impact Factor: 2.77).
04/2012; 470(8):2116-23. DOI: 10.1007/s11999-012-2341-4
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.
Available from: biomedcentral.com
- "Their incisions were directly over the anteroinferior iliac spine for pedicle screw placement, which is a high-risk zone in regard to injuring the lateral femoral cutaneous nerve. A similar study by Heisterman et al.was a randomized controlled trial that compared anterior pelvic external fixation versus anterior pelvic internal fixation for unstable pelvic ring injuries. They presented the idea of an anterior pelvic bridge, which is a percutaneous method for fixing the anterior pelvis through limited incisions over the iliac crest and pubic symphysis. "
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Unstable pelvic fractures usually result from high-energy trauma. There are several treatment modalities available. The purpose of this study was to evaluate the clinical application of a new less invasive ilioinguinal approach combined with a minimally invasive posterior approach technique in patients with unstable pelvic fractures. We also address the feasibility, validity, and limitations of the technique.
Thirty-seven patients with unstable pelvic fractures were treated with our minimally invasive technique. The anterior pelvic ring fractures were treated with a less invasive ilioinguinal approach, and the sacral fractures were treated with a minimally invasive posterior approach. The clinical outcome was measured using the Majeed scoring system, and the quality of fracture reduction was evaluated. The patients were followed up for 13 to 60 months (mean, 24 months).
Anatomical or near to anatomical reduction was achieved in 26 (70.3 %) of the anterior pelvic ring fractures and a satisfactory result was obtained in another 11(29.7 %). For the posterior sacral fractures, excellent reduction was obtained in 33 (89.2 %) of the fractures, with a residual deformity in the other 4 patients. One superficial wound infection and two deep vein thromboses occurred, all of which resolved with conservative treatment. The clinical outcome at one year was "excellent" in 29 patients and "good" in 8 patients (Majeed score).
The satisfactory results showed that a reduction and fixation of unstable pelvic fractures is possible through a combination of a limited ilioinguinal approach and posterior pelvic ring fixation. We believe our method is a new and effective alternative in the management of pelvic fractures.
Available from: Hans Christoph Pape
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ABSTRACT: Percutaneous anterior stabilization of pelvic ring instability may be useful if closed reduction and stability can be achieved. The first clinical results are promising showing sufficient anterior stabilization, where the soft tissue is spared. In this report we describe the indication and technique for the percutaneous anterior internal pelvic fixator and discuss advantages and disadvantages in context of the current literature. After posterior stability is restored by the standard techniques (eg iliosacral screw placement or posterior plating), the patient is prepared in supine position with the lower limbs included to facilitate reduction. An oblique incision of 3 cm beneath the anterior superior iliac spine bilaterally is made. Blunt dissection of the soft tissue, including the fascia, is followed by the use of a Jamshidi needle to establish the corridor in the ilium. A C-arm and wire-guided implantation of the cannulated pedicle screw is followed by subcutaneous placement of a contoured connecting rod above the abdominal muscle fascia. The described technique facilitates a definitive anterior fixation of vertically and rotationally unstable pelvic ring fractures. Sufficient posterior stability or fixation has to be assumed. Implant removal is required in a second operation. To our opinion, this technique has several advantages, but as an elective surgical approach is not applicable in hemodynamically unstable patients.
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Fractures of the pubic rami due to low energy trauma are common in the elderly, with an incidence of 26 per 100,000 people per year in those aged more than 60 years. The purpose of this study was to evaluate the clinical application of this minimally invasive technique in patients with pubic ramus fractures combined with a sacroiliac joint complex injury, including its feasibility, merits, and limitations.
Fifteen patients with pubic ramus fractures combined with sacroiliac joint injury were treated with the minimally invasive technique from June 2008 until April 2012. The quality of fracture reduction was evaluated according to the Matta standard.
Fourteen cases were excellent (93.3 %), and one case was good (6.7 %). The fracture lines were healed 12 weeks after the surgery. The 15 patients had follow-up visits between four to 50 months (mean, 22.47 months). All patients returned to their pre-injury jobs and lifestyles. One patient suffered a deep vein thrombosis during the peri-operative period. A filter was placed in the patient before the surgery and was removed six weeks later. There was no thrombus found at the follow-up visits of this patient.
The minimally invasive technique in patients with pubic ramus fractures combined with a sacroiliac joint complex injury provided satisfactory efficacy.
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