Anterior subcutaneous internal fixation combined with posterior percutaneous iliosacral screw for treatment of unstable pelvic fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

CHEN Jialei ,  FANG Yue , Walter M Chirume , YANG Yun , YAN Xin’an

Department of Orthopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding author：

FANG Yue, Email: fangyue1968@163.com

Keywords：

Pelvic fracture; internal fixation; iliosacral screw; pelvic ring injury

DOI：

10.7507/1002-1892.201905098

Video：

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Objective To assess the effectiveness of anterior subcutaneous internal fixation (INFIX) combined with posterior percutaneous iliosacral screw for the treatment of unstable pelvic fractures.Methods Between August 2016 and November 2017, 19 cases of unstable pelvic fractures were treated with anterior subcutaneous INFIX combined with posterior percutaneous iliosacral screw. There were 14 males and 5 females, with an average age of 40.6 years (range, 17-69 years). Causes of injury included traffic accident injury in 11 cases, falling from height in 5 cases, bruise injury by heavy object in 3 cases. According to Tile classification, there were 2 cases of type B1, 6 cases of type B2, and 11 cases of type C. Anterior ring injuries included bilateral pubic ischial ramus fractures in 12 cases, unilateral pubic ischial ramus fractures in 5 cases, and symphysis pubis separation in 2 cases. Posterior ring injuries included sacroiliac ligament injuries in 2 cases, unilateral iliac bone fractures in 3 cases, unilateral sacral fractures in 11 cases, unilateral sacroiliac joint dislocation in 2 cases, and bilateral sacral fracture in 1 case. The intraoperative blood loss and operation time were recorded, and the fracture healing and postoperative complications were observed. Matta score was used to evaluate the reduction of fracture, and Majeed score was used to evaluate the postoperative function of patients.Results The operation time was 47-123 minutes (mean, 61.4 minutes) and the intraoperative blood loss was 50-115 mL (mean, 61.1 mL). One case had superficial infection at the site of screw implantation, and 1 case had unilateral cutaneous nerve stimulation, which were cured after corresponding treatment. There was no damage of urinary system, reproductive system, and intestine. All cases were followed up 12-25 months (mean, 18.1 months). All the fractures healed after operation, the average healing time was 9.5 weeks (range, 8-13 weeks); no nonunion, delayed healing, internal fixation loosening, fracture, and other situations occurred. Of the 2 patients with lumbosacral plexus injury before operation, 1 recovered completely and 1 had residual mild claudication. At last follow-up, the reduction of fracture was evaluated by Matta scoring standard, the results were excellent in 13 cases and good in 6 cases, with an excellent and good rate of 100%; the function was evaluated by Majeed scoring standard, the results were excellent in 15 cases and good in 4 cases, with an excellent and good rate of 100%.Conclusion Minimally invasive pelvic stabilization by using anterior subcutaneous INFIX and posterior percutaneous iliosacral screw for treatment of unstable pelvic fractures, can achieve good fracture reduction and definitive stabilization with minimum complications and obtain excellent functional outcomes.

Citation： CHEN Jialei, FANG Yue, Walter M Chirume, YANG Yun, YAN Xin’an. Anterior subcutaneous internal fixation combined with posterior percutaneous iliosacral screw for treatment of unstable pelvic fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2020, 34(1): 21-26. doi: 10.7507/1002-1892.201905098 Copy

1.	张楠威, 于滨生. 经 S₂ 骶髂螺钉技术在脊柱骨盆稳定性重建中应用的研究进展. 中国修复重建外科杂志, 2018, 32(6): 764-768.
2.	Vigdorchik JM, Esquivel AO, Jin X, et al. Biomechanical stability of a supra-acetabular pedicle screw internal fixation device (INFIX) vs external fixation and plates for vertically unstable pelvic fractures. J Orthop Surg Res, 2012, 7: 31.
3.	Kuttner M, Klaiber A, Lorenz T, et al. The pelvic subcutaneous cross-over internal fixator. Unfallchirurg, 2009, 112(7): 661-669.
4.	Vaidya R, Colen R, Vigdorchik J, et al. Treatment of unstable pelvic ring injuries with an internal anterior fixator and posterior fixation: initial clinical series. J Orthop Trauma, 2012, 26(1): 1-8.
5.	Tile M, Helfet D, Kellams J. Fractures of the pelvis and acetabulum. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2003: 131-167.
6.	Keating JF, Werier J, Blachut P, et al. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma, 1999, 13(2): 107-113.
7.	Nork SE, Jones CB, Harding SP, et al. Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma, 2001, 15(4): 238-246.
8.	Matta JM, Tometta P 3rd. Internal fixation of unstable pelvic ring injuries. Clin Orthop Relat Res, 1996, (329): 129-140.
9.	Majeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg (Br), 1989, 71(2): 304-306.
10.	Bi C, Wang Q, Nagelli C, et al. Treatment of unstable posterior pelvic ring fracture with pedicle screw-rod fixator versus locking compression plate: a comparative study. Med Sci Monit, 2016, 22: 3764-3770.
11.	Mcdonald E, Theologis AA, Horst P, et al. When do anterior external or internal fixators provide additional stability in an unstable (Tile C) pelvic fracture? A biomechanical study. Eur J Trauma Emerg Surg, 2015, 41(6): 665-671.
12.	Wang Q, Wang Q, Wang J. Treatment of type B pelvic fracture using anterior subcutaneous internal fixator with triple pedicle screws: a new surgical technique. Arch Orthop Trauma Surg, 2017, 137(7): 887-893.
13.	李斯铭, 王冬梅, 曲爱丽, 等. 钉棒内固定 Tile B2 型骨盆骨折的生物力学效果. 医用生物力学, 2016, 31(3): 240-246.
14.	Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma, 2007, 21(10 Suppl): S1-S133.
15.	Müller FJ, Stosiek W, Zellner M, et al. The anterior subcutaneous internal fixator (ASIF) for unstable pelvic ring fractures: clinical and radiological mid-term results. Int Orthop, 2013, 37(11): 2239-2245.
16.	Fang C, Alabdulrahman H, Pape HC. Complications after percutaneous internal fixator for anterior pelvic ring injuries. Int Orthop, 2017, 41(9): 1785-1790.
17.	Vaidya R, Kubiak EN, Bergin PF, et al. Complications of anterior subcutaneous internal fixation for unstable pelvis fractures: a multicenter study. Clin Orthop Relat Res, 2012, 470(8): 2124-2131.
18.	Young JW, Burgess AR, Brumback RJ, et al. Pelvic fractures: value of plain radiography in early assessment and management. Radiology, 1986, 160(2): 445-451.
19.	Vaidya R, Nasr K, Feria-Arias E, et al. INFIX/EXFIX: massive open pelvic injuries and review of the literature. Case Rep Orthop, 2016, 2016: 9468285.
20.	Scheyerer MJ, Zimmermann SM, Osterhoff G, et al. Anterior subcutaneous internal fixation for treatment of unstable pelvic fractures. BMC Res Notes, 2014, 7: 133.
21.	Shetty AP, Bosco A, Perumal R, et al. Midterm radiologic and functional outcomes of minimally-invasive fixation of unstable pelvic fractures using anterior internal fixator (INFIX) and percutaneous iliosacral screws. J Clin Orthop Trauma, 2017, 8(3): 241-248.
22.	王谦, 周峰, 邓国英, 等. 3 钉椎弓根螺钉系统前环经皮内固定支架治疗 Tile B 型骨盆骨折. 中华创伤杂志, 2016, 32(12): 1067-1072.
23.	陈家磊, Walter M Chirume, 方跃. 内置外固定架治疗骨盆前环损伤的研究进展. 中国修复重建外科杂志, 2019, 33(11): 1462-1465.
24.	Vaidya R, Martin AJ, Roth M, et al. INFIX versus plating for pelvic fractures with disruption of the symphysis pubis. Int Orthop, 2017, 41(8): 1671-1678.
25.	Vaidya R, Woodbury D, Nasr K. Anterior subcutaneous internal pelvic fixation/INFIX: a systemic review. J Orthop Trauma, 2018, 32(Suppl 6): S24-S30.
26.	Gardner MJ, Mehta S, Mirza A, et al. Anterior pelvic reduction and fixation using a subcutaneous internal fixator. J Orthop Trauma, 2012, 26(5): 314-321.
27.	Hesse D, Kandmir U, Solberg B, et al. Femoral nerve palsy after pelvic fracture treated with INFIX: a case series. J Orthop Trauma, 2015, 29(3): 138-143.
28.	Wu XT, Liu ZQ, Fu WQ, et al. Minimally invasive treatment of unstable pelvic ring injuries with modified pedicle screw-rod fixator. J Int Med Res, 2018, 46(1): 368-380.

1. 张楠威, 于滨生. 经 S₂ 骶髂螺钉技术在脊柱骨盆稳定性重建中应用的研究进展. 中国修复重建外科杂志, 2018, 32(6): 764-768.
2. Vigdorchik JM, Esquivel AO, Jin X, et al. Biomechanical stability of a supra-acetabular pedicle screw internal fixation device (INFIX) vs external fixation and plates for vertically unstable pelvic fractures. J Orthop Surg Res, 2012, 7: 31.
3. Kuttner M, Klaiber A, Lorenz T, et al. The pelvic subcutaneous cross-over internal fixator. Unfallchirurg, 2009, 112(7): 661-669.
4. Vaidya R, Colen R, Vigdorchik J, et al. Treatment of unstable pelvic ring injuries with an internal anterior fixator and posterior fixation: initial clinical series. J Orthop Trauma, 2012, 26(1): 1-8.
5. Tile M, Helfet D, Kellams J. Fractures of the pelvis and acetabulum. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2003: 131-167.
6. Keating JF, Werier J, Blachut P, et al. Early fixation of the vertically unstable pelvis: the role of iliosacral screw fixation of the posterior lesion. J Orthop Trauma, 1999, 13(2): 107-113.
7. Nork SE, Jones CB, Harding SP, et al. Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma, 2001, 15(4): 238-246.
8. Matta JM, Tometta P 3rd. Internal fixation of unstable pelvic ring injuries. Clin Orthop Relat Res, 1996, (329): 129-140.
9. Majeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg (Br), 1989, 71(2): 304-306.
10. Bi C, Wang Q, Nagelli C, et al. Treatment of unstable posterior pelvic ring fracture with pedicle screw-rod fixator versus locking compression plate: a comparative study. Med Sci Monit, 2016, 22: 3764-3770.
11. Mcdonald E, Theologis AA, Horst P, et al. When do anterior external or internal fixators provide additional stability in an unstable (Tile C) pelvic fracture? A biomechanical study. Eur J Trauma Emerg Surg, 2015, 41(6): 665-671.
12. Wang Q, Wang Q, Wang J. Treatment of type B pelvic fracture using anterior subcutaneous internal fixator with triple pedicle screws: a new surgical technique. Arch Orthop Trauma Surg, 2017, 137(7): 887-893.
13. 李斯铭, 王冬梅, 曲爱丽, 等. 钉棒内固定 Tile B2 型骨盆骨折的生物力学效果. 医用生物力学, 2016, 31(3): 240-246.
14. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma, 2007, 21(10 Suppl): S1-S133.
15. Müller FJ, Stosiek W, Zellner M, et al. The anterior subcutaneous internal fixator (ASIF) for unstable pelvic ring fractures: clinical and radiological mid-term results. Int Orthop, 2013, 37(11): 2239-2245.
16. Fang C, Alabdulrahman H, Pape HC. Complications after percutaneous internal fixator for anterior pelvic ring injuries. Int Orthop, 2017, 41(9): 1785-1790.
17. Vaidya R, Kubiak EN, Bergin PF, et al. Complications of anterior subcutaneous internal fixation for unstable pelvis fractures: a multicenter study. Clin Orthop Relat Res, 2012, 470(8): 2124-2131.
18. Young JW, Burgess AR, Brumback RJ, et al. Pelvic fractures: value of plain radiography in early assessment and management. Radiology, 1986, 160(2): 445-451.
19. Vaidya R, Nasr K, Feria-Arias E, et al. INFIX/EXFIX: massive open pelvic injuries and review of the literature. Case Rep Orthop, 2016, 2016: 9468285.
20. Scheyerer MJ, Zimmermann SM, Osterhoff G, et al. Anterior subcutaneous internal fixation for treatment of unstable pelvic fractures. BMC Res Notes, 2014, 7: 133.
21. Shetty AP, Bosco A, Perumal R, et al. Midterm radiologic and functional outcomes of minimally-invasive fixation of unstable pelvic fractures using anterior internal fixator (INFIX) and percutaneous iliosacral screws. J Clin Orthop Trauma, 2017, 8(3): 241-248.
22. 王谦, 周峰, 邓国英, 等. 3 钉椎弓根螺钉系统前环经皮内固定支架治疗 Tile B 型骨盆骨折. 中华创伤杂志, 2016, 32(12): 1067-1072.
23. 陈家磊, Walter M Chirume, 方跃. 内置外固定架治疗骨盆前环损伤的研究进展. 中国修复重建外科杂志, 2019, 33(11): 1462-1465.
24. Vaidya R, Martin AJ, Roth M, et al. INFIX versus plating for pelvic fractures with disruption of the symphysis pubis. Int Orthop, 2017, 41(8): 1671-1678.
25. Vaidya R, Woodbury D, Nasr K. Anterior subcutaneous internal pelvic fixation/INFIX: a systemic review. J Orthop Trauma, 2018, 32(Suppl 6): S24-S30.
26. Gardner MJ, Mehta S, Mirza A, et al. Anterior pelvic reduction and fixation using a subcutaneous internal fixator. J Orthop Trauma, 2012, 26(5): 314-321.
27. Hesse D, Kandmir U, Solberg B, et al. Femoral nerve palsy after pelvic fracture treated with INFIX: a case series. J Orthop Trauma, 2015, 29(3): 138-143.
28. Wu XT, Liu ZQ, Fu WQ, et al. Minimally invasive treatment of unstable pelvic ring injuries with modified pedicle screw-rod fixator. J Int Med Res, 2018, 46(1): 368-380.

Chinese Journal of Reparative and Reconstructive Surgery

Anterior subcutaneous internal fixation combined with posterior percutaneous iliosacral screw for treatment of unstable pelvic fractures

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