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Internal Fixation of Posterior Pelvic Ring Injuries Using Iliosacral Screws in the Dysmorphic Upper Sacrum

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Internal Fixation of Posterior Pelvic Ring Injuries Using Iliosacral Screws in the Dysmorphic Upper Sacrum Internal Fixation of Posterior Pelvic Ring Injuries Using Iliosacral Screws in the Dysmorphic Upper Sacrum Saam Morshed, MD, PhD, MPH, Kevin Choo, MD, Utku Kandemir, MD, and Scott Patrick Kaiser, MD Based on an original article: J Bone Surg Am. 2014 Jul 16;96(14):e120. Introduction The surgical procedure starts with appropriate supine positioning and verification of adequate fluoro- The correct usage of preoperative and intraoperative im- scopic inlet, outlet, and lateral sacral views. The coronal aging allows fixation of posterior pelvic ring injuries with and axial angulation measured during preoperative plan- safely positioned iliosacral screws in the setting of sacral ning can then be used to determine the best insertion dysmorphism. site and trajectory of the iliosacral screw. Reduction of Percutaneous treatment of unstable pelvic ring the fracture is enabled by positioning with a longitudinal injuries is a technically demanding procedure with a steep central bump underneath the sacrum. Careful assess- learning curve. An in-depth understanding of pelvic os- ment of the trajectory of the guidewire and drill on outlet, seous, vascular, and neural anatomy is vital to prevent inlet, and lateral sacral fluoroscopic views is necessary serious complications. The surgeon must feel comfortable to ensure an intraosseous trajectory of each iliosacral translating difficult fluoroscopic imaging into a three-dimen- screw12,13. Alternatively, surgical navigation, which allows sional spatial visualization to attain reduction and establish real-time visualization of screw placement without radia- an effective and safe screw trajectory. Even surgeons tion, can be used when combined with intraoperative CT experienced in the use of percutaneous iliosacral screws for registration; however, the same principles regarding must be ready to adjust their technique when confronted accurate screw placement apply (see Clinical Comments with a dysmorphic anatomic phenotype (Video 1). section below). The drill can be used to subtly change Sacral dysmorphism has been shown to be the guidewire trajectory. During screw placement, outlet, present in 40% of the general population1,2. The dys- inlet, and lateral sacral views confirm the final trajectory, morphic sacrum differs from a nondysmorphic sacrum and the obturator outlet view can verify cortical seating in the morphology of the osseous corridors that connect of the iliosacral screw. the posterior ilium to the sacral bodies via the sacroiliac joint. In the dysmorphic upper sacral segment, this corri- dor has a smaller cross-sectional area and a more acute Step 1: Preoperative Planning angle in the coronal and axial planes than are seen in a Obtain CT reformats along the longitudinal axis of the nondysmorphic sacrum3,4.The morphology of the osse- sacrum to determine the orientation and diameter of the ous corridor in sacral dysmorphism has been previously osseous corridor for selection of the ideal screw size, described as having five associated qualitative charac- length, and trajectory. teristics identifiable on the outlet radiograph5. A trans- iliac, transsacral screw confers the greatest resistance to • When a pelvic outlet radiograph demonstrates vertical displacement; however, it is not possible to use signs of sacral dysmorphism (Fig. 1), obtain a such a screw in certain patients with upper sacral seg- fine-cut (0.625-mm-slice-thickness) CT scan ment dysplasia5-11. Preoperative planning involves coro- through the sacrum to confirm these findings nal and axial reformats of a 0.0625-mm-slice computed and aid in surgical planning. tomography (CT) scan along the longitudinal axis of the • Reformat the CT scan in the true coronal and sacrum. These reformats define the morphology and axial planes by defining the sagittal axis of the ideal trajectory of iliosacral screw placement, and use reformats as the posterior border of the sacrum of the sacral dysmorphism score can identify patients and the axial axis of the reformats along the in whom use of a transiliac, transsacral screw is highly upper end plate of the second sacral segment. risky or impossible1. This will provide coronal and axial cuts that accurately represent the trajectory of the upper doi:10.2106/JBJS.ST.N.00006 2015, 5(1):e3 1 and second sacral osseous corridors (Figs. 2-A beneath the table for the full range of fluoro- through 2-D) and correspond with intraoperative scopic imaging. Some patients require extreme inlet and outlet fluoroscopic projections. angulation of the fluoroscopic unit to obtain a • Select an axial reformat that maximizes the true outlet image. length of bone perpendicular to the axis of the • Place a central sacral support underneath the osseous corridor between the ipsilateral ala and sacrum. This positioning aid is typically made the first neural foramen. This represents the from two or three folded sheets or blankets wide diameter of the upper sacral segment corridor. enough to support the posterior superior iliac Given that this is not a perfect cylinder, if the spines and long enough to elevate the ischial diameter is <10 mm, take caution with insertion tuberosities. This central sacral support lifts the of a screw 6.5 mm in diameter or larger. pelvis evenly off the operating table to allow for • Measure the coronal angulation of the upper unobstructed angled trajectories for placement sacral segment corridor, defined as the angle of iliosacral screws in accordance with Step 1. subtended by a line connecting the iliac crests This facilitates reduction and access to the pos- and a second line along the axis of the upper terior pelvic ring (Fig. 4). sacral segment osseous corridor (Fig. 3-A). • Confirm the adequacy of outlet, inlet, and lateral • Measure the axial angulation of the upper sacral sacral views prior to sterile skin preparation. segment corridor, defined as the angle subtend- • Place adhesive drapes transversely along the ed by a line connecting the posterior iliac spines inferior costal margin to meet a drape placed and a second line along the axis of the upper longitudinally along the posterior aspect of the sacral segment osseous corridor (Fig. 3-B). buttock where it is in contact with the table. • Calculate the sacral dysmorphism score with Proper draping allows sterile preparation of the formula: (first sacral coronal angle) + 2(first skin caudal to the inferior costal margin anteri- sacral axial angle). The higher the score, the orly and laterally. Maintain the posterior sterile less likely there is a safe transsacral osseous margin as close to the table as possible, to take corridor. advantage of the elevated position of the pelvis • The ideal screw is one that best augments sta- on the central sacral support and to allow as bility. The entry site can vary depending on the much freedom as possible for the insertion angle injury pattern. With an entry site centered on the of the iliosacral screw. The inferior extent of the axis of the ipsilateral osseous corridor, the mea- skin preparation is a horizontal line at or just be- sured coronal angulation estimates the angle of low the anterosuperior aspect of the symphysis screw insertion relative to a horizontal line paral- pubis. The skin preparation can be extended dis- lel to the superior end plate of the upper sacral tally to incorporate the hindquarter ipsilateral to segment in the coronal plane of the sacrum on the injured hemipelvis should access to the limb the outlet image. The measured axial angulation be required to achieve a manipulative reduction estimates the angle between the longitudinal intraoperatively (Figs. 5-A and 5-B). axis of the osseous corridor and the horizontal in the axial plane of the sacrum visualized on the inlet projection. Step 3: Fracture Reduction • Analyze the second sacral segment in the same Reduction of the posterior pelvic ring confers stability; manner as the upper sacral segment. In many if closed reduction is unsuccessful, proceed with open dysmorphic sacra, the size and orientation of the reduction. second sacral segment are increased, enabling • Verify the vertical displacement of the posterior placement of one or two transsacral screws. pelvic ring on the outlet view and the rotational and anterior-posterior translation on the inlet view. Step 2: Patient Positioning • A distal femoral traction pin may be placed to Proper positioning enables reduction and accurate ilio- facilitate reduction. If the anesthetist induces sacral screw placement. adequate paralysis by using muscle relaxant • Position the patient supine on a radiolucent agents, >15 lb (>6.8 kg) of traction is seldom table. Slide the patient toward the table edge necessary. Other augments to reduction may ipsilateral to the injured side to allow the sur- include manipulation by placing a percutaneous geon’s hand to drop below the level of the table, Schanz pin in the gluteus medius tubercle, the thus directing the screw anteriorly in order to anterior inferior iliac spine, and/or the trochan- achieve proper placement into the upper sacral teric line of the femur, with or without use of segment. There must be adequate clearance external fixation or a universal distractor. doi:10.2106/JBJS.ST.N.00006 2015, 5(1):e3 2 • When the symphysis pubis is displaced in con- over the Kirschner wire and drill it into the sacral body junction with the posterior pelvic ring, perform an under fluoroscopic guidance, in accordance with the open reduction of the symphysis pubis through preoperative plan. a Pfannenstiel approach to aid in the indirect • Make a 1-cm longitudinally oriented incision reduction of the posterior pelvic ring. through the skin and subcutaneous tissue cen- • If closed reduction of the posterior pelvic ring is tered on the properly positioned Kirschner wire. unsuccessful, perform an open reduction via an • Insert the cannulated pin sleeve for the screw anterior or posterior approach, according to your system of choice (6.5 to 7.5 mm is most com- preference. Reduction both confers stability and mon) over the Kirschner wire and stabilize it is vital to safe iliosacral screw placement14.
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