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Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 640-645

Open versus percutaneous fixation of unstable posterior pelvic ring injuries

1 Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Orthopedic Surgery, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission25-Oct-2017
Date of Acceptance30-Dec-2017
Date of Web Publication25-Jun-2019

Correspondence Address:
Emad E El Agroudy
Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia 32511
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_699_17

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This is a prospective clinical study on 40 patients with unstable posterior pelvic ring injuries to compare percutaneous fixation technique with open fixation technique.
Unstable pelvic ring fractures are usually secondary to high-energy trauma and usually associated with high mortality and morbidity. There are several surgical approaches to the treatment of unstable posterior pelvic ring injury: open or percutaneous screw fixation and plate fixation of posterior pelvic ring injury, each having respective advantages and disadvantages.
Patients and methods
Two techniques have been used for the fixation of the posterior pelvis, each with advantages and disadvantages specific to the technique. A total of 40 cases of completely unstable pelvic ring injuries type C were managed by either percutaneous techniques (group I included 20 patients) or open reduction and internal fixation (group II included 20 patients). Anatomical reduction and restoration of the length of limb were the main aim during the surgery.
The data were analyzed as follows. Tile classification, radiological evaluation according to maximal residual displacement at final follow-up, and functional evaluation according to Lindhal scoring system. Forty patients were included, with 31 male and nine female patients. Overall, 11 patients had excellent results, 20 patients had good, eight patients had fair, and one patient had poor.
Percutaneous fixation of unstable posterior pelvic ring injuries shows better results and fewer complications in comparison with open technique of fixation.

Keywords: cannulated screws, open versus percutaneous, plates, posterior pelvic ring injuries

How to cite this article:
Zaki ESM, Hadhood MM, Ayoub MA, El Sawy MA, El Agroudy EE. Open versus percutaneous fixation of unstable posterior pelvic ring injuries. Menoufia Med J 2019;32:640-5

How to cite this URL:
Zaki ESM, Hadhood MM, Ayoub MA, El Sawy MA, El Agroudy EE. Open versus percutaneous fixation of unstable posterior pelvic ring injuries. Menoufia Med J [serial online] 2019 [cited 2020 May 27];32:640-5. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/640/260914

  Introduction Top

Pelvic ring fractures occur usually secondary to high-energy trauma and represent a severe energy force that is associated with other skeleton injuries[1]. Unstable pelvic ring disruptions have been associated with high rates of morbidity such as hemorrhage, nerve injuries, nonunion, malunion, and disabling chronic pain. Accurate reduction with stable fixation decreases hemorrhage, diminishes pain, permits early patient mobility, allows the pelvic ring to heal in an anatomic location, and improves patient outcome[2],[3].

Definitive stabilization of the pelvic ring disruption remains a challenge to the orthopedic surgeon. External pelvic fixators are useful in the acute situation to reduce pelvic volume and control hemorrhage but cannot stabilize the posterior lesion in an unstable type C pelvic disruption[4]. Several studies have found that internal fixation is much better than both external fixation and conservative treatment in managing unstable pelvic ring disruptions[2],[5],[6].

Percutaneous iliosacral screw fixation has the advantage of providing an excellent biomechanical stability through a minimally invasive approach but is still technically demanding[7].

This work compares percutaneous fixation techniques of unstable posterior pelvic ring injuries with open fixation techniques.

  Patients and Methods Top

A prospective study on 40 patients with completely unstable posterior pelvic ring injuries was conducted. All patients had Tile type C1 unilateral injury; 37 cases sacroiliac (SI) joint injury, two cases fracture sacrum zone I, and one case zone II' [Table 1]. Approval of the ethical committee of the hospital was taken. All cases were treated in Menoufia and Tanta Universities Hospitals during the period from March 2012 to February 2017. A written consent was taken from every patient. Inclusion criteria were patients who were ambulatory at the time of injury, had completely unstable pelvic ring fractures, were of adult age group, and had closed pelvic ring fractures. Exclusion criteria were patients with neuromuscular disorders with abnormal gait or associated lower limb fractures or spinal fractures with neurological affection, stable and partially unstable pelvic ring fractures, extremes of age children and elderly patients, open pelvic fractures, sacral dysmorphism, and associated with grossly displaced acetabular fractures. The age of the patients ranged from 21 to 50 years, with a mean age of 34.6 years in group I and 37.25 years in group II. Other preoperative patient data and associated injuries are shown in [Table 1].
Table 1: Demographic and preoperative data of the patients

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Patients were grouped alternatively through random method into two groups: the first group included 20 patients who were treated by percutaneous technique, and the second group included 20 patients who were treated by open technique (implants used were large set cannulated screws and small set dynamic compression plates that were made of stainless steel 316L by Zimmer, Zimmer Biomet, Warsaw, Indiana, USA). The average follow-up period was 13.5 months (range: 8–21 months). The average duration of hospital stay of group I was 4.25 ± 2.15 days, whereas that of group II was 9.20 ± 4.11 days. The average volume of blood loss was 550 ml intraoperatively (range: 250–850 ml) in open group II, whereas minimal blood loss was noted in percutaneous group I (mean blood loss volume: 50 ml). All cases were operated on within an average time of 8 days (range: 2–14 days). Preoperative radiographies of pelvis and computed tomography scan were done. All patients were operated under spinal anesthesia with image intensifier and radiolucent table to ensure adequate visualization, where pelvic anteroposterior, pelvic inlet, pelvic outlet, and lateral sacral views were used. It is very important to do correct pelvis inlet, outlet, and lateral sacral views. One should see the sacral foramen and the sacral canal in inlet and outlet projections. The average degree of the sagittal plane tilt of the fluoroscope from the vertical required to obtain ideal inlet view was found 25°, and for the ideal outlet view was 40°.

In the percutaneous method of fixation, the patient with supine posterior pelvic injury was indirectly reduced by traction and Schanz screw with T-handle applied percutaneously to the ipsilateral iliac crest for manipulation. Under image intensifier, reduction was checked on anteroposterior, inlet, outlet, and lateral sacral views. The starting point was marked on the skin and a 1 cm stab incision was made. The tip of the guide was placed on the starting spot and impacted into place with a mallet to prevent slipping and confirming safe passage on the inlet, outlet views, and lateral sacral views to ensure that the pin is within the sacral body. The screw length was measured. Drilling over the guidewire was done and the screw over the guidewire was advanced. The inlet view was used to measure screw placement in the relation to the vertebral body and the sacral canal, and the outlet view in the relation to the sacral foramina.

However, in open method of fixation with the patient supine, a skin incision over the iliac crest was curved forward until the anterior superior iliac spine and was deepened through the subcutaneous fat. Iliacus muscle was detached by blunt dissection remaining strictly in a subperiosteal plane; the iliacus muscle was striped off the inner wall of the pelvis to expose the underlying SI joint. Open reduction was done with the aids of ipsilateral leg traction, and Steinmann pin was inserted into iliac crest for manipulation. Small dynamic compression plates were contoured. One or two screws are placed into the sacral ala and directed parallel to the SI joint. The plate was attached to the iliac wing by fully threaded screws. After image intensification-confirmed reduction, the wound was closed in the appropriate fashion.

Posterior lesions were fixed first by either open or percutaneous technique, and then anterior pelvic ring injury was realigned and stabilized through limited measures. When anterior injury is reduced to its stable anatomical position, no further intervention was done (according to Matta's suggestion, pubic fractures displacements <20 mm do not need internal fixation). Unreduced anterior injuries needed further intervention (in group I, percutaneous external pelvic fixator or retrograde pubic remi cannulated screws were used, whereas in open technique, symphyseal plating was done).

Statistical analysis

The data were collected, tabulated, and analyzed by IBM compatible personal computer with SPSS software package (statistical package for social science, version 20.0; IBM Corp., Armonk, New York, USA).

  Results Top

The radiological results relied on the maximal anterior or posterior displacement reached at the end of the follow-up periods of each patient by way of constructing bony landmarks reference lines[3],[8]. The results were classified according to Lindahl and colleagues into the following groups: excellent (0–5 mm displacement), good (6–10 mm), fair (11–15 mm), and poor (>15 mm displacement)[3],[8]. In this series, radiologically, 19 cases had excellent results, 13 cases had good results, five cases had fair results, and three cases had a poor result. All unsatisfactory radiological results were owing to residual posterior displacement noticed postoperatively in six cases and loosening without loss of posterior reduction in two cases during the follow-up period [Figure 1], [Figure 2] and [Table 2].
Figure 1: Group I undergoing percutaneous fixation. (a) Preoperative plain radiography and computed tomography of a patient, (b) postoperative plain radiography, (c) photographic picture, and (d) final follow-up plain radiography.

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Figure 2: Group II undergoing open technique. (a) Preoperative plain radiography of a patient, (b) intraoperative picture, (c) postoperative plain radiography, and (d) final follow-up plain radiography.

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Table 2: The clinical and radiological results of all patients

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The functional results were classified according to the Lindahl et al.'s modification of the Majeed score[3],[8] into the following groups: excellent (78–80 points), good (70–77 points), fair (60–69 points), and poor (<60 points). Regarding function, 31 (77.5%) cases achieved satisfactory results, 11 excellent (eight of group I and three of group II), and 20 good results (nine of group I and 11 of group II). All unsatisfactory functional results were mainly because of the residual posterior SI pain and limited activities. Overall, nine (22.5%) cases achieved unsatisfactory results: eight cases had fair results, with three of group I and five of group II (six cases owing to postoperative residual pain with walking distance affection and using walking aids, and two cases owing to postoperative residual pain with affection of sitting and sexual function) and one case had poor result in group II (owing to residual pain, sitting affection, walking distance affection, gait affection, and using walking aids) [Table 2].

In this study, 28 cases had both satisfactory clinical and radiological results (14 of group I and 14 of group II), and five cases (two cases of group I and three cases of group II) had both unsatisfactory clinical and radiological results (all of them were SI joint disruptions with symphysis pubis diastasis and had initial displacement of >15 mm). However, three cases of group I achieved satisfactory clinical results in spite of having unsatisfactory radiological results. On the contrary, three cases of group II achieved satisfactory radiological results but with unsatisfactory clinical results; this occurred in one case only of group I. This relation between radiological and clinical results of both groups of patients showed statistical significance, with P value of 0.002 [Table 3].
Table 3: Relationship between clinical and radiological result

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Complications were faced in nine cases (two cases of group I and seven cases of group II). Three cases had early infection (all were of group II). Superficial infection occurred in two cases and was controlled by extended antibiotic therapy for 2 weeks. Deep infection complicated one case and was managed with debridement, parenteral antibiotic, and secondary wound closure after 3 weeks. Sciatic nerve affection was noticed in two cases of group II; both cases showed improvement by final follow-up at 18 months. Urological troubles such as urgency and incontinence complicated one case of group II. Insignificant loosened screws, without loss of posterior reduction, were faced by two cases of group I at follow-up. The screws had correct intercortical positions. One case was a non-cooperative patient, and he started weight bearing as early as 3 weeks postoperatively, and the other patient was obese. Both cases were managed by prolonged period of nonweight bearing and protective pelvic binder. One case of delayed union was noted in group II patients.

Postoperative care

Postoperatively, active hip and knee joint motion was encouraged. Nonweight bearing with under arm crutches was allowed as soon as possible according to the general condition. Partial weight bearing was allowed at 4–6 weeks, and full weight bearing usually began at 12–14 weeks postoperatively.

  Discussion Top

Accurate reduction with stable fixation of the injured pelvis diminishes pain, allows early mobility, and improves patient outcome. Whatever fixation method is chosen, the surgeon must be familiar with the sacral anatomy and fluoroscopic imaging.

In the present study, the pelvic ring injuries commonly involved the young adults in both groups [Table 1]. That is similar to the findings of Lange and Hansen[9] and Lindahl et al.[10]. This can be explained by the fact that young adults are at high risk of high-energy trauma as they are highly active, ambitious, and hasty during driving. Moreover, males were more affected than females in both groups [Table 1]; this nearly agrees with the findings of Dujardin et al.[11] and Rommens et al.[12]. Road traffic accidents were responsible for most causative trauma in both groups of patients [Table 1]. Miranda et al.[13] reported nearly similar findings and explained that by the fact that road traffic accidents entails the worst high-energy trauma as compared with other causative agents.

Posterior operative time was calculated in minutes for both groups of patients. Short operative time was evident in group I where mean operative time was ∼52.5 ± 9.25 min, whereas mean operative time in group II was about 103.5 ± 15.23 min. Statistically it was found highly significant. Moreover, hospital stay was shorter in group I with 4.25 ± 2.15 days than in group II with 9.20 ± 4.11 days; it was found statistically highly significant. Healing time was shorter in group I with 6.30 ± 1.17 weeks than in group II with 8.85 ± 1.35 weeks. Statistically it was found highly significant [Table 4]. In group I, no blood transfusion was needed neither intraoperatively or postoperatively, with hemoglobin concentration of more than 10 mg/dl postoperatively, which is in contrast to group II patients, where four patients needed blood transfusion: three cases intraoperatively and one case postoperatively. In a retrospective clinical study, Ayoub[3] reported that iliosacral screwing during the first week had strong effect on the hospital stay duration, and it has lowered significantly the needed total amount of transfused blood before and after its application.
Table 4: Comparison between both groups regarding durations of operation, hospital stay, and healing time

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Matta et al.[5] and Trikha and Gupta[14] have found that postoperative residual posterior displacement of more than 1 cm was associated with increased long-term pain and disability. Satisfactory radiological and functional results of percutaneous group I (75 and 85%, respectively) compared with satisfactory radiological and functional results of open group II (85 and 70%) pay attention toward the effectiveness of percutaneous iliosacral screws in management of unstable posterior pelvic ring instabilities. Oh et al.[15] have found a high rate of satisfactory functional outcomes (84%) in managing unstable pelvic ring injuries using percutaneous iliosacral screws.

No posterior infection was recorded in group I inspite of the presence of Morel-Lavalle lesion in two cases whereas three cases of infection were recorded in group II that had one case with Morel-Lavalle lesion. This confirmed the golden role of the percutaneous technique in the presence of these massive soft-tissue injuries to avoid subsequent infection and impaired surgical wound healing. In this series, incidence of infection in open group was 15%. However, no posterior infection was reported in percutaneous group I apart from two cases that developed superficial anterior external fixator pin tract infections.

Open reduction and internal fixation of posterior pelvic injuries in particular were associated with high wound complication rate. The earlier series of Goldstein et al.[16] reported 18–25% incidence of infection. Kellam et al.[17] reported a 25% incidence of skin breakdown for such posterior incisions. Morsi et al.[18] reported 10% incidence of infection.

Early and accurate closed reduction in conjunction with stable fixation using percutaneous insertion techniques should be ideal treatment for pelvic ring disruptions, especially in patients with polytrauma[2].

  Summary and Conclusion Top

Percutaneous fixation compared with open technique of posterior pelvic ring injuries offers safe and short operative time technique, less complications, better results, short hospital stay, and early healing, and therefore, it should be the standard way for pelvic ring fractures fixation.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Stephen DJG. Management of high-energy pelvic fractures. Curr Orthop 2003; 17:335–345.  Back to cited text no. 1
Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res 2000; 375:15–29.  Back to cited text no. 2
Ayoub MA. Type C pelvic ring injuries in polytrauma patients: can percutaneous iliosacral screws reduce morbidity and costs? Eur J Orthop Surg Traumatol 2012; 22:137–144.  Back to cited text no. 3
Failinger M, Mc Ganity PL. Current concepts review: unstable fractures of the pelvic ring. J Bone Joint Surg 1992; 74:781–791.  Back to cited text no. 4
Matta JM, Tornetta I. Internal fixation of unstable pelvic ring injuries. Clin Orthop 1996; 329:129–140.  Back to cited text no. 5
Bosch EW, Kleyn R, Hogervorst M, Vugt AB. Functional outcome of internal fixation for pelvicring fractures. J Trauma 1999; 47:365.  Back to cited text no. 6
Peng KT, Huang KC, Chi Chen M, Yao Li Y, Robert Hsu WW. Percutaneous placement of iliosacral screws for unstable pelvic ring injuries. J Trauma 2006; 60:602–608.  Back to cited text no. 7
Ayoub MA. Vertically unstable sacral fractures with neurological insult: outcomes of surgical decompression and reconstruction plate internal fixation. Int Orthop 2009; 33:261–267.  Back to cited text no. 8
Lange RH, Hansen ST. Pelvic ring disruptions with symphysis pubis diastasis: indications, techniques and limitations of anterior internal fixation. Clin Orthop 1985; 201:130.  Back to cited text no. 9
Lindahl J, Hirvensalo E, Bostman 0, Santavirta S. Failure of reduction with an external fixator in the management of injuries of the pelvic ring. Long-term evaluation of 110 pts. J Bone 1999; 81:955.  Back to cited text no. 10
Dujardin FH, Hossenbaccus M, Duparc F, Biga N, Thomine JM. Long-term functional prognosis of posterior injuries in high-energy pelvic disruption. J Orthop Trauma 1998; 12:145–151.  Back to cited text no. 11
Rommens PM, Hessman MB. Staged reconstruction of pelvic ring disruption: difference in morbidity, mortality, radiology and functional outcomes between B 1, B2/B3, and C type lesions. J Orthop Trauma 2002; 16:92–98.  Back to cited text no. 12
Miranda MA, Riemer BL, Butterfield SL, BurkeIII CJ. Pelvic ring injuries: a long-term functional outcome study. Chin Orthop 1996; 329:152.  Back to cited text no. 13
Trikha V, Gupta H. Current management of pelvic fractures. J Clin Orthop Trauma 2011; 2:1.  Back to cited text no. 14
Oh CW, Kim PT, Kim JW, Min WK, Kyuung HS, Kim SY, et al. Anterior plating and percutaneous iliosacral screwing in an unstable pelvic ring injury. J Orthop Sci 2008; 13:107–115.  Back to cited text no. 15
Goldstein A, Phillip T, Sclafani A, Scalea T, Duncan A, Goldstein J, et al. Early open reduction and internal fixation of the unstable pelvic fractures. J Trauma 1986; 26:325–333.  Back to cited text no. 16
Kellam JF, McMurtry RY, Paley D, Tile M. The unstable pelvic fracture: operative treatment. Orthop Clin North Am 1987; 18:25–41.  Back to cited text no. 17
Morsi E, El Sawy M, Hannout Y, El-Dakhakhney B. Stabilization of sacroiliac joint disruption through anterior approach by plates and screws. J Am Sci 2014; 10:66–72.  Back to cited text no. 18


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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