Comparative Efficacy of Retrograde Pubic Ramus Intramedullary Nails and Percutaneous Cannulated Screws in Treating Anterior Pelvic Ring Fractures: A Retrospective Cohort Study

Abstract

Objective

To compare the clinical outcomes of retrograde pubic ramus intramedullary nail (RPRIN) and percutaneous cannulated screw (PCS) in the treatment of anterior pelvic ring fractures (APRFs).

Methods

This retrospective cohort study included 45 patients with APRFs treated between February 2019 and October 2022 in our trauma center. Patients were divided into two groups based on the surgical method: 20 received RPRIN fixation, and 25 received PCS fixation. Key variables including operation time, fluoroscopic time, blood loss, and postoperative complications were analyzed. Fracture reduction quality was assessed using the Matta score system, and pelvic functional recovery was evaluated using the Majeed score system at the final follow-up. Quantitative variables were compared using the independent sample t test, while categorical variables were analyzed using Chi‐square and Fisher’s exact tests.

Results

The RPRIN group had significantly shorter operation time (36.3 ± 5.6 min vs. 49.5 ± 6.9 min, P < 0.01), fluoroscopic time (32.0 ± 2.8 s vs. 48.4 ± 3.6 s, P < 0.01), and less blood loss (20.4 ± 7.6 mL vs. 34.0 ± 5.7 mL, P < 0.01) than the PCS group. Fracture reduction quality (Matta outcome) and pelvic functional recovery (Majeed outcome) were comparable between the two groups (P > 0.05). No significant complications were reported in either group.

Conclusions

Both RPRIN and PCS are effective for treating APRFs. However, RPRIN offers distinct advantages by reducing operation time, fluoroscopic time, and blood loss, making it a more efficient and less invasive option. Further multicenter studies and biomechanical analyses are warranted to confirm these findings.

Keywords

Anterior pelvic ring fracture / Retrograde pubic ramus intramedullary nail / Percutaneous cannulated screw / Minimally invasive surgery / Functional recovery

References

[1] ColePA, GaugerEM, AnavianJ, et al.. anterior pelvic external fixator versus subcutaneous internal fixator in the treatment of anterior ring pelvic fractures. J Orthop Trauma., 2012, 26(5): 269-277

[2] RommensPM, HopfJC, HerteleerM, et al.. Isolated pubic ramus fractures are serious adverse events for elderly persons: an observational study on 138 patients with fragility fractures of the pelvis type I (FFP Type I). J Clin Med., 2020, 9(8): 2498

[3] BerkT, ZdericI, CasparJ, et al.. A novel implant for superior pubic ramus fracture fixation-development and a biomechanical feasibility study. Medicina (Kaunas)., 2023, 59(4): 740

[4] ShahulhameedA, RobertsCS, PomeroyCL, et al.. Mapping the columns of the acetabulum–implications for percutaneous fixation. Injury., 2010, 41(4): 339-342

[5] WangH, WuG, ChenCY, et al.. Percutaneous screw fixation assisted by hollow pedicle finder for superior pubic ramus fractures. BMC Surg., 2022, 22(1): 216

[6] de RidderVA, de LangeS, PoptaJV. Anatomical variations of the lateral femoral cutaneous nerve and the consequences for surgery. J Orthop Trauma., 1999, 13(3): 207-211

[7] MarecekGS, ScolaroJA. Anterior pelvic ring: introduction to evaluation and management. J Orthop Trauma., 2018, 32(Suppl 6): S1-S3

[8] RouttMLJr, SimonianPT, GrujicL. The retrograde medullary superior pubic ramus screw for the treatment of anterior pelvic ring disruptions: a new technique. J Orthop Trauma., 1995, 9(1): 35-44

[9] WeatherbyDJ, Chip RouttMLJr, EastmanJG. The retrograde-antegrade-retrograde technique for successful placement of a retrograde superior ramus screw. J Orthop Trauma., 2017, 31(7): e224-e229

[10] MüllerKH, Müller-FärberJ. Die osteosynthese mit dem fixateur externe am becken [The technique of operation with the fixateur externe on the pelvis (author's transl)]. Arch Orthop Trauma Surg (Germany)., 1978, 92(4): 273-283

[11] RommensPM, GraafenM, ArandC, et al.. Minimal-invasive stabilization of anterior pelvic ring fractures with retrograde transpubic screws. Injury., 2020, 51(2): 340-346

[12] StahelPF, MooreEE, BurlewCC, et al.. Preperitoneal pelvic packing is not associated with an increased risk of surgical site infections after internal anterior pelvic ring fixation. J Orthop Trauma., 2019, 33(12): 601-607

[13] WinkelhagenJ, van den BekeromMP, BolhuisHW, et al.. Preliminary results of cannulated screw fixation for isolated pubic ramus fractures. Strategies Trauma Limb Reconstr., 2012, 7(2): 87-91

[14] MarshJL, SlongoTF, AgelJ, 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] EastmanJG, ChipRouttMLJr. Intramedullary fixation techniques for the anterior pelvic ring. J Orthop Trauma., 2018, 32(Suppl 6): S4-S13

[16] MattaJM, TornettaP3rd. Internal fixation of unstable pelvic ring injuries. Clin Orthop and Relat Res., 1996, 329: 129-140

[17] MajeedSA. Grading the outcome of pelvic fractures. J Bone Joint Surg Br., 1989, 71(2): 304-306

[18] BerkT, ZdericI, VargaP, et al.. Evaluation of cannulated compression headless screw (CCHS) as an alternative implant in comparison to standard S1–S2 screw fixation of the posterior pelvis ring: a biomechanical study. BMC Musculoskelet Disord., 2023, 24(1): 215

[19] KongJ, ChuY, ZhouC, et al.. A biomechanics study on ligamentous injury in anterior-posterior compression type II pelvic injury. J Orthop Surg Res., 2021, 16(1): 41

[20] OkcuG, ErkanS, YercanHS, et al.. The incidence and location of corona mortis: a study on 75 cadavers. Acta Orthop Scand., 2004, 75(1): 53-55

[21] TurgutA, KalendererÖ, AkanI, et al.. Do patients with acute isolated pubic ramus fractures have to be hospitalized?. Acta Orthop Belg., 2017, 83(4): 574-580

[22] BendersKEM, LeenenLPH. Management of hemodynamically unstable pelvic ring fractures. Front Surg., 2020, 7601321

[23] MeyhoffCS, ThomsenCH, RasmussenLS, et al.. High incidence of chronic pain following surgery for pelvic fracture. Clin J Pain., 2006, 22(2): 167-172

[24] HasegawaIG, SakkaB, DuongAM, et al.. Anterior internal versus external fixation of unstable pelvis fractures was not associated with discharge destination, critical care, length of stay, or hospital charges. Eur J Orthop Surg Traumatol., 2024, 34(5): 2773-2778

[25] ComadollSM, MatuszewskiPE, LiuB, et al.. Factors associated with failure of superior pubic ramus screws. J Orthop Trauma., 2021, 35(4): 181-186

[26] AcklinYP, ZdericI, BuschbaumJ, et al.. Biomechanical comparison of plate and screw fixation in anterior pelvic ring fractures with low bone mineral density. Injury., 2016, 47(7): 1456-1460

[27] ShiehAK, HayesCB, SheltonTJ, et al.. Low superior pubic ramus screw failure rate with combined anterior and posterior pelvic ring fixation. J Orthopaedic Trauma., 2021, 35(4): 175-180

[28] StarrAJ, NakataniT, ReinertCM, et al.. Superior pubic ramus fractures fixed with percutaneous screws: what predicts fixation failure?. J Orthop Trauma., 2008, 22(2): 81-87

[29] ScolaroJA, RouttML. Intraosseous correction of misdirected cannulated screws and fracture malalignment using a bent tip 2.0 mm guidewire: technique and indications. Arch of Orthop Trauma Surg., 2013, 133(7): 883-887

[30] TosounidisTH, GiannoudisPV. 'Reverse guide wire' technique for placement of anterior column/superior pubic ramus screw in pelvis and acetabular surgery. Ann R Coll Surg Engl., 2018, 100(5): 418

[31] GoyalT, SinghG, Kumar TripathyS, et al.. Acetabulum fractures in elderly: a systematic review of fracture pattern and treatment. J Clin Orthop Trauma., 2020, 11(6): 989-1001

[32] HongG, Cong-FengL, Cheng-FangH, et al.. Percutaneous screw fixation of acetabular fractures with 2D fluoroscopy-based computerized navigation. Arch Orthop Trauma surg., 2010, 130(9): 1177-1183

[33] MouhsineE, GarofaloR, BorensO, et al.. Percutaneous retrograde screwing for stabilisation of acetabular fractures. Injury., 2005, 36(11): 1330-1336

[34] LinYC, ChenCH, HuangHT, et al.. Percutaneous antegrade screwing for anterior column fracture of acetabulum with fluoroscopic-based computerized navigation. Arch Orthop Trauma Surg., 2008, 128(2): 223-226

[35] XuL, CaoX, LuH, et al.. Biomechanical evaluation of percutaneous anterograde and retrograde screw implantation for superior ramus pubis fractures: a finite element analysis. Am J Transl Res., 2022, 14(12): 8676-8685

[36] BerkT, ZdericI, SchwarzenbergP, et al.. Evaluation of cannulated compression headless screws as an alternative implant for superior pubic ramus fracture fixation: a biomechanical study. Int Orthop., 2023, 47(4): 1079-1087

[37] HempenEC, WheatleyBM, SchimolerPJ, et al.. A biomechanical comparison of superior ramus plating versus intramedullary screw fixation for unstable lateral compression pelvic ring injuries. Injury., 2022, 53(12): 3899-3903

Funding

Clinical Application-oriented Medical Innovation Foundation from National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation(2021-NCRC-CXJJ-ZH-24)

Jiangsu China-Israel Industrial Technical Research Institute Foundation; National Key R&D Plan of the 14th Five-Year Plan(2022YFC2504303)

RIGHTS & PERMISSIONS

The Author(s), under exclusive licence to Huazhong University of Science and Technology