New Minimally Invasive Method for Treating Posterior Pelvic Ring Fractures: Biomechanical Validation and Clinical Application of Sacroiliac Joint Locking Plate

Abstract

Objective: Considering the high incidence and complexity of unstable posterior pelvic ring fractures, and the need for less invasive and more effective treatment options, this study aims to introduce a novel minimally invasive, safe, and simple internal fixation method for the treatment of unstable posterior pelvic ring fractures using the sacroiliac joint locking plate (SJP) system, and to provide biomechanical validation and clinical evaluation of this method.

Methods: Biomechanical research was conducted using standard pelvic bone models from Synbone, Switzerland, to create Denis II zone unstable posterior pelvic ring fracture models, and to assess the stability of the SJP under different loads compared with traditional fixation methods. A retrospective clinical study analyzed the clinical efficacy of SJP treatment in 62 patients (mean age of 51.7 ± 11.9 years and male-to-female ratio of 42/20) treated at our hospital from October 2016 to January 2023.

Results: Biomechanical tests showed that at a maximum load of 300 N, the displacement values for the SJP (3.361 ± 0.246 mm) and two iliosacral (IS) screws (3.325 ± 0.335 mm) were significantly lower than those for a single IS screw (4.281 ± 0.399 mm) and tension band plate (TBP) (4.678 ± 0.534 mm). In the stiffness test of the compression-separation experiment, the average stiffness of the SJP (92.09 ± 1.17 N/mm) was higher than that of a single IS screw (80.06 ± 2.57 N/mm) and TBP (71.67 ± 1.12 N/mm) (p < 0.05 for both), but lower than that of two IS screws (104.94 ± 1.16 N/mm) (p < 0.05). Clinically, postoperative pain scores decreased to 1.9 ± 0.9 after SJP surgery, which was a significant reduction compared with the preoperative score of 9.1 ± 1.1. Functional prognosis scores improved from 36.1 ± 11.5 preoperatively to 88.4 ± 14.2, showing a marked improvement. The postoperative Majeed scores for the patients were 87.4 ± 8.1, and the incidence of complications was low, with only one case reported so far.

Conclusion: The SJP demonstrates robust stability in biomechanical experiments, making it highly advantageous for clinical applications and widespread adoption. It offers several benefits, including straightforward surgical operation, minimal risk of vascular and neural injury, low surgical requirements, and eliminates the need for fluoroscopy. These advantages contribute to its remarkable clinical efficacy and potential for extensive utilization.

Keywords

biomechanics / minimally invasive / posterior pelvic ring fracture / sacroiliac joint locking plate

References

[1] P. Incagnoli, A. Puidupin, S. Ausset, et al., “Early Management of Severe Pelvic Injury (First 24 Hours),” Anaesthesia Critical Care & Pain Medicine 38, no. 2 (2019): 199-207, https://doi.org/10.1016/j.accpm.2018.12.003.

[2] A. D'Antoni, “V. Gray's Anatomy, the Anatomical Basis of Clinical Practice, 41st Edition,” Clinical Anatomy 29, no. 2 (2016): 264-265.

[3] Y. C. Yoon, D. S. Ma, S. K. Lee, J. K. Oh, and H. K. Song, “Posterior Pelvic Ring Injury of Straddle Fractures: Incidence, Fixation Methods, and Clinical Outcomes,” Asian Journal of Surgery 44, no. 1 (2021): 59-65, https://doi.org/10.1016/j.asjsur.2020.03.021.

[4] T. Wu, W. Chen, Q. Zhang, et al., “Biomechanical Comparison of Two Kinds of Internal Fixation in a Type C Zone II Pelvic Fracture Model,” Chinese Medical Journal 128, no. 17 (2015): 2312-2317, https://doi.org/10.4103/0366-6999.163377.

[5] F. Gu, J. Zhang, Z. Sui, K. Zhang, X. Xie, and T. Yu, “Minimally Invasive Percutaneous TightRope® System Fixation for an Unstable Posterior Pelvic Ring: Clinical Follow-Up and Biomechanical Studies,” Orthopaedic Surgery 14, no. 6 (2022): 1078-1092, https://doi.org/10.1111/os.13261.

[6] C. A. Becker, A. C. Kussmaul, E. M. Suero, et al., “Tape Suture for Stabilization of Incomplete Posterior Pelvic Ring Fractures-Biomechanical Analysis of a New Minimally Invasive Treatment for Incomplete Lateral Compression Pelvic Ring Fractures,” Journal of Orthopaedic Surgery and Research 14, no. 1 (2019): 465, https://doi.org/10.1186/s13018-019-1509-y.

[7] N. Grüneweller, D. Wähnert, and T. Vordemvenne, “Instability of the Posterior Pelvic Ring: Introduction of Innovative Implants,” Journal of Orthopaedic Surgery and Research 16, no. 1 (2021): 625, https://doi.org/10.1186/s13018-021-02770-2.

[8] D. O. Verbeek and M. L. Routt, “High-Energy Pelvic Ring Disruptions With Complete Posterior Instability: Contemporary Reduction and Fixation Strategies,” Journal of Bone and Joint Surgery (American Volume) 100, no. 19 (2018): 1704-1712, https://doi.org/10.2106/JBJS.17.01289.

[9] D. Krappinger, R. Larndorfer, P. Struve, R. Rosenberger, R. Arora, and M. Blauth, “Minimally Invasive Transiliac Plate Osteosynthesis for Type C Injuries of the Pelvic Ring: A Clinical and Radiological Follow-Up,” Journal of Orthopaedic Trauma 21, no. 9 (2007): 595-602, https://doi.org/10.1097/BOT.0b013e318158abcf.

[10] V. M. Khaleel, N. Pushpasekaran, N. Prabhu, A. Pandiyan, and G. M. Koshy, “Posterior Tension Band Plate Osteosynthesis for Unstable Sacral Fractures: A Preliminary Study,” Journal of Clinical Orthopaedics and Trauma 10, no. Suppl 1 (2019): S106-S111, https://doi.org/10.1016/j.jcot.2019.05.017.

[11] D. Behrendt, M. Mütze, H. Steinke, M. Koestler, C. Josten, and J. Böhme, “Evaluation of 2D and 3D Navigation for Iliosacral Screw Fixation,” International Journal of Computer Assisted Radiology and Surgery 7, no. 2 (2012): 249-255, https://doi.org/10.1007/s11548-011-0652-7.

[12] J. Maslow and C. A. Collinge, “Risks to the Superior Gluteal Neurovascular Bundle During Iliosacral and Transsacral Screw Fixation: A Computed Tomogram Arteriography Study,” Journal of Orthopaedic Trauma 31, no. 12 (2017): 640-643, https://doi.org/10.1097/BOT.0000000000000996.

[13] M. Tile, “Pelvic Ring Fractures: Should They Be Fixed?,” Journal of Bone and Joint Surgery. British Volume (London) 70, no. 1 (1988): 1-12, https://doi.org/10.1302/0301-620X.70B1.3276697.

[14] S. A. Majeed, “Grading the Outcome of Pelvic Fractures,” Journal of Bone and Joint Surgery. British Volume (London) 71, no. 2 (1989): 304-306, https://doi.org/10.1302/0301-620X.71B2.2925751.

[15] R. A. Keith, C. V. Granger, B. B. Hamilton, and F. S. Sherwin, “The Functional Independence Measure: A New Tool for Rehabilitation,” Advances in Clinical Rehabilitation 1 (1987): 6-18.

[16] W. Lehmann, L. Großterlinden, and J. M. Rueger, “Posterior Approaches to the Pelvic Ring,” Der Unfallchirurg 116, no. 3 (2013): 205-212, https://doi.org/10.1007/s00113-012-2330-9.

[17] P. F. Stahel, C. Mauffrey, W. R. Smith, et al., “External Fixation for Acute Pelvic Ring Injuries: Decision Making and Technical Options,” Journal of Trauma and Acute Care Surgery 75, no. 5 (2013): 882-887, https://doi.org/10.1097/TA.0b013e3182a9005f.

[18] E. M. Suero, A. Greiner, C. A. Becker, et al., “Biomechanical Stability of Sacroiliac Screw Osteosynthesis With and Without Cement Augmentation,” Injury 52, no. 10 (2021): 2707-2711, https://doi.org/10.1016/j.injury.2020.01.043.

[19] O. Pieske, C. Landersdorfer, C. Trumm, et al., “CT-Guided Sacroiliac Percutaneous Screw Placement in Unstable Posterior Pelvic Ring Injuries: Accuracy of Screw Position, Injury Reduction and Complications in 71 Patients With 136 Screws,” Injury 46, no. 2 (2015): 333-339, https://doi.org/10.1016/j.injury.2014.11.009.

[20] H. L. Deng, D. Y. Li, Y. X. Cong, et al., “Clinical Analysis of Single and Double Sacroiliac Screws in the Treatment of Tile C1 Pelvic Fracture,” BioMed Research International 2022 (2022): 6426977, https://doi.org/10.1155/2022/6426977.

[21] T. Wu, K. Su, Y. Z. Zhang, Z. Y. Yang, H. J. Li, and Y. T. Han, “Biomechanical Comparison of Three Kinds of Fixation in Fracture-Dislocation of the Sacroiliac Joint,” Technology and Health Care 27, no. 1 (2019): 89-99, https://doi.org/10.3233/THC-181274.

[22] J. A. Iorio, A. M. Jakoi, and S. Rehman, “Percutaneous Sacroiliac Screw Fixation of the Posterior Pelvic Ring,” Orthopedic Clinics of North America 46, no. 4 (2015): 511-521, https://doi.org/10.1016/j.ocl.2015.06.005.

[23] Z. Hou, Q. Zhang, W. Chen, et al., “The Application of the Axial View Projection of the S1 Pedicel for Sacroiliac Screw,” Journal of Trauma 69, no. 1 (2010): 122-127, https://doi.org/10.1097/TA.0b013e3181ccba66.

[24] D. Templeman, A. Schmidt, J. Freese, and I. Weisman, “Proximity of Iliosacral Screws to Neurovascular Structures After Internal Fixation,” Clinical Orthopaedics and Related Research 329 (1996): 194-198, https://doi.org/10.1097/00003086-199608000-00023.

[25] S. Li, X. Meng, W. Li, et al., “Effects of Minimally Invasive Plate-Screw Internal Fixation in the Treatment of Posterior Pelvic Ring Fracture,” Experimental and Therapeutic Medicine 16, no. 5 (2018): 4150-4154, https://doi.org/10.3892/etm.2018.6670.

[26] X. Chen, F. Zheng, G. Zhang, et al., “An Experimental Study on the Safe Placement of Sacroiliac Screws Using a 3D Printing Navigation Module,” Annals of Translational Medicine 8, no. 22 (2020): 1512, https://doi.org/10.21037/atm-20-7080.

[27] A. Al-Naseem, A. Sallam, A. Gonnah, O. Masoud, M. M. Abd-El-Barr, and I. S. Aleem, “Robot-Assisted Versus Conventional Percutaneous Sacroiliac Screw Fixation for Posterior Pelvic Ring Injuries: A Systematic Review and Meta-Analysis,” European Journal of Orthopaedic Surgery and Traumatology 33, no. 1 (2023): 9-20, https://doi.org/10.1007/s00590-021-03167-x.

[28] C. Zhao, G. Zhu, Y. Wang, and X. Wu, “TiRobot-Assisted Versus Conventional Fluoroscopy-Assisted Percutaneous Sacroiliac Screw Fixation for Pelvic Ring Injuries: A Meta-Analysis,” Journal of Orthopaedic Surgery and Research 17, no. 1 (2022): 525, https://doi.org/10.1186/s13018-022-03420-x.

[29] S. Ghisla, F. Napoli, G. Lehoczky, et al., “Posterior Pelvic Ring Fractures: Intraoperative 3D-CT Guided Navigation for Accurate Positioning of Sacro-Iliac Screws,” Orthopaedics & Traumatology, Surgery & Research 104, no. 7 (2018): 1063-1067, https://doi.org/10.1016/j.otsr.2018.07.006.

[30] R. H. Daffner and R. L. Sciulli, “CT-Guided Iliosacral Screw Placement,” Seminars in Musculoskeletal Radiology 17, no. 4 (2013): 407-415, https://doi.org/10.1055/s-0033-1356470.

[31] M. Zarei, M. Moosavi, S. Saghebdoust, M. Shafizadeh, and M. Rostami, “Percutaneous Iliosacral Screw Insertion With Only Outlet and Inlet Fluoroscopic View for Unstable Pelvic Ring Injuries: Clinical and Radiological Outcomes,” Surgical Neurology International 13 (2022): 455, https://doi.org/10.25259/SNI_616_2022.

[32] S. Oğuzkaya, Y. S. Güvercin, T. B. Kızkapan, G. Eken, F. Arat, and A. Misir, “Fracture Lines and Comminution Zones of Traumatic Sacral Fractures,” Ulusal Travma ve Acil Cerrahi Dergisi 29, no. 2 (2023): 247-251, https://doi.org/10.14744/tjtes.2022.15163.

[33] M. Kelly, J. Zhang, C. A. Humphrey, J. T. Gorczyca, and A. Mesfin, “Surgical Management of U/H Type Sacral Fractures: Outcomes Following Iliosacral and Lumbopelvic Fixation,” Journal of Spine Surgery 4, no. 2 (2018): 361-367, https://doi.org/10.21037/jss.2018.05.03.

[34] C. H. Kim and J. W. Kim, “Plate Versus Sacroiliac Screw Fixation for Treating Posterior Pelvic Ring Fracture: A Systematic Review and Meta-Analysis,” Injury 51, no. 10 (2020): 2259-2266, https://doi.org/10.1016/j.injury.2020.07.003.

[35] M. A. Ayoub, H. M. Gad, and O. A. Seleem, “Standalone Percutaneous Transiliac Plating of Vertically Unstable Sacral Fractures: Outcomes, Complications, and Recommendations,” European Spine Journal 25, no. 4 (2016): 1153-1162, https://doi.org/10.1007/s00586-015-3976-0.

[36] K. E. Wenning, E. Yilmaz, T. A. Schildhauer, and M. F. Hoffmann, “Comparison of Lumbopelvic Fixation and Iliosacral Screw Fixation for the Treatment of Bilateral Sacral Fractures,” Journal of Orthopaedic Surgery and Research 16 (2021): 604, https://doi.org/10.1186/s13018-021-02768-w.

[37] N. K. Kanakaris, V. Ciriello, P. Z. Stavrou, R. M. West, and P. V. Giannoudis, “Deep Infection Following Reconstruction of Pelvic Fractures: Prevalence, Characteristics, and Predisposing Risk Factors,” European Journal of Trauma and Emergency Surgery 48, no. 5 (2022): 3701-3709, https://doi.org/10.1007/s00068-021-01618-y.

[38] B. Dolati, R. Larndorfer, D. Krappinger, and R. E. Rosenberger, “Stabilization of the Posterior Pelvic Ring With a Slide-Insertion Plate,” Operative Orthopädie und Traumatologie 19, no. 1 (2007): 16-31, https://doi.org/10.1007/s00064-007-1193-7.

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2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.