Freehand Placement of a Transiliac-Transsacral Screw for Fixation of Posterior Pelvic Ring Injuries

Abstract

Objective: There are many advantages to stabilize the posterior pelvic ring injuries with a transiliac-transsacral (TITS) screw percutaneously. To identify the correct entry point and insert a guidewire accurately for a TITS screw, we propose a method of specifying the optimal entry point, and introduce a technique of enabling freehand placement of a guidewire with fluoroscopic guidance.

Methods: In this retrospective study, 116 patients who underwent pelvic CT scans and pelvic lateral radiographs at our institution from January 2020 to April 2022 were enrolled. The optimal entry point for a TITS screw was formulated in the strict mid-sagittal CT plane, and then transferred to the pelvic lateral radiograph relying on the sacral cortexes which were easily visible even in the poor fluoroscopy. The relative position of this point to other anatomical markers was checked to confirm its feasibility as an entry point. With the method to locate the entry point, 18 patients suffered the posterior pelvic ring injuries were treated with TITS screws through hammering a reverse Kirschner wire (K-wire) to insert a guidewire assisted by a canula, followed by the validation of the screw placement accuracy.

Results: The transferred point in radiograph was consistently beneath the sacral alar slope, and located posteroinferior to the iliac cortical density (ICD) and anterosuperior to the sacral nerve root tunnel in all 116 patients. In clinical practice, 18 TITS screws were successfully placed in 18 patients without cortex violation. The average operative time for each screw was 20.11 ± 6.29 min, with an average of 14.11 ± 6.81 fluoroscopic shots per screw. At the 3-month follow-up, fracture healing was confirmed in all patients. The average Majeed score was 89.61 ± 6.90 at the final follow-up.

Conclusions: It’s feasible to identify an entry point for a TITS screw based on the sacral cortexes, and hammering a reverse K-wire assisted by a percutaneous kyphoplasty (PKP) canula is a safe and practical technique for guidewire insertion.

Keywords

entry point / fluoroscopy / pelvic fracture / posterior pelvic ring injury / Transiliac-transsacral screw

References

[1] R. Cintean, C. Fritzsche, I. Zderic, B. Gueorguiev-Rüegg, F. Gebhard, and K. Schütze, “Sacroiliac Versus Transiliac–Transsacral Screw Osteosynthesis in Osteoporotic Pelvic Fractures: A Biomechanical Comparison,” European Journal of Trauma and Emergency Surgery 49, no. 6 (2023): 2553–2560.

[2] E. T. Araiza, S. Medda, J. F. Plate, et al., “Comparing the Efficiency, Radiation Exposure, and Accuracy Using C-Arm Versus O-Arm With 3D Navigation in Placement of Transiliac–Transsacral and Iliosacral Screws: A Cadaveric Study Evaluating an Early Career Surgeon,” Journal of Orthopaedic Trauma 34, no. 306 (2020): 302–306.

[3] J. M. Conflitti, M. L. Graves, and M. L. Chip Routt, Jr., “Radiographic Quantification and Analysis of Dysmorphic Upper Sacral Osseous Anatomy and Associated Iliosacral Screw Insertions,” Journal of Orthopaedic Trauma 24, no. 10 (2010): 630–636,

[4] J. G. Eastman, T. J. Shelton, M. L. C. Routt, and M. R. Adams, “Posterior Pelvic Ring Bone Density With Implications for Percutaneous Screw Fixation,” European Journal of Orthopaedic Surgery and Traumatology 31, no. 2 (2020): 383–389.

[5] W. Zhou, J. Chen, X. Pei, et al., “Incidence of and Risk Factors for Screw Loosening After Iliosacral Screw Fixation for Posterior Pelvic Ring Injury,” Orthopaedic Surgery 15, no. 7 (2023): 1814–1822.

[6] J. G. Eastman, R. J. Kuehn, and M. L. Chip Routt, Jr., “Useful Intraoperative Technique for Percutaneous Stabilization of Bilateral Posterior Pelvic Ring Injuries,” Journal of Orthopaedic Trauma 32, no. 5 (2018): e191–e197,

[7] M. J. Gardner and M. L. Routt, Jr., “Transiliac-transsacral screws for posterior pelvic stabilization,” Journal of Orthopaedic Trauma 25, no. 6 (2011): 378–384,

[8] P.-H. Chen, C.-Y. Chen, K.-C. Lin, and C.-J. Hsu, “Quantification of the Safe Zone of the First to Third Sacral Segments for Transiliac–Transsacral Screw Fixation in Normal and Dysmorphic Sacra,” Orthopedics 47, no. 1 (2024): e13–e18.

[9] J. B. Walker, S. M. Mitchell, S. D. Karr, J. A. Lowe, and C. B. Jones, “Percutaneous Transiliac–Transsacral Screw Fixation of Sacral Fragility Fractures Improves Pain, Ambulation, and Rate of Disposition to Home,” Journal of Orthopaedic Trauma 32, no. 9 (2018): 452–456.

[10] E. Sevillano-Perez, M. Prado-Novoa, S. Postigo-Pozo, A. Peña-Trabalon, and E. Guerado, “L4 Fixation Is Not Necessary in L5-Iliac Spinopelvic Fixation After Trauma, but Coadjutant Transilio-Transsacral Fixation Is,” Injury 55, no. 3 (2024): 111378.

[11] S. W Mardam-Bey, M. J. Beebe, J. C. Black, et al., “The Effect of Transiliac-Transsacral Screw Fixation for Pelvic Ring Injuries on the Uninjured Sacroiliac Joint,” Journal of Orthopaedic Trauma 30, no. 9 (2016): 463–468,

[12] C. S. Day, M. J. Prayson, T. E. Shuler, J. Towers, and G. S. Gruen, “Transsacral Versus Modified Pelvic Landmarks for Percutaneous Iliosacral Screw Placement—a Computed Tomographic Analysis and Cadaveric Study,” American Journal of Orthopedics (Belle Mead, N.J.) 29, no. S9 (2000): 16–21.

[13] D. A. McLaren, G. A. Busel, H. R. Parikh, et al., “Corridor-Diameter-Dependent Angular Tolerance for Safe Transiliosacral Screw Placement: An Anatomic Study of 433 Pelves,” European Journal of Orthopaedic Surgery and Traumatology 31, no. 7 (2021): 1485–1492.

[14] M. L. Routt, Jr., P. T. Simonian, S. G. Agnew, and F. A. Mann, “Radiographic Recognition of the Sacral Alar Slope for Optimal Placement of Iliosacral Screws: A Cadaveric and Clinical Study,” Journal of Orthopaedic Trauma 10, no. 3 (1996): 171–177.

[15] M. J. Gardner, S. Morshed, S. E. Nork, W. M. Ricci, and M. L. Chip Routt, Jr., “Quantification of the Upper and Second Sacral Segment Safe Zones in Normal and Dysmorphic Sacra,” Journal of Orthopaedic Trauma 24, no. 10 (2010): 622–629.

[16] M. M. Hadeed, D. Woods, J. Koerner, K. E. Strage, C. Mauffrey, and J. A. Parry, “Risk Factors for Screw Breach and Iatrogenic Nerve Injury in Percutaneous Posterior Pelvic Ring Fixation,” Journal of Clinical Orthopaedics and Trauma 33 (2022): 101994.

[17] M. Pishnamaz, T. Dienstknecht, B. Hoppe, et al., “Assessment of Pelvic Injuries Treated With Ilio-Sacral Screws: Injury Severity and Accuracy of Screw Positioning,” International Orthopaedics 40, no. 7 (2016): 1495–1501.

[18] J. Zwingmann, O. Hauschild, G. Bode, N. P. Südkamp, and H. Schmal, “Malposition and Revision Rates of Different Imaging Modalities for Percutaneous Iliosacral Screw Fixation Following Pelvic Fractures: A Systematic Review and Meta-Analysis,” Archives of Orthopaedic and Trauma Surgery 133, no. 9 (2013): 1257–1265.

[19] T. Mendel, H. Noser, J. Kuervers, F. Goehre, G. O. Hofmann, and F. Radetzki, “The Influence of Sacral Morphology on the Existence of Secure S1 and S2 Transverse Bone Corridors for Iliosacroiliac Screw Fixation,” Injury 44, no. 12 (2013): 1773–1779.

[20] K. Chen, S. Yao, F. Yang, et al., “Minimally Invasive Screw Fixation of Unstable Pelvic Fractures Using the “Blunt End” Kirschner Wire Technique Assisted by 3D Printed External Template,” BioMed Research International 2019 (2019): 1–9.

[21] C. Wu, B. Zeng, J. Deng, et al., “Finite Element Analysis and Transiliac-Transsacral Screw Fixation for Posterior Pelvic Ring With Sacrum Dysplasia,” Orthopaedic Surgery 15, no. 1 (2022): 337–346.

[22] J. A. Scolaro and M. L. Routt, “Intraosseous Correction of Misdirected Cannulated Screws and Fracture Malalignment Using a Bent Tip 2.0 Mm Guidewire: Technique and Indications,” Archives of Orthopaedic and Trauma Surgery 133, no. 7 (2013): 883–887.

[23] M. Tile, “Pelvic Ring Fractures: Should They Be Fixed?,” Journal of Bone and Joint Surgery. British Volume (London) 70, no. 1 (1988): 1–12.

[24] H. Chen, Q. Zhang, Y. Wu, et al., “Achieve Closed Reduction of Irreducible, Unilateral Vertically Displaced Pelvic Ring Disruption With an Unlocking Closed Reduction Technique,” Orthopaedic Surgery 13, no. 3 (2021): 942–948.

[25] H. Cai, R. Zhang, Y. Yin, J. Li, Z. Hou, and Y. Zhang, “Specifying the Starting Point for S1 Iliosacral Screw Placement in the Dysmorphic Sacrum,” Journal of Bone and Joint Surgery 106, no. 2 (2024): 129–137.

[26] S. A. Majeed, “Grading the Outcome of Pelvic Fractures,” Journal of Bone and Joint Surgery. British Volume (London) 71, no. 2 (1989): 304–330.

[27] Z.-H. Zheng, F. Xu, Z.-Q. Luo, et al., “A Useful Intraoperative Technique for Transiliac-Transsacral Screws: A Point-To-Point Coaxial Guide Apparatus,” Journal of Orthopaedic Surgery and Research 16, no. 1 (2021): 89.

[28] J. Zwingmann, G. Konrad, E. Kotter, N. P. Südkamp, and M. Oberst, “Computer-Navigated Iliosacral Screw Insertion Reduces Malposition Rate and Radiation Exposure,” Clinical Orthopaedics and Related Research 467, no. 7 (2009): 1833–1838.

[29] 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.

[30] P. Wang, K. Yang, H. Qi, et al., “Multimodal Neuroelectrophysiological Monitoring Combined With Robot-Assisted Placement of a Transiliac–Transsacral Screw for the Treatment of Transforaminal Sacral Fractures,” BioMed Research International 2022 (2022): 1–9.

[31] W. Han, T. Zhang, Y. G. Su, et al., “Percutaneous Robot-Assisted Versus Freehand S2 Iliosacral Screw Fixation in Unstable Posterior Pelvic Ring Fracture,” Orthopaedic Surgery 14, no. 2 (2021): 221–228.

[32] J. Q. Wang, Y. Wang, Y. Feng, et al., “Percutaneous Sacroiliac Screw Placement: A Prospective Randomized Comparison of Robot-Assisted Navigation Procedures With a Conventional Technique,” Chinese Medical Journal 130, no. 21 (2017): 2527–2534.

[33] J. G. Eastman and M. L. Routt, Jr., “Correlating Preoperative Imaging With Intraoperative Fluoroscopy in Iliosacral Screw Placement,” Journal of Orthopaedics and Traumatology 16, no. 4 (2015): 309–316.

[34] K. R. Renate, V. E. Elisabeth, S. A. A. Maria, S. K. Sabine, R. W. Renate, and H. G. G. Maria, “Three-Dimensional Morphometry of the First Two Sacral Segments and Its Impact on Safe Transiliac-Transsacral Screw Placement,” Injury 52, no. 10 (2021): 2959–2967.

[35] J. Tidwell, R. Cho, J. S. Reid, H. Boateng, C. Copeland, and E. Sirlin, “Percutaneous Sacroiliac Screw Technique,” Journal of Orthopaedic Trauma 30, no. 2 (2016): S19–S20.

[36] P. M. Rommens, E. M. Nolte, J. Hopf, D. Wagner, A. Hofmann, and M. Hessmann, “Safety and Efficacy of 2D-Fluoroscopy-Based Iliosacral Screw Osteosynthesis: Results of a Retrospective Monocentric Study,” European Journal of Trauma and Emergency Surgery 47, no. 6 (2020): 1687–1698.

[37] J. Scherer, P. Guy, K. A. Lefaivre, H.-C. Pape, C. M. L. Werner, and G. Osterhoff, “Guide Wire Insertion for Percutaneous LC2 Screws in Acetabular and Pelvic Ring Fixation Using a Transpedicular Working Cannula,” Injury 48, no. 10 (2017): 2360–2364.

[38] N. C. Tejwani, D. Raskolnikov, T. McLaurin, and R. Takemoto, “The Role of Computed Tomography for Postoperative Evaluation of Percutaneous Sacroiliac Screw Fixation and Description of a Safe Zone,” American Journal of Orthopedics (Belle Mead, N.J.) 43, no. 11 (2014): 513–516.

[39] L. Zhang, P. Yin, W. Zhang, et al., “An Effective and Feasible Method, “Hammering Technique,” for Percutaneous Fixation of Anterior Column Acetabular Fracture,” BioMed Research International 2016 (2016): 1–6.

[40] D. Wagner, L. Kamer, T. Sawaguchi, et al., “Space Available for Trans-Sacral Implants to Treat Fractures of the Pelvis Assessed by Virtual Implant Positioning,” Archives of Orthopaedic and Trauma Surgery 139, no. 10 (2019): 1385–1391.

[41] C.-S. Chon, J.-H. Jeong, B. Kang, H. S. Kim, and G.-H. Jung, “Computational Simulation Study on Ilio-Sacral Screw Fixations for Pelvic Ring Injuries and Implications in Asian Sacrum,” European Journal of Orthopaedic Surgery and Traumatology 28, no. 3 (2017): 439–444.

[42] E. Gautier, R. Bächler, P. F. Heini, and L. P. Nolte, “Accuracy of Computer-Guided Screw Fixation of the Sacroiliac Joint,” Clinical Orthopaedics and Related Research 393 (2001): 310–317.

[43] A. F. Hinsche, P. V. Giannoudis, and R. M. Smith, “Fluoroscopy-Based Multiplanar Image Guidance for Insertion of Sacroiliac Screws,” Clinical Orthopaedics and Related Research 395 (2002): 135–144.

[44] M. Takao, T. Nishii, T. Sakai, H. Yoshikawa, and N. Sugano, “Iliosacral Screw Insertion Using CT-3D-Fluoroscopy Matching Navigation,” Injury 45, no. 6 (2014): 988–994.

[45] F. R. Avilucea and M. L. Chip Routt, Jr., “Blunt End Wire and Lateral Sacral View: A Technical Trick to Precisely Terminate Percutaneous Pelvic Brim Screw Fixation in the Posterior Ilium,” Journal of Orthopaedic Trauma 35, no. 1 (2021): e34–e36.

[46] J. G. Eastman and M. L. Chip Routt, Jr., “Intramedullary Fixation Techniques for the Anterior Pelvic Ring,” Journal of Orthopaedic Trauma 32, no. S6 (2018): S4–s13.

RIGHTS & PERMISSIONS

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