MINIMALLY INVASIVE OSTEOSYNTHESIS OF PELVIC RING INJURIES WITH POLYTRAUMA
Bondarenko A.V., Kruglykhin I.V., Plotnikov I.A., Talashkevich M.N.
Altay State Medical University, Regional Clinical Hospital of Emergency Medical Care, Barnaul, Russia
Improvement
in techniques of intensive care promoted the increase in survival of patients
with severe pelvic injury, resulting in appearance of some new problems
relating to development of complications, increasing amount of unsatisfactory
outcomes and disability [1-3]. Patients with pelvic injury often demonstrate
pelvic ring deformations, disproportions in length of extremities, development
of contractures, degenerative lesions of joints and articulations, disordered
pelvic organs functioning, neurological and vascular disorders [4-7].
For
preservation of supporting and movement, pelvic ring injuries require for
precise reposition – accurate anatomic alignment of injured structures,
fixation stability, which allows achieving early function consisting in early
activation of the patient which is especially necessary in treatment of
polytrauma (PT) [8-10].
The
use of conservative techniques for these purposes is unacceptable. Opened
surgical interventions, which are traditionally used for pelvic ring
reconstruction, are quite complex and high-level, are associated with
significant surgical aggression and high intrasurgical blood loss, and their
realization in PT is often impossible owing to severe condition of patients
[11-13]. All of these dictate the need for wide practical implementation of
minimally invasive osteosynthesis (MIO) methods, which do not worsen patients’
condition and allow carrying out reposition and stable fixation of the pelvic
ring at early stages of treatment.
At
the present time in our and foreign countries, internal transcutaneous
osteosynthesis of the posterior semi-ring with use of cannulated screws is
used. As compared the traditional techniques, the indicated method is
characterized by low traumatic potential and sufficient strength of fixation,
which allows mobilizing the patient and realizing the load from body weight and
walking within the first days after surgery [14-18].
Moreover,
some unsolved issues of the use of transcutaneous osteosynthesis for the
posterior complex exist:
1.
Which pelvic injuries require for its realization?
2.
Is there a necessity for reposition and stabilization of the anterior complex?
If yes, then what is the sequence?
3.
Is it possible to use cannulated screws for stabilization of sacral fractures?
Study objective
– to find out the features of the
use of ileosacral transcutaneous cannulated screws in the reconstruction of
pelvic ring injuries in patients with PT.
MATERIALS AND METHODS
For the last 10 years, MIO
for the posterior complex with cannulated screws was used for pelvic ring
reconstruction for 297 patients with PT. Among them, 196 patients did not
receive fixation of the anterior complex, 101 patients received its additional
fixation. For this purpose, 43 patients received external fixators (EF), 58 –
plates and screws.
There were 162 men (54.5 %)
and 135 women (45.5 %), the age of 10-79 (mean age – 34). There were 156 (52.5
%) working patients, 83 (27.9 %) non-working patients of working age, 58 (19.6
%) students and retired persons.
The causes of injuries were
road traffic accidents – 202 (68.1 %), falling from height – 82 (27.6 %),
pelvic compression from heavy objects – 13 (4.3 %).
The associated injury was
identified in 213 (71.7 %) patients, multiple fractures – in 81 (27.2 %),
combined injury – in 3 (1.1 %). PT with ISS [19] of 17-25 points was identified
in 146 (49.2 %), 26-40 – in 89 (29.9 %), more than 41 – in 62 (20.9 %)
patients. Traumatic brain injuries of various severity were diagnosed in 154
(51.9 %), injuries to internal organs – 133 (44.8 %), locomotor system injuries
in other regions – in 160 (53.8 %), burns – in 3 (1.1 %).
AO classification was used
for estimation of pelvic ring injuries [20]. Osteosynthesis for the posterior
complex in stable pelvic ring injuries (type A) was not conducted. Partially
stable injuries (type B) with horizontal and rotational instability after
injuries from anterioposterior and external compression were noted in 196 (65.9
%) patients, unstable (type C) with vertical instability as result of injuries
from shift or combined impacts – in 101 (34.1 %). 172 (57.9 %) patients had
unilateral injuries to the posterior complex, 125 (42.1 %) patients – bilateral
ones. Totally, 297 patients had 422 injuries to structures of the posterior
pelvic semi-ring. Fractures of bones (the sacrum and the iliac bone) were
diagnosed in 198 cases, lacerations of ligamentous apparatus in the sacroiliac
joints (SIJ) – in 224.
At admission, at the stage
of critical care, 71 patients received the temporary fixation with external
fixing devices – pelvic pliers and EF. The indication for urgent stabilization
was opened and mechanically and hemodynamically unstable injuries to the pelvic
ring.
The pelvic reconstruction
with cannulated screws was carried out in compliance with patients’ condition
stabilization. Within the first three days post injury, osteosynthesis of the
posterior complex was conducted for 34 patients, from 3 days to 3 weeks – for
229, more than 3 weeks – for 34. The terms of carrying out of operations varied
from 1 to 78 days. The median (Me) – 10 days, interquartile range – 6-15 days.
Pelvic reconstruction was conducted with the metal constructs from Synthes
(Switzerland) and Osteomed (Russia).
Totally, osteosynthesis of
the posterior complex with cannulated screws for closed injuries was used for
266 patients, for opened injuries – for 31, for unilateral ones – for 172, for
bilateral ones – for 125.
As the main technique
without anterior pelvic semi-ring stabilization, the posterior complex
osteosynthesis with screws was carried out for 196 patients. Among them, opened
fractures were 15 (7.7 %) and were presented by bladder laceration in 12 cases
and by urethra laceration in 3. 161 patients had injuries of type B, 35
patients – type C, 124 – unilateral injuries, 72 – bilateral ones. Injuries to
the anterior semi-ring were in 3 patients with pubic symphysis lacerations, in
193 – with fractures of pubic bones. SIJ rupture as the main injury to the
posterior pelvic complex was in 75 patients, iliac and sacral fractures – in 121.
Figure 1. X-ray images of the patient B., age of 31, a pelvic ring injury
61-B1: a) before reconstruction; b) after fixation of the posterior
complex with the screw (7.3
mm canal)
As a rule, isolated
osteosynthesis with cannulated screws for the posterior complex was used for
patients without displacement of fragments or with slight displacement. In case
of displacements exceeding 2.5 cm in length and 1 cm in width, reposition and additional
fixation of the anterior semi-ring was required in all cases. The question of
subsequence of the stages of surgical intervention arose. Which pelvic semi-ring
is to be restored firstly: anterior or posterior? Reposition and stable
fixation of fragments of the anterior complex promoted restoration of correct
relationships between the posterior pelvic structures in horizontal or
rotational instability that significantly simplified the realization of
transcutaneous fixation of the posterior complex. In case of injuries from
dislocation or in mixed mechanism of with vertical or posterior displacement,
the posterior semi-ring was restored first of all, and then – the anterior one,
because some problems in reposition of the anterior complex appeared in other
case.As addition to the posterior
complex osteosynthesis, 43 patients received the anterior complex
osteosynthesis with EF (Fig. 2). Among them, opened injuries were in 10 (23.3
%) and were presented by urinary bladder lacerations in 7 patients, urethra
lacerations – in 2, opened fracture of iliac wing – in 1. 18 patients had type B
injuries, 25 – type C, 22 – unilateral, 21 – bilateral. 10 patients had pubic
symphysis ruptures, 33 – fractures of pubic bone branches. Among 10 patients
with pubic symphysis laceration, 2 patients had the posterior pelvic complex
injuries of type B, 8 – type C. SIJ as the main injury to the posterior pelvic
ring was in 28 patients, fractures of iliac and sacral bones – in 15.
Figure 2. X-ray images of the patient I., age of 27, a pelvic ring injury
61-B2: a) at admission; b) after reconstruction of the anterior
complex of the pelvis with use of EFD; c) after fixation of the posterior
pelvic complex with 7.3 mm screw
58 patients additionally
received the anterior complex osteosynthesis with plates and screws. Among
them, opened injuries were in 6 (10.3 %) patients and were presented by urinary
bladder laceration in 4 cases, urethra laceration – in 2. 17 patients had
injuries of B type, 41 – C type, unilateral – 24, bilateral – 34. 50 patients
had pubic symphysis, 8 – fractures of branches of pubic bones. Among 50
patients with pubic symphysis rupture, 14 patients had injuries to the
posterior complex of B type, 36 – C type. SIJ lacerations as the main injury to
the posterior complex of the pelvic ring were in 37, sacral and iliac fractures
– 21.
In case of lacerations of
pubic symphysis, we used plate osteosynthesis (Fig. 3), for fractures of the
pubic bone – fixation was conducted with screws in most cases (Fig. 4). The
indication was type B2 pelvic ring injuries from lateral compression or C type
from shift or combined impacts.
Figure 3. X-ray images of the patient A., age of 48, a pelvic ring injury
61-B3: a) at admission, with cystography; b) after application of
pelvic forceps; c) after final reconstruction of the anterior pelvic
semi-ring with the plate; the posterior semi-ring was fixed with 7.3 mm screws
Figure 4. X-ray images and computer 3D reconstruction of the
pelvis of the patient K., age of 19,
a pelvic ring injury 61-B2: a) pelvic X-ray image
before surgery; b) X-ray image after screw fixation for anterior and
posterior pelvis; c) pelvic 3D reconstruction before surgery; d) 3D
pelvic reconstruction after fixation of anterior and posterior complexes
Estimation of the results
considered the patterns of complications and treatment results. The analysis of
the data was initiated from construction of the frequency diagram. Me and
interquartile range were estimated. χ2 test with Yates’ correction and Bonferroni’s technique with multiple
comparisons were used for estimation of statistical significance of
differences. The critical level of significance was less than 0.05 in testing
the null hypotheses [21].
The study was conducted in
compliance with the ethical principles of World Medical
Association Declaration of Helsinki – Ethical Principles for Medical Research
Involving Human Subjects, 2013, and the Rules for clinical practice in the
Russian Federation (the Order of Russian Health Ministry, 19 June 2003, No.266)
with receiving the patients’ agreement for participation in the study and
approval from the local ethical committee.
RESULTS AND DISCUSSION
3
(1 %) patients
died.
The causes of death were
pulmonary embolism in the first case, bleeding from gastric stress ulcer in the
second case and sepsis in the third case. The lethal outcomes were not
associated with surgical interventions for the pelvic ring and were the
consequences of complications of the severe PT.
There were 155 somatic complications
in 105 (35.4 %) patients. The table 1 shows their patterns and the incidence.
Deep venous thrombosis in the lower extremities was the most common, less
frequently – bronchopulmonary and abdominal complications, bedsores, sepsis and
others.
Table 1. Characteristics and incidence of somatic complications (n = 297)
Type of complications |
Abs. number |
% |
Deep venous thrombosis in lower extremities |
77 |
49.7 |
Pneumonia, pleuritis |
47 |
30.3 |
Bedsores |
15 |
9.8 |
Abdominal complications |
7 |
4.5 |
Sepsis |
3 |
1.9 |
Multiple organ dysfunction |
3 |
1.9 |
Gastric stress-ulcers |
2 |
1.3 |
PE |
1 |
0.6 |
TOTAL |
155 |
100 |
Most somatic complications
were identified in the patients with PT severity > 25 according to ISS, with
severe TBI, thoracic or abdominal injuries. 57 (54.3 %) patients had a
bilateral unstable injury to the pelvic ring (type C), 61 (58.1 %) – a
dominating injury to the ligamentous apparatus of the posterior pelvic
semi-ring.
There were 63 local
complications in 41 (13.8 %) patients. The table 2 shows the characteristics
and the incidence. Peripheral neurological disorders were the most common and
were presented by injuries to lumbosacral junction roots in 11 patients,
fibular nerve lesions – in 10, sciatic nerve lesions – in 9. In all cases, the
signs of neurological deficiency were immediately after trauma and were its
consequences. The patients received the complex of conservative treatment.
Within one and a half year, the full recovery of the function was achieved in
21 patients, improvement – in 9. The patients with improvement did not show any
motional neurological deficiency and had only in skin sensitivity disorders.
Table 2. Characteristics and incidence of local
complications (n = 297)
Complications |
Amount |
% |
Neurologic disorders |
30 |
46.9 |
Hematoma inflammation in pelvic region |
11 |
17.2 |
Postsurgical wound complications |
11 |
17.2 |
Migration and fractures of constructs |
8 |
12.5 |
Secondary displacements |
4 |
6.2 |
TOTAL |
64 |
100 |
Hematoma inflammation in the
pelvic region was in 11 patients. Among them, ISS > 25 was in 9, type B
pelvic ring injuries – in 6, type C – 5, unilateral – 3, bilateral – 8. A
dominating injury to the bone component of the posterior semi-ring was in 8
patients, the ligamentous component – in 3. 4 patients had pubic symphysis
lacerations, 7 – bone fractures in the anterior semi-ring. All patients received
opening and draining of hematomas and secondary tension healing.
The inflammation of
postsurgical wounds was in 11 patients. Among them, ISS > 25 was in 7, type
B pelvic ring injuries – in 8, type C – in 3, unilateral – in 5, bilateral – in
6, a dominating injury to the bone component of the posterior semi-ring – in 8,
the ligamentous one – in 3. 8 patients had pubic symphysis lacerations, 3 –
bone fractures in the anterior semi-ring. Opened fractures were in 3, closed –
in 8. The signs of inflammation were identified on the days 4-7 after surgery.
7 patients experienced postsurgical wound inflammation in the region of the
anterior pelvic semi-ring after plate osteosynthesis for pubic symphysis,
including 3 patients with opened injuries (urinary bladder lacerations). 4
inflammatory events appeared in the region of the posterior pelvic semi-ring,
in the place of positioning of cannulated screws fixing SIJ. Moreover, all
patients had unstable metal constructs. Inflammatory foci sanitation was
conducted in all cases. Additional stabilization of the pelvic ring with EF was
in 4 cases.
Migration and fracture of
constructs were identified in 8 patients. Among them, ISS > 25 was in 5,
type B injuries – in 2, type C – in 6, unilateral – in 2, bilateral – in 8, a dominating
injury to the bone component of the posterior semi-ring – 2, the ligamentous
one – 6. 6 patients had the pubic symphysis lacerations, fractures in the
anterior semi-ring – in 2.
3 patients with the pubic
symphysis laceration had the migration and a fracture of the constructs in the
anterior pelvic semi-ring, 2 patients – displacement in the posterior pelvic
structures, 1 – hemipelvis reluxation, 2 – unstable posterior complex. 3
patients with migration and fractures of screws in the region of the plate on
the pubic, two patients had type C pelvic injuries, one – type B. All injuries
were bilateral, with the unstable posterior complex through SIJ lacerations.
Migration of fractures of screws was identified within 1.5-2 months in control
follow-up. All patients had the excessive body mass. The constructs were
removed. 3 patients with secondary displacements required for recurrent
fixation of the pelvic ring with the anterior frame of EF and remounting of
migrated screws to the posterior complex. One patient received the conservative
treatment.
Local complications were
more often in patients with ISS > 25, with unstable and bilateral injuries
to the posterior semi-ring, with a dominating injury to the ligamentous
apparatus of both anterior and posterior pelvic semi-ring and in patients with
excessive body mass.
Within 3-12 years after
hospital discharge, 152 persons with cannulated screws were examined (51.2 % of
the primary group). There were 83 men (54.6 %) and 69 women (45.4 %).
Meijid score results were
[22]: excellent – 63 (41.4 %), good – 44 (28.9 %), satisfactory – 39 (25.7 %),
poor – 6 (3.9 %). The poor outcomes were determined by pain in the pelvic
region and during walking, and by need for additional supporting during long
term physical load. 4 of 6 patients with poor outcomes of treatment had the
vertical displacement (more than 2 cm) in the posterior pelvic semi-ring and
intense pain syndrome. 4 patients with posttraumatic deformations of the pelvic
ring had a relative shortening of the extremities, resulting in claudication,
need for obligatory use of additional supporting and shortening correction with
orthopedic footwear. Among them, 2 had some persistent root disorders in view
of flaccid paralysis of one branch of the fibular nerve on the side of
hemipelvis displacement.
The poor treatment outcomes
were identified in patients with complete injuries to the pelvic ring of C type
through sacral fractures with displacement of a half of the pelvic upwards and
posteriorly. According to our opinion, treatment of such injuries with MIO and
iliosacral screws is difficult and even impossible in most cases. Firstly,
there are some difficulties of closed reposition with displacement of sacral
fragments. Secondly, a zone for fixation of the threading part of the screw in
the sacrum is limited, resulting in loosening and migration of screws in
mobilization of patients, especially in a bilateral injury. Thirdly, “safe”
active mobilization of patients requires for prolongation of bed rest, up to
primary union of a sacral fracture that is unacceptable in PT.
Considering this fact, such
injuries require for other approach to treatment – creation of the additional
third supporting point on the spine – distant spinal and pelvic fixation. The
figures 5 and 6 show an example of use of this technique.
Figure 5. The patient T., age of 45, a pelvic injury 61-C3,
bilateral transsacral instability, displacement of the left hemi-pelvis
upwards: a) pelvic X-ray image at admission; b) after temporary
fixation with EFD; c) X-ray image after plate fixation of anterior pelvic
semi-ring, and posterior semi-ring – with screws with screw migration and
recurrent displacement of hemi-pelvis; d) horizontal CT image; e) X-ray
image after removal of metal constructs; f) horizontal CT image
Figure 6. The patient T., age of 45, a pelvic ring injury 61-C3:
X-ray images after lumboiliac fixation with augmentation screws, left-sided
displacement of hemi-pelvis was corrected
Among patients with
satisfactory outcomes, the residual vertical displacement was within 1 cm with
ectad rotation about 10-15 degrees in 9 persons. However it did not cause any
inconvenience for the patients.
The analysis of
health-related life quality was estimated with MOSSF-36 [23]. The results are
presented in the table 3. As the table shows, the patients had a relatively
high physical and life activity with sufficient level of social communication.
They showed high psychoemotional background with low pain syndrome.
CONCLUSION
Therefore, the analysis of
the results of treatment of pelvic ring injuries in patients with PT with use
of MIO for posterior semi-ring with transcutaneous iliosacral cannulated screws
showed that:
- the highest amount of
complications was noted in patients with unstable bilateral injuries to the
posterior semi-ring with a dominating injury to the ligamentous apparatus;
- transsympheseal and
transpubic instability in displacement > 2.5 cm required for additional
stabilization of the anterior pelvic semi-ring;
- EF is the most optimal for
opened injuries, B1 injuries and as additional measure for pelvic ring fixation
in obese patients;
- the use of plate
osteosynthesis of the anterior semi-ring is possible for all types of closed
injuries. Screws for fixation of the anterior complex are indicated for B2
fractures and for urinary tract injuries in patients with type C injuries and
fractures of pubic bones;
- during pelvic
reconstruction in horizontal or rotational instability, first of all,
reposition and fixation of the anterior semi-ring and then the posterior one
are conducted; and, conversely, for vertical instability or displacement in the
posterior semi-ring;
- presence of an opened
pelvic ring fracture is not an obstacle to transcutaneous iliosacral cannulated
screws for stabilization of the posterior complex of the pelvic ring;
- vertical displaced
fractures of the sacrum requires for distant spinal and pelvic fixation in most
cases.
Information on financing and conflict of interests
The study was conducted
without sponsorship.
The authors declare the
absence of any clear or potential conflicts of interests relating to
publication of this article.
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