THE EXPERIENCE WITH SURGICAL TREATMENT OF VERTICAL INSTABLE INJURIES TO THE PELVIC RING WITH DISTANT TRIANGULAR LUMBOILIAC FIXATION

THE EXPERIENCE WITH SURGICAL TREATMENT OF VERTICAL INSTABLE INJURIES TO THE PELVIC RING WITH DISTANT TRIANGULAR LUMBOILIAC FIXATION

Tutynin K.V., Shnyakin P.G., Shubkin V.N.

Krasnoyarsk State Medical University named after professor V.F. Voyno-Yasenetkiy,
 Krasnoyarsk Interdistrict Clinical Emergency Hospital named after N.S. Karpovich, Krasnoyarsk, Russia

Vertical unstable injuries to the pelvic ring appear after high energetic impact and are often accompanied by severe multiple and associated injuries with high mortality (10-20 %) and unsatisfactory long term outcomes (30-60 %) [1-3].
A key to stability of the pelvic ring is integrity of its posterior parts – the sacrum, sacroiliac joints and posterior parts of iliac bones. Such injuries consist for 30.4-51.0 % among other pelvic damages and are classified as vertical unstable and severe ones (type C according to AO-ASIF classification) [1, 2].
The modern principle for treating severe pelvic fractures is active surgical management and early functional stable osteosynthesis for fast painless activation. The tasks of surgical treatment are solved by means of restoration and stabilization of anatomic relationships between pelvic injuries, decompression and revision of pelvic junction elements in presence of neurologic deficiency – disordered function of pelvic organs and skin sensitivity in the perineum [1, 2, 4-7].
With consideration of severe patients’ condition, the stage-by-stage approach for this category of patients should be based on damage control orthopedics. At the emergent stage, the main task is primary relative stabilization of the pelvic ring and decreasing volume of small pelvis cavity for bleeding arrest by means of external fixation [1, 2, 7].
After relative compensation of patient’s condition, the final internal fixation of posterior parts of the pelvic ring is performed with reconstructive plates and spongious screws. But according to the literature data, the stability of osteosynthesis with such implants is sometimes unsatisfactory, and the patient’s activation should be limited up to the moment of bone union to prevent the secondary displacement of a pelvic injury [4, 9, 10].
Transpedicular fixation has been the gold standard for surgical treatment of thoracolumbar spine during many years [11]. The literature shows the increasing rates of use of distant triangular lumboiliac fixation with the spinal transpedicular system for stabilization of vertical unstable fractures of posterior parts of the pelvic bones. Triangular osteosynthesis of posterior parts of the pelvis consists in vertical fixation of the iliac bone to basilar vertebrae, and horizontal and rotation fixation with iliosacral screws, resulting in stability in the region of injuries of posterior pelvic parts with ability to experience early load from body mass [4, 6, 9, 12].
The objective of the study – to evaluate the results of surgical treatment of vertical unstable injuries to the pelvic ring by the method of distant triangular lumboiliac fixation.

MATERIALS AND METHODS

The analysis included the treatment outcomes of 36 patients with vertical unstable pelvic ring injuries in Krasnoyarsk Interdistrict Clinical Emergency Hospital in 2014-2017.
All patients received the complex clinical and instrumental examination. The patients’ condition was assessed with ISS. Management was based on Damage Control Orthopedics [1, 2].
Surgical management was planned according to results of multispiral computer tomography (MSCT) of the pelvic bones and the lumbar spine with 3D-reconstruction and estimation of a fracture type according to AO-ASIF, Denis and Roy-Camille [2]. Neurological deficiency after the pelvic ring injury was estimated with the score from American Spinal Injury Association (ASIA) [13].
Distant triangular lumboiliac fixation was carried out on both sides by means of transpedicular introduction of the screws into the vertebral bodies 4 and 5 and into the thickness of the iliac bones through the posterior superior spines with their subsequent nail fixation. Correction for displacement of injuries to the posterior pelvic parts was realized with single-moment distraction on the nail between the screws, and with use of additional traction for the lower extremity with counter support, followed by connecting the two-side system of the screws with use of the transverse connector. Additional horizontal and rotation stability was realized through the iliac bone into S1 body, with the cannulated spongious screws from the injured side.
Some authors [4, 9, 12] stabilize injuries of the posterior support complex on the injured side only, but bilateral stabilization was performed for prevention of degenerative changes in the intervertebral disks in this field and for higher stability by means of multi-level fixation.
Final fixation of the anterior pelvic ring part injuries was realized with reconstructive plates or cannulated screws.
Visual analogue scale (VAS) was used for estimation of pain before and after surgical treatment.
The long term results of the treatment were estimated with the score by S.A. Majeed for the period from 6 months till 1.5 year [14].
All persons gave their written consent for participation in the study and for publishing the clinical observations.
The data analysis was performed with StatSoft Statistica 6. The results are presented as described below: for qualitative signs – with amount of observations with percentage (%), for quantitative data – as mean arithmetic (M) and standard deviation (σ). Student’s test for independent samples was used for estimation of statistical significance in case of confirmation of normal distribution of the variables in the groups. P value < 0.05 was considered as statistically significant [15].

RESULTS

This technique was used for 36 patients with vertical unstable fracture of the pelvic bones (type C): 16 women (44 %), 20 men (56 %), the mean age of 32.8 ± 5.6 (19-52).
The structure of the pelvic ring injuries was as described below: ruptures of the sacroiliac junctions – 7 (19.4 %), sacral fractures – lateral mass (Denis I) – 10 (27.7 %), transforaminal (Denis II) – 17 (47.3 %), central (Denis III) – 2 (5.6 %). The damages in the anterior parts of the pelvis: fractures of pubic and ischial bones – 31 (84.2 %), pubic symphysis rupture – 5 (13.8 %) patients. Two patients (5.6 %) had the vertical unstable sacral fracture accompanied by L4 burst fracture.
Most patients (31 persons, 86.1 %) had the associated multiple injury with ISS of 17.1 ± 3.1 (the range 12-32). Pelvic belt immobilization was done for 14 patients with stable hemodynamics at the moment of admission (38.9 %). Unstable patients (22 persons, 61.1 %) received the urgent fixation of the pelvic ring injuries with the external frame systems in compliance with Damage Control Orthopedics.
The mean time of external fixation before using the internal elements was 4.4 ± 1.6 days. Presurgical pain was 6.5 ± 0.5 according to VAS.
A key to the pelvic ring stability is the posterior structures. Therefore, according to the principle by E. Letournel, they were treated in the first instance [2]. Most patients (34, 94.4 %) required for surgical stabilization of the posterior and anterior departments of the pelvis, but with consideration of severity of the patients’ condition. The surgical management for the ventral parts was conducted with delay for decreasing surgical aggression in the patients with severe injuries.
31 patients (86.2 %) had not any injuries to the neural structures with clinically significant neurological deficiency. The indications for decompression of the sacral plexus roots in view of cauda equina syndrome were noted in two patients (5.6 %) with central fractures of the sacrum (Denis III) and in three patients (8.2 %) with bilateral transforaminal fractures of the sacrum (Denis III). These patients received laminectomy of sacral canal with extension of sacrum orifices and elimination of compression of neural structures at the level of injury. Two patients (5.6 %) had the L5 root injuries with disordered dorsal flexion of the foot. They received hemilaminectomy and root canal decompression on the side of injury.
The fixation was long in two cases (5.6 %) in combination of fractures of the sacrum and L4 vertebral body: proximally, the level of stabilization was transpedicular in L2 and L3, distally – at the level of L5 and the body of iliac bones.
The mean time of surgery for stabilization of the posterior parts of the pelvis was 105 ± 15 minutes, the mean blood loss – 291 ± 53 ml.
After surgery for triangular stabilization of the posterior parts of the pelvic ring, the pain intensity decreased by 3 points according to VAS and was 3.5 ± 0.5; it was reliably lower than presurgical values – 6.5 ± 0.5 (p < 0.05). Pain decrease and additional immobilization with the pelvic orthopedic belt allowed vertical position of the patients on the third day after surgery.
After compensation of condition, the final stabilization of pelvic fractures was carried out 5-7 days later by means of fixation of injuries to the anterior art of the ring with use of the reconstructive plates or the cannulated spongious screws. The mean time of surgery before stabilization of the anterior parts of the pelvis was 55 ± 14 minutes, the approximate blood loss – 207 ± 53 ml (blood transfusion was not required).
After final stabilization of pelvic fractures, the pain syndrome was 2.5 ± 0.5 points according to VAS on the third day after the second surgery as compared to the presurgical period and after the first surgery (p < 0.05). All patients could stand on the third-fourth day and walk with crutches in one-way direction and with limited load (10-15 % of body weight) to the injury side, in two-way direction – walking with external support with deload of both lower extremities.
After surgery, the control X-ray images and MSCT showed the displacement in the injuries to the posterior parts of the pelvic ring with the value not more than 5 mm.
The mean hospital stay was 19.5 ± 1.5 days. All patients were discharged for outpatient treatment, their condition was satisfactory and they were able to self-care.
Two cases (5.5 %) showed the long term healing of the postsurgical wounds in the sacrum region, with further secondary healing. In one case (2.7 %) with distant spinal-pelvic fixation, the patient with severe polytrauma and a crushing injury to the subcutaneous soft tissues in the posterior parts of the pelvis had the early postsurgical purulent inflammation that required secondary surgical preparation, sanitation and multiple procedures of local treatment with low pressure for two weeks. At the background of complex treatment, purulent inflammation was corrected, and the secondary healing of the postsurgical wounds was achieved. The metal constructs were not removed.
Most patients (32, 88.8 %) returned to the preinjury level of physical activity and resumed their professional activity within 4-8 months. The staged X-ray and MSCT control (for the period of 18 months) confirmed the efficiency of the treatment including preservation of primary reposition and stability of the pelvic ring with the metal construct and consolidation of the injuries.
All patients with cauda equina syndrome showed the recovery of skin sensitivity in the perineum, defecation act and urination.
According to the score by S.A. Majeed, the following long term results were achieved: 9 cases (25 %) – fine results, 22 (61.1 %) – good ones, 5 cases (13.9 %) – satisfactory ones.

The clinical case 1

The patient P., age of 45, received an injury as result of a road traffic accident. After the examination, the diagnosis was made: “Associated injury, vertical unstable fracture of pelvic bones (61-C1.3 according to AO-ASIF [2]), a transforaminal fracture of sacrum to the left (Denis II [2]), a fracture of pubic and ischial bones to the left” (Fig. 1a). ISS was 13. The patient was stable. She received the immobilization with the pelvic splint.
Two days after admission, after closed correction of vertical displacement of the left side with lower extremity traction, the first stage was distant lumboiliac fixation of the vertical fracture with additional sacroiliac fixation with the full-threaded cannulated screw (Fig. 1b). Five days later, the final stabilization of the pelvic ring injury was realized by means of fixation of the left pubic bone (Fig. 1c).

Figure 1. The patient P., age of 45: a) MSCT-3D-reconstruction after injury; b) the X-ray image after the first surgery; c) the X-ray image after final surgical stabilization.

     



The postsurgical period was without complications. The patient was activated later. On the third day after surgery, she could stand and walk with crutches with limited support up to 15 % of body mass on the injured side. The patient was discharged on 17th day after admission.
One month after discharge, the patient could walk with the cane, after two months – without external support. She had not any complaints after 11 months, and resumed her work. The control X-ray image showed the correct position of the pelvic ring and the metal constructs. S.A. Majeed [13] score showed the good result – 97 points.

The clinical case 2

The patient Ch., age of 22, suffered after falling to her buttocks from the third floor. The examination resulted in the clinical diagnosis: “Associated injury, vertical unstable H-shaped bilateral transforaminal and transverse fracture of the sacrum (С3.3 according to АО-ASIF, Denis II, type II according to Roy-Camille [2]) (Fig. 2а, b) with traumatic stenosis of the sacral channel complicated by a sacral junction with cauda equina syndrome manifesting as decreasing skin sensitivity in the region of the perineum and the sacrum, absent tone of anal sphincter, disordered function of urinary bladder and rectum emptying in the form of incontinence”. According to ASIA, the injury to the pelvic junction was assessed as the type B [13]. ISS was 18 points. Immobilization with the pelvic splint was carried out at the moment of admission.
The surgery was conducted on the third day – laminectomy of the posterior wall of the sacral channel, widening the sacrum orifices and removal of Urban’s bone wedge for pelvic plexus decompression. A defect appeared in the supporting part of the sacrum after the injury and resection, with necessity for long term bed rest and crutch walking up to union. Distant lumboiliac fixation with additional bilateral transiliac introduction of full-threaded screws into S1 vertebra, and plate fixation of sacral fracture was performed (Fig. 2c).

Figure 2. The patient Ch., age of 22, at the moment of admission: a) MSCT in the coronary plain; b) MSCT-3D-reconstruction; c) the X-ray image after surgery.

     

The earlypostsurgical period was without complications. She could stand and walk with crutches on the fourth day. The load to the extremity was limited (15 % of body mass). Several days after surgery, the positive time trends in skin sensitivity in the sacral region, appearance of desire for urination and defecation, appearance of sphincter tone were noted. Before discharge, the neurological deficiency was as estimated as Type C.
The patient was discharged for outpatient treatment on the 15th day. She could walk without external support in three months after the injury. 7 months later, the control examination showed the recovered function of the pelvic organs, with slightly decreasing sensitivity in the perineal region (type E according ASIA). The patient resumed her professional activity. The control X-ray image showed the correct position of the pelvic ring and the metal constructs. The good long term functional outcome was observed – 94 points according to the score by S.A. Majeed [14].

CONCLUSION

Distant triangular lumboiliac fixation provides the primary stability of vertical unstable pelvic ring at the background of decreasing postsurgical pain (mean VAS = 3) and allows fast activation and rehabilitation of patients in short term postsurgical period. Rigid fixation provides the prevention of secondary displacement at the background of load, resulting in excellent and good results in 87 % of cases (according to the score by S.A. Majeed) and return the preinjury physical activity within 4-8 months.

Information about conflict of interests

The study was conducted without sponsorship. The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.

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