Treatment sequence of combined pelvic injury, consisted of upper pubic ramus fracture, sacroiliac joint dislocation with open book injury, using Stoppa approach

Background: The best operative management for open-book pelvic injury with anterior sacroiliac disruption (OTA/AO B1.1 classification) is still debated. This biomechanical study aimed to find the best internal fixation technique for such injury. Methods: Open-book injury with anterior sacroiliac joint disruption was simulated on 25 artificial pelvic bones. Twenty five artificial pelvic bones were divided into 5 groups (n=5 /group) and fixated with five different fixation techniques: 1). 1SP+1IS; 2). 2SP; 3). 2SP+2SIP; 4). 1SP+2IS S1, and 5). 1SP+1IS S1+S2. Biomechanical properties of each fixation technique were assessed using Tensilon® RTF-1310 to measure the resistance to translation and load to failure. Data were statistically analyzed using one-way ANOVA followed by post-hoc Bonferroni test.Results: The highest mean load to failure of axial forces (1490.36 N) was achieved by the fixation technique using one symphyseal plate and two iliosacral screws located at S1 dan S2. The addition of one iliosacral screw significantly increased the mean load to failure for axial compression (p<0.05).Conclusion: The addition of sacroiliac joint posterior fixation, either with plate or screw, will increase the fixation biomechanical strength. Single symphyseal plate and two iliosacral screws on S1 and S2 provided the best mechanical resistance to axial loading. Thus, it can be concluded that such fixation technique is best for open-book pelvic injury with anterior sacroiliac disruption.

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Surgical management of chronic pelvic instability following periacetabular osteotomy nonunion

Hip International ◽

10.1177/1120700020922202 ◽

2020 ◽

Vol 30 (6) ◽

pp. 787-792

Author(s):

Alexander D Shearman ◽

Aresh Hashemi-Nejad ◽

Marcus JK Bankes ◽

Angus D Lewis

Keyword(s):

Stress Fracture ◽

Soft Tissues ◽

Periacetabular Osteotomy ◽

Case Series ◽

Stress Fractures ◽

Pubic Ramus ◽

Ilioinguinal Approach ◽

Superior Pubic Ramus ◽

Stoppa Approach ◽

Pelvic Instability

Introduction: Periacetabular osteotomy (PAO) is an established treatment for symptomatic acetabular dysplasia in skeletally mature individuals without arthritis. Pelvic nonunion and associated stress fractures are under-reported. Nonunited stress fractures can cause continued buttock pain and pelvic instability. The aim of this study is to report on our experience managing patients with ongoing pain following nonunion of PAO. Patients and methods: 8 patients presented to a tertiary referral pelvic service with symptomatic PAO nonunion between 2015-2018. All patients underwent open reduction internal fixation of the superior pubic ramus nonunion, with ipsilateral iliac autograft, at an average of 48.1 (15–82) months following initial osteotomy. Demographic and perioperative data were recorded. Follow-up was on average to 9.9 months, once union was confirmed radiographically. Results: All patients were female and average age was 31.8 (18–41) years. In 7/8 (87.5%) patients a modified Stoppa approach was successfully utilised. 1 patient required an ilioinguinal approach due to the amount of rotational correction. All patients went on to union at the superior pubic ramus and reported improvement in mechanical symptoms. 5/8 (62.5%) patients were noted to develop union of the posterior column or inferior pubic ramus stress fracture indirectly. 2/8 (25%) patients developed progression of intra-articular pain, despite restoration of pelvic stability. 1 patient required intraoperative transfusion due to femoral vein injury. There were no other complications seen in this series. Conclusions: To our knowledge, this is the largest case series of surgically managed PAO nonunion. Pelvic instability resulting from nonunion and stress fracture can be satisfactorily addressed by mobilising, grafting and plating the nonunion at the superior pubic ramus. The modified Stoppa approach is suitable in most cases, allowing excellent exposure whilst minimising the insult to soft tissues. The altered anatomy of the pelvis following PAO should be anticipated to reduce the risk to nearby neurovascular structures.

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Biomechanical Stability of Primary and Revision Sacroiliac Joint Fusion Devices: A Cadaveric Study

Global Spine Journal ◽

10.1177/2192568220948028 ◽

2020 ◽

pp. 219256822094802

Author(s):

Jake Carbone ◽

Isaac Swink ◽

Thomas Muzzonigro ◽

Daniel Diehl ◽

Michael Oh ◽

...

Keyword(s):

Axial Compression ◽

Sacroiliac Joint ◽

Degrees Of Freedom ◽

Bone Ingrowth ◽

Translational Motion ◽

Pubic Symphysis ◽

Primary Treatment ◽

Titanium Implants ◽

Flexion Extension

Study Design: An in vitro biomechanics study. Objective: To evaluate the efficacy of triangular titanium implants in providing mechanical stabilization to a sacroiliac joint with primary and revision sized implants. Methods: Ten lumbopelvic cadaveric specimens were tested in 4 stages: intact, pubic symphysis sectioned, primary, and simulated revision. Primary treatment was performed using 3 laterally placed triangular titanium implants. To simulate revision conditions before and after bone ingrowth and ongrowth on the implants, 7.5-mm and 10.75-mm implants were randomly assigned to one side of each specimen during the simulated revision stage. A 6 degrees of freedom spinal loading frame was used to load specimens in 4 directions: flexion extension, lateral bending, axial torsion, and axial compression. Biomechanical evaluation was based on measures of sacroiliac joint rotational and translational motion. Results: Both primary and revision implants showed the ability to reduce translational motion to a level significantly lower than the intact condition when loaded in axial compression. Simulated revision conditions showed no statistically significant differences compared with the primary implant condition, with the exception of flexion-extension range of motion where motions associated with the revised condition were significantly lower. Comparison of rotational and translation motions associated with the 7.5- and 10.75-mm implants showed no significant differences between the treatment conditions. Conclusions: These results indicate that implantation of laterally placed triangular titanium implants significantly reduces the motion of a sacroiliac joint using either the primary and revision sized implants. No statistically significant differences were detected when comparing the efficacy of primary, 7.5-mm revision, or 10.75-mm revision implants.

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A biomechanics study about the mechanism of ligaments injury in anterior posterior compression type Ⅱ pelvic injury

10.21203/rs.3.rs-22184/v1 ◽

2020 ◽

Author(s):

xiaolong Shui ◽

Jianzhong kong ◽

Yupeng Chu ◽

Chengwei Zhou ◽

Shuaibo Sun ◽

...

Keyword(s):

Sacroiliac Joint ◽

Rotation Angle ◽

External Rotation ◽

Pubic Symphysis ◽

Separation Distance ◽

Pelvic Injury ◽

Control Group ◽

Sacrospinous Ligament ◽

Restricted Group ◽

Anterior Posterior

Abstract Background The anterior and posterior compression (APC) pelvis fracture is a classic pelvic injury, and APC type II is considered to be a typical one caused by the destruction of pelvic ligaments, while the mechanism of ligaments injury and treatment of which is still controversial. This study aims to explore ligaments injury in anterior posterior compression(APC)type II pelvic injury. Method: Fourteen human cadaveric pelvis samples (5 female, 9 male) with the sacrospinous, sacrotuberous, anterior sacroiliac ligaments and partial bone retaining unilaterally were made for this study. To simulate the APC pattern pelvic injury, the samples were divided into two groups randomly, set one group as hemipelvis restricted group (experimental group) and the other one as unrestricted group (control group). According to the biomechanical data, eye observation, motion capture system and real-time video system to record the separation distance of the pubic symphysis and anterior sacroiliac joint, external rotation angle and force when the anterior sacroiliac ligament ruptured. Continuing the external rotation violence, observing the bone and posterior ligaments change since sacrospinous and sacrotuberous ligaments from being damaged to completely ruptured. Result When anterior sacroiliac ligament failed, the mean separation distance of pubic symphysis and anterior sacroiliac joint between restricted group and unrestricted group was 28.6 ± 8.4 mm to 23.6 ± 8.2 mm(P = 0.11) and 11.4 ± 3.8 mm to 9.7 ± 3.9 mm (P = 0.30) respectively. In addition, the external rotation angle and force was 33.9 ± 5.5° to 48.9 ± 5.2°(P < 0.01) and 553.9 ± 82.6 N to 756.6 ± 41.4 N (P < 0.01) respectively. The two distances were not significantly different (P > 0.05), however, the external rotation angle and violence was significantly different (P < 0.05), which was bigger in the unrestricted group. In the unrestricted group, when anterior sacroiliac ligament ruptured, no distinct sacrospinous or sacrotuberous ligaments injury was observed, but in the restricted group, all of samples had two ligaments injury and even two samples had ligaments failed. Moreover, with the extreme external rotation violence continuing, there was still no sacrospinous or sacrotuberous ligaments injury in the unrestricted group. But interosseous sacroiliac ligament, posterior sacroiliac ligaments injury and slight sagittal rotation and sacroiliac joint displacement appeared. In the control group, the sacrospinous ligament ruptured firstly and then the sacrotuberous ligament ruptured. When both of the two ligaments failed, the interosseous sacroiliac ligament was damaged while posterior ligament was not. In the restricted group, when all of the anterior sacroiliac ligament, sacrospinous ligament or sacrotuberous ligament failed, mean separation distance of pubic symphysis and anterior sacroiliac joint increased significantly (from 28.6 ± 8.4 to 42.0 ± 7.6 mm, 11.4 ± 3.8 to 16.7 ± 4.2 mm respectively, all P < 0.05). Conclusion We have three main findings: First, pelvic external rotation injury can divide into two situations: hemipelvis is restricted and unrestricted, which result into two different outcomes. When anterior sacroiliac ligament rupture, the unrestricted group needs more external rotation angle and force, without obvious sacrotuberous or sacrospinous ligaments injury. But in the restricted group, both of two ligaments injury appear. Second, when anterior sacroiliac ligament fail, pubic symphysis displacement ranges from 14 to 40 mm, which has a high fluctuation. Third, when the anterior sacroiliac ligament is damaged, we dose not observe the inevitable destruction of the pelvic floor ligaments (sacrospinous ligament and sacrotubercular ligament).

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A biomechanics study on ligamentous injury in anterior posterior compression type II pelvic injury

10.21203/rs.3.rs-24176/v2 ◽

2020 ◽

Author(s):

jianzhong kong ◽

Yupeng Chu ◽

Chengwei Zhou ◽

shuaibo Sun ◽

guodong Bao ◽

...

Keyword(s):

Sacroiliac Joint ◽

Rotation Angle ◽

External Rotation ◽

Pubic Symphysis ◽

Pelvic Injury ◽

Pelvic Bone ◽

Type Ii ◽

Significant Difference ◽

Joint Separation ◽

Anterior Posterior

Abstract Background: Anterior posterior compression (APC) type II pelvis fracture is caused by the destruction of pelvic ligaments. This study aims to explore ligaments injury in APC type II pelvic injury.Method: Fourteen human cadaveric pelvis samples with sacrospinous ligament (SPL), sacrotuberous ligament (SBL), anterior sacroiliac ligament (ASL), and partial bone retaining unilaterally were acquired for this study. They were randomly divided into hemipelvis restricted and unrestricted groups. We recorded the separation distance of the pubic symphysis and anterior sacroiliac joint, external rotation angle, and force when ASL ruptured. We observed the external rotation damage to the pelvic bone and ligaments.Result: When ASL failed, there was no significant difference in pubic symphysis separation (28.6 ± 8.4 mm to 23.6 ± 8.2 mm, P = 0.11) and anterior sacroiliac joint separation (11.4 ± 3.8 mm to 9.7 ± 3.9 mm, P = 0.30) between restricted and unrestricted groups. The external rotation angle (33.9 ± 5.5° to 48.9 ± 5.2°, P < 0.01) and force (553.9 ± 82.6 N to 756.6 ± 41.4 N, P < 0.01) were significantly different. Pubic symphysis separation between two groups ranged from 14 mm to 40 mm. In the restricted group, both SBL and SPL were injured. SPL ruptured first, and then SBL and the interosseous sacroiliac ligament were damaged while the posterior ligament remained unharmed. In the unrestricted group, interosseous sacroiliac ligament and posterior sacroiliac ligaments were damaged, while SBL and SPL were not. When the ASL, SBL, and SPL all failed, pubic symphysis and anterior sacroiliac joint separation between two groups increased significantly (from 28.6 ± 8.4 to 42.0 ± 7.6 mm, 11.4 ± 3.8 to 16.7 ± 4.2 mm respectively, all P < 0.05).Conclusion: Pelvic external rotation injury is either hemipelvic restricted or unrestricted, which can result in different outcomes. When the ASL ruptures, the unrestricted group needs greater external rotation angle and force, without SBL or SPL injury, while both SBL and SPL were injured in another group. When ASL fails in two groups, pubic symphysis separation fluctuates considerably. Finally, when the ASL ruptures, SBL and SPL may be undamaged.

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A biomechanics study about ligaments injury in anterior posterior compression type Ⅱ pelvic injury

10.21203/rs.3.rs-24176/v1 ◽

2020 ◽

Author(s):

jianzhong kong ◽

Yupeng Chu ◽

Chengwei Zhou ◽

shuaibo Sun ◽

guodong Bao ◽

...

Keyword(s):

Sacroiliac Joint ◽

Rotation Angle ◽

External Rotation ◽

Pubic Symphysis ◽

Separation Distance ◽

Pelvic Injury ◽

Type Ii ◽

Pelvis Fracture ◽

Restricted Group ◽

Anterior Posterior

Abstract Background Anterior posterior compression(APC)type II pelvis fracture is considered to be a typical one caused by the destruction of pelvic ligaments, while the mechanism of ligaments injury is still controversial. This study aims to explore ligaments injury in APC type II pelvic injury. Method: Fourteen human cadaveric pelvis samples with sacrospinous ligament (SPL), sacrotuberous ligament (SBL), anterior sacroiliac ligament (ASL) and partial bone retaining unilaterally were made for this study. They were divided into hemipelvis restricted group and unrestricted group randomly. Record the separation distance of pubic symphysis and anterior sacroiliac joint, external rotation angle and force when the ASL ruptured. Continuing external rotation violence, observing bone and pelvic ligaments change. Result When ASL failed, there were no significant differences in mean separation distance of pubic symphysis (28.6 ± 8.4 mm to 23.6 ± 8.2 mm,P = 0.11) and anterior sacroiliac joint (11.4 ± 3.8 mm to 9.7 ± 3.9 mm ,P = 0.30) between restricted group and unrestricted group, but external rotation angle(33.9 ± 5.5° to 48.9 ± 5.2°,P < 0.01) and force(553.9 ± 82.6 N to 756.6 ± 41.4 N,P < 0.01) were not. In restricted group, both of SAL and SPL injury occurred, which was different in unrestricted group. Besides, separation distance of pubic symphysis between two groups ranged from 14 mm to 40 mm. With external rotation violence continuing, SPL ruptured firstly, then SBL ruptured and the interosseous sacroiliac ligament was damaged while posterior ligament was not; in another group, interosseous sacroiliac ligament, posterior sacroiliac ligaments were damaged while SAC and SPL were not. When all of ASL, SBL, SPL failed, mean separation distance of pubic symphysis and anterior sacroiliac joint between two groups increased significantly (from 28.6 ± 8.4 to 42.0 ± 7.6 mm, 11.4 ± 3.8 to 16.7 ± 4.2 mm respectively, all P < 0.05). Conclusion First, pelvic external rotation injury can divide into hemipelvis is restricted and unrestricted, which result into different outcomes; When ASL ruptures, the unrestricted group needs more external rotation angle and force, without SBL or SPL injury. But in restricted group, both of two ligaments are injured. Second, when ASL fails, pubic symphysis displacement has a high fluctuation. Third, ASL rupture does not mean SBL and SPL are injured inevitably.

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BIOMECHANICAL FIXATION STRENGTH COMPARISON OF ILIOINGUNIAL AND MEDIAL STOPPA APPROACHES ON ANTERIOR COLUMN FRACTURES

Journal of Mechanics in Medicine and Biology ◽

10.1142/s0219519416500810 ◽

2016 ◽

Vol 16 (06) ◽

pp. 1650081 ◽

Cited By ~ 2

Author(s):

BURKAY KUTLUHAN KAÇIRA ◽

MUSTAFA ÖZKAYA ◽

UYGAR KIRAN ◽

FAIK TÜRKMEN ◽

MEHMET ARAZI ◽

...

Keyword(s):

Compression Test ◽

Pubic Symphysis ◽

Treated Group ◽

Anterior Column ◽

Fixation Strength ◽

Control Group ◽

Ilioinguinal Approach ◽

Test Models ◽

Stoppa Approach ◽

Treatment Control Group

Background: Both the ilioinguinal and Stoppa approaches have been used as standard methods for treating anterior column fractures of the pelvis. Objective: We aimed to compare the rigidity of pelvises that were treated using these two approaches. Methods: Fifteen synthetic pelvises were used as test models. Of these, 5 pelvises did not undergo any treatment (control group), and 10 pelvises underwent treatment of one column using the ilioinguinal approach and the other using the medial Stoppa approach (treated group). The compression test was performed on all pelvises, and rigidity of the pelvises was compared between the control and treated groups. Results: A statistical difference was found in the angle between the center of the femoral head and the line from the pubic symphysis to load application between the control and treated groups, using the ilioinguinal approach. The parametric displacement was greater in the treated group using the ilioinguinal approach than in the control group. There were no significant differences between the control and treated groups using the Stoppa approach, and the ilioinguinal approaches. Conclusion: Clinically, the Stoppa approach has several advantages over the ilioinguinal approach. However, based on the compression test, there was no difference in biomechanical rigidity between the fixations performed using these two approaches.

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A biomechanics study on ligamentous injury in anterior posterior compression type II pelvic injury

10.21203/rs.3.rs-24176/v3 ◽

2020 ◽

Author(s):

Jianzhong Kong ◽

Yupeng Chu ◽

Chengwei Zhou ◽

Shuaibo Sun ◽

Guodong Bao ◽

...

Keyword(s):

Sacroiliac Joint ◽

Rotation Angle ◽

External Rotation ◽

Pubic Symphysis ◽

Pelvic Injury ◽

Pelvic Bone ◽

Type Ii ◽

Significant Difference ◽

Joint Separation ◽

Anterior Posterior

Abstract Background: Anterior posterior compression (APC) type II pelvis fracture is caused by the destruction of pelvic ligaments. This study aims to explore ligaments injury in APC type II pelvic injury.Method: Fourteen human cadaveric pelvis samples with sacrospinous ligament (SPL), sacrotuberous ligament (SBL), anterior sacroiliac ligament (ASL), and partial bone retaining unilaterally were acquired for this study. They were randomly divided into hemipelvis restricted and unrestricted groups. We recorded the separation distance of the pubic symphysis and anterior sacroiliac joint, external rotation angle, and force when ASL ruptured. We observed the external rotation damage to the pelvic bone and ligaments.Result: When ASL failed, there was no significant difference in pubic symphysis separation (28.6 ± 8.4 mm to 23.6 ± 8.2 mm, P = 0.11) and anterior sacroiliac joint separation (11.4 ± 3.8 mm to 9.7 ± 3.9 mm, P = 0.30) between restricted and unrestricted groups. The external rotation angle (33.9 ± 5.5° to 48.9 ± 5.2°, P < 0.01) and force (553.9 ± 82.6 N to 756.6 ± 41.4 N, P < 0.01) were significantly different. Pubic symphysis separation between two groups ranged from 14 mm to 40 mm. In the restricted group, both SBL and SPL were injured. SPL ruptured first, and then SBL and the interosseous sacroiliac ligament were damaged while the posterior ligament remained unharmed. In the unrestricted group, interosseous sacroiliac ligament and posterior sacroiliac ligaments were damaged, while SBL and SPL were not. When the ASL, SBL, and SPL all failed, pubic symphysis and anterior sacroiliac joint separation between two groups increased significantly (from 28.6 ± 8.4 to 42.0 ± 7.6 mm, 11.4 ± 3.8 to 16.7 ± 4.2 mm respectively, all P < 0.05).Conclusion: Pelvic external rotation injury is either hemipelvic restricted or unrestricted, which can result in different outcomes. When the ASL ruptures, the unrestricted group needs greater external rotation angle and force, without SBL or SPL injury, while both SBL and SPL were injured in another group. When ASL fails in two groups, pubic symphysis separation fluctuates considerably. Finally, when the ASL ruptures, SBL and SPL may be undamaged.

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Management of Complex Pelvic Fracture with Associated Both Column Acetabular Fracture Judet-Letournel Type and a Coccygeal Fracture in a Severe Polytrauma Patient

Case Reports in Orthopedic Research ◽

10.1159/000515563 ◽

2021 ◽

pp. 192-201

Author(s):

Jessica Fiolin ◽

Ludwig Andre Powantia Pontoh ◽

Ismail Hadisoebroto Dilogo

Keyword(s):

Pelvic Fracture ◽

Hypovolemic Shock ◽

Stable Condition ◽

Acetabular Fractures ◽

Advanced Technique ◽

Operative Strategy ◽

Ilioinguinal Approach ◽

Outcome Score ◽

Satisfactory Outcome ◽

Sacroiliac Joint Disruption

Comprehensive emergency managements and early stabilization are pivotal upon treating complex pelvic and acetabular fractures. A thorough operative strategy is required to determine the best operative approach based on the patient’s general condition, available facilities, and surgeon preferences in such complex fracture configuration. Advanced technique of the fixation is necessary during a skillful execution of surgery in order to achieve good treatment results. An 18-years-old female crushed by a bus upon crossing street, presented with hypovolemic shock with ISS polytrauma score 50 consisting of right acetabular associated both column fracture, bilateral pelvic fracture anteroposterior compression type 3, and coccygeal fracture with bilateral drop foot. She underwent emergency laparotomy, had her ovary, bladder, and intestine primarily sutured, and then we immobilized the pelvic using anterior frame external fixator, which was maintained for 6 days. Upon stable condition, we performed right ilioinguinal approach and modified Stoppa with lateral window for the left side, while Kocher-Langenbeck technique was used to approach the posterior acetabular column. Postoperative radiology showed an adequate internal fixation in both right acetabular columns, successful reconstruction of pelvic ring which was fixated the left ischium, left superior and inferior pubic rami, and full restoration of left sacroiliac joint disruption. Majeed pelvic outcome score was 54, while Hannover pelvic outcome score was good and the patient was able to sit without pain 2 months postoperative. Management of complex pelvic-acetabular-coccygeal fracture requires a holistic chain of treatment by emphasizing the prompt emergency management, accurate preoperative planning, and excellent execution of reconstructive surgical strategy to achieve satisfactory outcome.

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