Preoperative CT Simulation of Iliosacral Screws for Treating Unstable Posterior Pelvic Ring Injury

BackgroundPercutaneous iliosacral screw placement is an important surgical method for the treatment of pelvic unstable fractures, but either intraoperative X-ray screws or navigational screws may be misplaced. This study aimed to demonstrate a safe, effective, and rapid medthod for placing iliosacral screws for the treatment of unstable posterior pelvic ring injury according to preoperative computed tomography (CT) planning using simulated screws. MethodsAfter preoperative CT simulation of iliosacral screws planning screw insertion point and trajectory, intraoperative percutaneous iliosacral screws were used to treat unstable pelvic posterior ring injury.The mechanism of injury, Tile classification, number of screw implants, operative time of each screw implantation, radiation exposure time of each screw implantation screw position, complications, and postoperative follow-up time were collected.Screw position grading was evaluated by Smith grading. ResultsA total of 24 screws were implanted in 21 patients (9 men and 12 women;mean age 41.3 years:range 14-71 years). Tile classification included:Tile B:15 patients;Tile C:6 patients. The mean placement time of each screw was 19.5 minutes (range 14-32min); Radiation exposure time: 0.6 min (range 0.5-0.9min); Two screws were inserted in 3 patients; One screw was inserted in 18 patients; According to Smith grading standard, grade0:20 cases; and Grade1:1 case; Mean postoperative follow-up time was 17.1months (range12-25 months); None of the patients showed nonunion. ConclusionsPreoperative CT simulation of iliosacral screws for placement planning, screw trajectory, and intraoperative placement of screws is a safe method that can be used to reduce surgical time, radiation exposure, and accurate screw placement.

Are Sarcopenia and Myosteatosis in Elderly Patients with Pelvic Ring Injury Related to Mortality, Physical Functioning and Quality of Life?

The purpose of this study was to evaluate the prevalence of sarcopenia and/or myosteatosis in elderly patients with pelvic ring injuries and their influence on mortality, patient-perceived physical functioning and quality of life (QoL). A multicenter retrospective cohort study was conducted including elderly patients aged ≥ 65 treated for a pelvic ring injury. Cross-sectional computed tomography (CT) muscle measurements were obtained to determine the presence of sarcopenia and/or myosteatosis. Kaplan–Meier analysis was used for survival analysis, and Cox proportional hazards regression analysis was used to determine risk factors for mortality. Patient-reported outcome measures for physical functioning (SMFA) and QoL (EQ-5D) were used. Multivariable linear regression analyses were used to determine the effect of sarcopenia and myosteatosis on patient-perceived physical functioning and QoL. Data to determine sarcopenia and myosteatosis were available for 199 patients, with a mean follow-up of 2.4 ± 2.2 years: 66 patients (33%) were diagnosed with sarcopenia and 65 (32%) with myosteatosis, while 30 of them (15%) had both. Mortality rates in patients at 1 and 3 years without sarcopenia and myosteatosis were 13% and 21%, compared to 11% and 36% in patients with sarcopenia, 17% and 31% in patients with myosteatosis and 27% and 43% in patients with both. Higher age at the time of injury and a higher Charlson Comorbidity Index (CCI) were independent risk factors for mortality. Patient-reported mental and emotional problems were significantly increased in patients with sarcopenia.

Does 3D-Assisted Operative Treatment of Pelvic Ring Injuries Improve Patient Outcome?—A Systematic Review of the Literature

Background: There has been an exponential growth in the use of advanced technologies for three-dimensional (3D) virtual pre- and intra-operative planning of pelvic ring injury surgery but potential benefits remain unclear. The purpose of this study was to evaluate differences in intra- and post-operative results between 3D and conventional (2D) surgery. Methods: A systematic review was performed including published studies between 1 January 2010 and 22 May 2020 on all available 3D techniques in pelvic ring injury surgery. Studies were assessed for their methodological quality according to the Modified McMaster Critical Review form. Differences in operation time, blood loss, fluoroscopy time, screw malposition rate, fracture reduction and functional outcome between 3D-assisted and conventional (2D) pelvic injury treatment were evaluated and a best-evidence synthesis was performed. Results: Eighteen studies fulfilled the inclusion criteria, evaluating a total of 988 patients. Overall quality was moderate. Regarding intra-operative results of 3D-assisted versus conventional surgery: The weighted mean operation time per screw was 43 min versus 52 min; for overall operation time 126 min versus 141 min; blood loss 275 ± 197 mL versus 549 ± 404 mL; fluoroscopy time 74 s versus 125 s and fluoroscopy frequency 29 ± 4 versus 63 ± 3. In terms of post-operative outcomes of 3D-assisted versus conventional surgery: weighted mean screw malposition rate was 8% versus 18%; quality of fracture reduction measured by the total excellent/good rate by Matta was 86% versus 82% and Majeed excellent/good rate 88% versus 83%. Conclusion: The 3D-assisted surgery technologies seem to have a positive effect on operation time, blood loss, fluoroscopy dose, time and frequency as well as accuracy of screw placement. No improvement in clinical outcome in terms of fracture reduction and functional outcome has been established so far. Due to a wide range of methodological quality and heterogeneity between the included studies, results should be interpreted with caution.

Treatment of unstable pelvic ring injury with a dual internal anterior subcutaneous fixator using spinal instrumentation called “dual INFIX”: A Case Report

Introduction: External fixation, various subcutaneous screw fixations, and plate fixation can be considered as fixation methods for unstable pelvic ring fractures. We describe a first case of treated unstable pelvic ring injury using a dual internal anterior subcutaneous fixator we called “dual INFIX,” comprising four screws, two subcutaneous rods, and two cross-link connectors, without posterior fixation. Case Report: An 81-year-old man sustained an unstable pelvic injury (AO type B2) with fracture of the left ilium and pubis. Dual INFIX was used to stabilize the pelvic ring injury. Polyaxial screws were introduced along a path between the anterior inferior iliac spine and ipsilateral posterior superior iliac spine until the head of the screw lay immediately above the fascia. Bilateral cranial screws were connected by a rod passed subcutaneously, and caudal screws were connected by the other rod. Finally, cross-link connectors connected cranial and caudal rods on the right and left. One year after the first operation, the patient could walk without a cane and had no limitation of daily living and bony fusion was achieved. Conclusion: The stability of the pelvic ring of dual INFIX was sufficient to achieve bony fusion in this case. The stability of dual INFIX should be stronger than that of INFIX. Dual INFIX as with INFIX has other advantages such as ease of management compared with external fixation, and nonnecessity of strict anatomical reduction compared with various percutaneous screw fixation. Furthermore, this technique is simple and minimally invasive compared with plate fixation because it does not require open surgery. However, because the type C fracture with an unacceptable position of reduction by closed reduction has the possibility to become a symptomatic malunion, such cases should not be treated by this method. Furthermore, it is necessary for pelvic stabilization using dual INFIX that the contralateral pelvis is intact because dual INFIX stabilizes