Treatment of unstable pelvic fractures by cannulated screw internal fixation with the assistance of three-dimensional printing insertion template_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YANG Hongqi ¹ ,  LEI Qing ¹ , CAI Lihong ² , LIU Feng ¹ , ZHOU Weili ¹ , CHEN Song ¹ , CHEN Li ¹ , LIU Tangyou ¹ , JIANG Minghui ¹ , WANG Kang ¹ , XIAO Sishun ¹ , LIU Wenqian ¹

1. Department of Orthopedics, the 3rd Hospital of Changsha, Changsha Hunan, 410015, P.R.China;
2. Department of Radiology, the 3rd Hospital of Changsha, 3D Printing Institute for Medical Application of Changsha, Changsha Hunan, 410015, P.R.China;

Corresponding author：

LEI Qing, Email: 13077309988@139.com

Keywords：

Unstable pelvic fracture; three-dimensional printing technology; insertion template; internal fixation

DOI：

10.7507/1002-1892.201708059

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ObjectiveTo evaluate the effectiveness of unstable pelvic fractures treated by cannulated screw internal fixation with the assistance of three-dimensional (3D) printing insertion template.MethodsThe clinical data of 10 patients who underwent surgical treatment for unstable pelvic fractures by cannulated screw internal fixation with the assistance of 3D printing insertion template between May 2015 and June 2016 were retrospectively analysed. There were 7 males and 3 females with an average age of 37.5 years (range, 20-58 years). The causes of injury included falling from height in 5 cases, crushing from heavy load in 1 case, and traffic accidents in 4 cases. The interval from injury to admission was 1-5 hours (mean, 3.1 hours). The fracture situation included 6 cases of sacral fracture, 1 case of right sacroiliac joint dislocation, and 3 cases of iliac bone fracture. There were 10 cases of superior and inferior pubic rami fracture, including 3 cases on the left side (2 cases of suprapubic fracture adjacent to symphysis pubis), 2 cases on the right side, and 5 cases on the bilateral. All fractures were classified according to the Tile system, there were 4 cases of type B2, 1 of type B3, 4 of type C1, and 1 of type C2. The radiological outcome was evaluated by Matta scale, and the positions of the iliosacral screw and superior pubic ramus screw were evaluated according to 3D reconstruction of CT postoperatively. The functional outcome was evaluated by Majeed function scale.ResultsThe average time of each screw implantation was 30 minutes, and the average blood loss per screw incision was 50 mL. The time of implantation of each sacroiliac screw was 24-96 seconds (mean, 62 seconds), and the time of implantation of each suprapubic screw was 42-80 seconds (mean, 63.2 seconds). The hospitalization duration was 17-90 days (mean, 43.7 days). All incisions healed by first intention. All patients were followed up 12-22 months (mean, 15.6 months). The radiological outcome was excellent in 8 cases and good in 2 cases according to Matta scale; and 3D reconstruction of CT demonstrated that all the 9 iliosacral screws were placed as type Ⅰ, and all the 13 suprapubic ramus screws were placed as grade 0 on the first postoperative day. No complication such as neurovascular injury, screw back out or rupture, or secondary fracture displacement was observed during the follow-up. At 6 months after operation, the X-ray films showed good fracture healing in all the 10 patients. The functional outcome was excellent in 9 cases and good in 1 case according to Majeed scale at 1 year after operation. One patient sustained Tile C2 pelvic disruption complicated with L₅ nerve root injury achieved complete nervous functional recovery at last follow-up.ConclusionIt has advantages of precise screw insertion and lower risk of neurovascular injury to treat unstable pelvic fractures by cannulated screw internal fixation with the assistance of 3D printing insertion template, which can be a good alternative for the treatment of unstable pelvic fractures.

Citation： YANG Hongqi, LEI Qing, CAI Lihong, LIU Feng, ZHOU Weili, CHEN Song, CHEN Li, LIU Tangyou, JIANG Minghui, WANG Kang, XIAO Sishun, LIU Wenqian. Treatment of unstable pelvic fractures by cannulated screw internal fixation with the assistance of three-dimensional printing insertion template. Chinese Journal of Reparative and Reconstructive Surgery, 2018, 32(2): 145-151. doi: 10.7507/1002-1892.201708059 Copy

1.	Routt ML Jr, Meier MC, Kregor PJ, et al. Percutaneous iliosacral screws with the patient supine technique. Oper Tech Orthop, 1993, 3(1): 35-45.
2.	Routt ML Jr, Simonian PT, Grujic L. The retrograde medullary superior pubic ramus screw for the treatment of anterior pelvic ring disruptions: a new technique. J Orthop Trauma, 1995, 9(1): 35-44.
3.	Matta JM, Dickson KF, Markovich GD.Surgical treatment of pelvic nonunions and malunions.Clin Orthop Relat Res, 1996, (329): 199-206.
4.	Gras F, Marintschev I, Wilharm A, et al. 2D-fluoroscopic navigated percutaneous screw fixation of pelvic ring injuries-a case series. BMC Musculoskelet Disord, 2010, 11:153.
5.	Smith HE, Yuan PS, Sasso R, et al. An evaluation of image-guided technologies in the placement of percutaneous iliosacral screws. Spine (Phila Pa 1976), 2006, 31(2): 234-238.
6.	Majeed SA.Grading the outcome of pelvic fractures. J Bone Joint Surg(Br), 1989, 71(2): 304-306.
7.	Suzuki T, Hak DJ, Ziran BH, et al. Outcome and complications of posterior transiliac plating for vertically unstablesacral fractures. Injury, 2009, 40(4): 405-409.
8.	Routt Jr ML, Kregor PJ, Simonian PT, et al. Early results of percutaneous iliosacral screws placed with the patient in the supine position. J Orthop Trauma, 1995, 9(3): 207-214.
9.	Hinsche AF, Giannoudis PV, Smith RM. Fluoroscopy-based multiplanar image guidance for insertion of sacroiliac screws. Clin Orthop Relat Res, 2002, (395): 135-144.
10.	Rampersaud R, Foley KT, Shen AC, et al. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine (Phila Pa 1976), 2000, 25: 2637-2645.
11.	van den Bosch EW, van Zwienen CM, van Vugt AB. Fluoroscopic positioning of sacroiliac screws in 88 patients. J Trauma, 2002, 53(1): 44-48.
12.	Zwingmann J, Konrad G, Kotter E,et al. Computer-navigated iliosacral screw insertion reduces malposition rate and radiation exposure. Clin Orthop Relat Res, 2009, 467(7): 1833-1838.
13.	Conflitti JM, Graves ML, Chip Routt ML Jr. Radiographic quantification and analysis of dysmorphic upper sacral osseous anatomy and associated iliosacral screw insertions. J Orthop Trauma, 2010, 24(10): 630-636.
14.	Mendel T, Appelt K, Kuhn P, et al. Bony sacroiliac corridor. A virtual volume model for the accurate insertion of transarticular screws. Unfallchir Surg, 2008, 111(1): 19-26.
15.	Gardner MJ, Routt ML Jr. Transiliac-transsacral screws for posterior pelvic stabilization. J Orthop Trauma, 2011, 25(6): 378-384.
16.	Vaidya R, Colen R, Vigdorchik J, et al. Treatment of unstable pelvic ring injuries with an internal anterior fixator and posterior fixation: initial clinical series. J Orthop Trauma, 2012, 26(1): 1-8.
17.	Hiesterman TG, Hill BW, Cole PA.Surgicaltechnique: a percutaneous method of subcutaneous fixation for the anterior pelvic ring: the pelvic bridge. Clin Orthop Relat Res, 2012, 470(8): 2116-2123.
18.	Oh HK, Choo SK, Kim JJ, et al. Stoppa Approach for Anterior Plate Fixation in Unstable Pelvic Ring Injury. Clin Orthop Surg, 2016, 8(3): 243-248.
19.	Winkelhagen J, van den Bekerom MP, Bolhuis HW, et al. Preliminary results of cannulated screw fixation for isolated pubic ramus fractures. Strategies Trauma Limb Reconstr, 2012, 7(2): 87-91.
20.	Grossterlinde L, Nuechter J, Begemann PG, et al. Computer-assisted surgery and intraoperative three-dimensional imaging for screw placement in different pelvic regions. J Trauma, 2011, 71(4): 926-932.
21.	Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res, 2000, (375): 15-29.
22.	Kaneyama S, Sugawara T, Sumi M. Safe and accurate midcervical pedicle screw insertion procedure with the patient-specific screw guide template system. Spine (Phila Pa 1976), 2015, 40(6): E341-348.

1. Routt ML Jr, Meier MC, Kregor PJ, et al. Percutaneous iliosacral screws with the patient supine technique. Oper Tech Orthop, 1993, 3(1): 35-45.
2. Routt ML Jr, Simonian PT, Grujic L. The retrograde medullary superior pubic ramus screw for the treatment of anterior pelvic ring disruptions: a new technique. J Orthop Trauma, 1995, 9(1): 35-44.
3. Matta JM, Dickson KF, Markovich GD.Surgical treatment of pelvic nonunions and malunions.Clin Orthop Relat Res, 1996, (329): 199-206.
4. Gras F, Marintschev I, Wilharm A, et al. 2D-fluoroscopic navigated percutaneous screw fixation of pelvic ring injuries-a case series. BMC Musculoskelet Disord, 2010, 11:153.
5. Smith HE, Yuan PS, Sasso R, et al. An evaluation of image-guided technologies in the placement of percutaneous iliosacral screws. Spine (Phila Pa 1976), 2006, 31(2): 234-238.
6. Majeed SA.Grading the outcome of pelvic fractures. J Bone Joint Surg(Br), 1989, 71(2): 304-306.
7. Suzuki T, Hak DJ, Ziran BH, et al. Outcome and complications of posterior transiliac plating for vertically unstablesacral fractures. Injury, 2009, 40(4): 405-409.
8. Routt Jr ML, Kregor PJ, Simonian PT, et al. Early results of percutaneous iliosacral screws placed with the patient in the supine position. J Orthop Trauma, 1995, 9(3): 207-214.
9. Hinsche AF, Giannoudis PV, Smith RM. Fluoroscopy-based multiplanar image guidance for insertion of sacroiliac screws. Clin Orthop Relat Res, 2002, (395): 135-144.
10. Rampersaud R, Foley KT, Shen AC, et al. Radiation exposure to the spine surgeon during fluoroscopically assisted pedicle screw insertion. Spine (Phila Pa 1976), 2000, 25: 2637-2645.
11. van den Bosch EW, van Zwienen CM, van Vugt AB. Fluoroscopic positioning of sacroiliac screws in 88 patients. J Trauma, 2002, 53(1): 44-48.
12. Zwingmann J, Konrad G, Kotter E,et al. Computer-navigated iliosacral screw insertion reduces malposition rate and radiation exposure. Clin Orthop Relat Res, 2009, 467(7): 1833-1838.
13. Conflitti JM, Graves ML, Chip Routt ML Jr. Radiographic quantification and analysis of dysmorphic upper sacral osseous anatomy and associated iliosacral screw insertions. J Orthop Trauma, 2010, 24(10): 630-636.
14. Mendel T, Appelt K, Kuhn P, et al. Bony sacroiliac corridor. A virtual volume model for the accurate insertion of transarticular screws. Unfallchir Surg, 2008, 111(1): 19-26.
15. Gardner MJ, Routt ML Jr. Transiliac-transsacral screws for posterior pelvic stabilization. J Orthop Trauma, 2011, 25(6): 378-384.
16. Vaidya R, Colen R, Vigdorchik J, et al. Treatment of unstable pelvic ring injuries with an internal anterior fixator and posterior fixation: initial clinical series. J Orthop Trauma, 2012, 26(1): 1-8.
17. Hiesterman TG, Hill BW, Cole PA.Surgicaltechnique: a percutaneous method of subcutaneous fixation for the anterior pelvic ring: the pelvic bridge. Clin Orthop Relat Res, 2012, 470(8): 2116-2123.
18. Oh HK, Choo SK, Kim JJ, et al. Stoppa Approach for Anterior Plate Fixation in Unstable Pelvic Ring Injury. Clin Orthop Surg, 2016, 8(3): 243-248.
19. Winkelhagen J, van den Bekerom MP, Bolhuis HW, et al. Preliminary results of cannulated screw fixation for isolated pubic ramus fractures. Strategies Trauma Limb Reconstr, 2012, 7(2): 87-91.
20. Grossterlinde L, Nuechter J, Begemann PG, et al. Computer-assisted surgery and intraoperative three-dimensional imaging for screw placement in different pelvic regions. J Trauma, 2011, 71(4): 926-932.
21. Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clin Orthop Relat Res, 2000, (375): 15-29.
22. Kaneyama S, Sugawara T, Sumi M. Safe and accurate midcervical pedicle screw insertion procedure with the patient-specific screw guide template system. Spine (Phila Pa 1976), 2015, 40(6): E341-348.

Chinese Journal of Reparative and Reconstructive Surgery

Treatment of unstable pelvic fractures by cannulated screw internal fixation with the assistance of three-dimensional printing insertion template

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