Kyle F. Dickson, M.D. M.B.A. Professor Baylor College of Medicine Southwest Orthopaedic Group, Houston, Texas

ORIF of the Iliosacral Joint Kyle Dickson MD, MBA Professor Baylor College of Medicine Southwest Orthopaedic Group, Houston Texas

Conclusion Most SI joint disruptions require ORIF with iliosacral screws Start from the back (SI) and then move forward (acetabulum then symphysis) Check skin

LQ 33 yo MVA In shock, >500 lbs Bilateral SI instability R transtectal Tr PW and L infratectal Symphyseal disruption

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External fixation is a resuscitative fixation and cannot be used as the definitive fixation in completely unstable pelvic injuries

Incision Midline vs. pfannenstiel Leave rectus attachment Single 6 hole or 4 hole plate

Techniques Pubic Ramus Fractures ORIF if distracted over 1.5 cm Or significantly rotated to impinge on vaginal vault, bladder, or rectum (‘tilt fracture’)

Techniques Pubic Ramus Fractures Rarely repaired in Bucholz type II fractures Matta series-over 84 percent treated nonoperatively, even in unstable injuries treated posteriorly (Bucholz III or Tile C)

Incision Anterior vs. posterior Start from the back and work forward

Kellam, Ortho Clin NA 1987 25% infection rate with posterior exposure

Leighton, Clin Orthop 1996 30% injury to lateral femoral cutaneous nerve 50% symptoms after 1 year

Anterior Approach Drape leg free Lateral iliac wing Gentle retraction on LFCN Use free leg for exposure and reduction

Techniques Supine position-Anterior Approach Fixation involves anterior plating, using recon-type plates or dynamic compression plates placed at 90° to each other (at least three hole plate with one screw into the sacrum) M Tile in Schatzker, Tile (eds). Rationale of Operative Fracture Care, Springer, Berlin, 1996, p221-270

Anterior Approach Benefits Relative Better visualization of joint Multiple trauma Approach SI joint and symphysis

Anterior Approach Benefits Absolute Posterior crush injury Multiple trauma Iliac wing fracture (anterior to SI joint) dislocation

Anterior Approach Problems Posterior displacement (clamp reduction) Sacral fractures Nerve injury (sacral foramina & L5) Lateral femoral cutaneous nerve lesion

Posterior Approach Assesses soft tissue Bump under thighs and prep both iliac crests Gluteus maximum flap Distal to proximal exposure of sciatic notch

Matta, Surgical Approaches to the Acetabulum

Surgical approach 1 cm lateral to PSIS Elevate subcutaneous fat from gluteus fascia to midline Detach gluteus from midline origin as a muscular flap Thoracolumbar fascia Gluteus maximus

Surgical approach Incise fascia/ligaments along sacral border of greater sciatic notch Piriformis

Surgical approach Elevate piriformis anteriorly from sacral attachment

Posterior Approach Benefits Relative Widely displaced hemipelvis Time delay Posterior displaced hemipelvis Type of fixation 

Posterior Approach Benefits Absolute Sacral fracture or sacral fracture/dislocations Iliac wing fracture/dislocations (crescent) Decompression of nerve injuries

Techniques Posterior reduction techniques (Matta and Tornetta) A pointed reduction clamp is placed with one point on the anterior sacral ala lateral to the S1 foramen and the other placed on the outer ilium. A Weber clamp can be used for cephalad displacement

Reduction techniques Difficult to reduce sacral fractures Secondary reduction (reduce anterior ring) Traction “joy stick” manipulation Weber – spinous process to posterior superior iliac spine

Reduction technique Carefully slide long angled Matta clamp along finger to contralateral side of S1 body

Reduction Technique Clamp to ipsilateral PSIS Reduces AP displacement

Reduction Technique Weber pointed reduction clamp from sacral spine to PSIS Reduces medial-lateral and vertical displacement

Reduction Technique Final Clamp combination

Matta and Tornetta, CORR 329, pp129-140, 1996

Techniques Reduction of the posterior ring injury can be aided by initial reduction and plating of the anterior ring injury (if anterior injury is a symphysis disruption) Reduction for rotational and vertical displacement an anchoring plate with a Jungbluth (AO) reduction clamp can be effective for anterior reductions prior to symphyseal plating

Matta and Tornetta, CORR 329, pp129-140, 1996

Posterior Fixation Depends on the Fracture Pattern

Techniques Posterior fixation Single or multiple iliosacral screws can be placed (2 preferred with threads into S1 superior portion) An anatomic ‘safe zone’ has been established

Techniques - Sacral Fixation Between the S1 foramen and the superior margin of the ala on the 40 degree cephalic (outlet) view Between the neural canal and the anterior margin of the body on the 40 degree caudad (inlet) view from Matta JM, Saucedo T: Clin Orthop 242:83, 1989; original by Zilbert

Several structures can be at risk during surgical fixation Hardware Placement Take Care To Avoid Injury to Neurovascular Structures Several structures can be at risk during surgical fixation L5/S1 nerve roots, sacral canal, branches of the internal iliac system.

Iatrogenic Neurological Injury >2000 iliosacral screws with one iatrogenic nerve injury Ensured screw was safe by CT and prayed Complete resolution of nerve palsy

Use of Short Thread 6.5mm Screws Screws break at the thread shank interval. This moves this interval as far as possible from fracture site. Compression comes from the clamps for reduction not the screws

Percutaneous Iliosacral Screw Non or minimally displaced fractures do not need to be fixed Closed reduction difficult and must be done ASAP-iliosacral screws difficult or impossible without reduction Canulated screws-guide pin without tactile sensation and bends

Vertical Shear

Letournel’s Principle “Start at the Back and Move Forward”

Caveat – few Degrees of rotation can translate into 2 cm of displacement

Percutaneous L.F.B. (Louisiana Fat Boy) vs ORIF 11 – 50% failure of sacral fractures (transsacral fixation) 0% ORIF (Dickson 2010)

Indications For ORIF Failure of closed reduction (SI joint, fractures of the iliac wing, > 5 days from injury)

Complication of Injury Pain Deformity Soft-tissue degloving lesions Neurologic injury Impotence

Complications of Treatment Infection Neurologic Injury Loss of reduction

Prevention of Complications Recognize soft-tissue injury Avoid incisions through compromised tissue Use appropriate fixation for the injury Use care when placing implants

Materials and Methods Retrospective review senior author’s (K.F.D.) series November 1996 through March 2002 131 surgically treated pelvic ring injuries Single hospital (TUHSC), single surgeon 98 pelvic ring injuries treated at TUHSC 39 sacral fractures (39.8%)

Results Average duration of follow-up 3.7 years Range 16 to 81 months Radiographic follow-up on 20/20 at 1-7 years 19/20 completed follow-up Interval history and physical exam Iowa Pelvic Score questionnaire

Results All fractures united No infections No additional surgeries No infections No iatrogenic neurologic or vascular injuries

Results: Complications 1 hardware failure: 1 broken and 1 loosened screw B.D.: 24 y.o. male snowboarding accident 6 years post-op no refracture no displacement no pain

Matta & Tornetta, Clin Orthop 1994 60% excellent reductions (< 4 mm) 29% good reductions ( 4 mm – 1 cm) 95% total good to excellent reductions

Results: Radiographic 14.72 (mm) displacement 3.25 2.42 (AP only)

Results: Radiographic Rating of reduction (Matta and Tornetta, CORR Number 329, August 1996: 129-140) Excellent: 17 (85%) 4 mm or less Good: 2 (10%) 5 to 10 mm Fair: 1 (5%) 10 to 20 mm Poor: 0 (0%) > 20 mm One patient (“excellent”) displaced 2mm at long term follow-up = “good” rating 95% good to excellent reductions

Results: Neurologic 6/19 (31.6%) with neurologic residua Sensory 6 Motor 2 10.5% Bowel Bladder 3 15.8%

Results: Sexual Dysfunction 5/19 (26.3%) with sexual dysfunction 1/11 (9.1%) females with dyspareunia 3/9 (33.3%) males with erectile dysfunction

Results: IPS Iowa Pelvic Score: Max score 100 19/20 Completed scores ADLs (20) work history (20) pain (25) limp (20) pain VAS (10) cosmesis (5) Max score 100 19/20 Completed scores Range 58-100 Average 92.2

Results: Pain 13 (68.4%) report no pain 6 (31.6%) report pain Average 2.67 (range 2 to 4) on VAS

Results: Work/Activity 13 work/activity full time, no change (72.2%) 3 work/activity full time, changed jobs (16.7%) 2 cannot work (11.1%) 1 never worked 88.9% full time work/activity

1 year post-op M.G.: 21 y.o. male BMX freestyle semi-pro Left sacral fracture with pubic symphysis diastasis DOS: Oct 1, 2000

Deformaties Cephalad translation most common Posterior translation, internal rotation, flexion common Equal number of abduction and adduction injuries

Semba 1983 Long term follow up < 1 cm displacement: asymptomatic > 1 cm displacement: 60% moderate to severe back pain

Outcomes The most common outcome is residual pain The most significant influence on outcome was neurologic injury

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Conclusion Most SI joint disruptions require ORIF with iliosacral screws Start from the back (SI) and then move forward (acetabulum then symphysis) Check skin

Thank You