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

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

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

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

5. LQ

6. LQ

7. LQ

8. LQ

9. LQ

10. LQ

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

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

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

32. 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)

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

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

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

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

41. 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, p

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

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

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

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

47. Matta, Surgical Approaches to the Acetabulum

49. 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

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

51. Surgical approach
Elevate piriformis anteriorly from sacral attachment

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

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

54. 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

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

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

57. Reduction Technique
Clamp to ipsilateral PSIS
Reduces AP displacement

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

59. Reduction Technique
Final Clamp combination

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

62. 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

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

64. Posterior Fixation Depends on the Fracture Pattern

69. 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

70. 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

72. 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.

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

74. 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

79. 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

80. Vertical Shear

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

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

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

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

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

103. Complications of Treatment
Infection
Neurologic Injury
Loss of reduction

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

105. 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%)

106. 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

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

108. 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

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

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

111. Results: Radiographic
Rating of reduction (Matta and Tornetta, CORR Number 329, August 1996: )
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

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

113. 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

114. 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
Average 92.2

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

116. 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

117. 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

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

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

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

121. LQ

122. LQ

123. LQ

124. LQ

125. LQ

126. LQ

127. LQ

128. LQ

129. LQ

130. LQ

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

132. Thank You