Figure - available from: European Journal of Trauma and Emergency Surgery
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Prone positioning and draping for percutaneous fixation of posterior column fracture fixation (a and b). The draping scheme we demonstrate is also utilized when a Kocher-Langebeck surgical exposure is completed
Source publication
Purpose
Percutaneous retrograde fixation of posterior column acetabular fractures is becoming a commonly practiced technique. Prone positioning provides reliably reproducible intraoperative fluoroscopic images necessary for precise preparation of the osseous fixation corridor necessary for accurate and safe implant placement. Additionally, the pron...
Citations
... Based on the previous research, the entry point of the percutaneous retrograde lag screw is the sciatic tuberosity [5]. The majority of the literature reported [6,7] that on the condition that the patient is in the supine position and retrograde lag screws are placed, the patient needs to fully flex the hip and knee to effectively reach the sciatic tuberosity and specify the nail entry point while avoiding injury to the sciatic nerve. ...
... The majority of the literature reported [6,7] that on the condition that the patient is in the supine position and retrograde lag screws are placed, the patient needs to fully flex the hip and knee to effectively reach the sciatic tuberosity and specify the nail entry point while avoiding injury to the sciatic nerve. A prone or lateral position has also been reported [5]. ...
Background
Currently, there is a lack of research investigating the feasibility of employing anterograde lag screw fixation through the iliac crest for minimally invasive percutaneous treatment of the posterior acetabular column, which encompasses retrograde and anterograde screw fixation in posterior acetabular lag screw fixation. And consequently, the purpose of this study was to examine the anatomical parameters of anterograde lag screw fixation of the posterior column of the pelvis through the iliac crest as well as to investigate the intraoperative fluoroscopy technique, to furnish a scientific rationale supporting the practical utilization of this method within clinical settings.
Methods
In this study, pelvic CT data of 60 healthy adults, including 30 males and 30 females, were accumulated. The mimics 21.0 software was developed to reconstruct the three-dimensional pelvis model, simulate the anterograde lag screw fixation of the posterior column of the acetabulum through use of the iliac crest, and precisely identify the insertion point: Utilizing the widest iliac tubercle as the starting point, the insertion point was moved toward the anterior superior iliac spine by 1.0 cm at a time until it reached 4.0 cm. With a total of five insertion points, all oriented toward the lesser sciatic notch, the initial diameter of the virtual screw measured 5.0 mm, and it was progressively enlarged by 1.0 mm increments until reaching a final diameter of 8.0 mm. Besides, the longest lengths of virtual screws with distinct diameters at divergent entry points were measured and compared. At the same time, the intraoperative fluoroscopy technique for optimal access was analyzed.
Results
The cross-section from the iliac crest to the lesser sciatic notch was irregular, with multiple curved shapes. Furthermore, the diameter of the screw was determined by the anteroposterior radians and width of the iliac crest plate, while the screw length was determined by the curvature of the square body. On the condition that the screw diameter of the D channel (3.0 cm outward from the widest part of the iliac tubercle to the lesser sciatic notch) was 5 mm, 6 mm as well as 7 mm, the longest screw lengths were (145.6 ± 12.8) mm, (143.6 ± 14.4) mm and (139.9 ± 16.6) mm, correspondingly, indicating statistically substantial distinctions from other channels (P < 0.0001). Intraoperative fluoroscopy demonstrated that the C-arm machine was tilted (60.7 ± 2.9) ° to the iliac at the entrance position and perpendicular to the D-channel at the exit position.
Conclusion
It is possible to use the new channel to fix the posterior column of the acetabulum with an anterograde lag screw through the iliac crest. In specific, the channel is 3.0 cm outward from the widest part of the iliac tubercle to the lesser sciatic notch. Providing a wide channel, long screw insertion, and high safety, this technique offers a novel approach for minimally invasive treatment of posterior column fractures of the acetabulum.
... In clinical and cadaveric studies conducted for the fixation of acetabulum posterior column, it has been stated that screws from 6.5 mm to 8 mm are used safely 4,8,14,17,23,31,32,35,36 . In radiological studies, the posterior column diameter varied from 11.4mm to 20.7mm on average, and the length of the posterior column from 96.4mm to 139.5mm 1,24,36 . ...
This study aimed to evaluate the effect of pelvis type in percutaneous acetabular column fixation. What is the effect of pelvis type in percutaneous acetabular colon fixation? The available pelvic computed tomography (CT) scans which were obtained in the diagnostic imaging center with a 1 mm slice width were evaluated. The pelvic type was classified with the help of MPR (Multiplanar Reformat) and 3D (Three Dimensional) imaging modes. All evaluated bony pelvic structures were anatomically intact. 40 types of android, gynecoid, anthropoid, and platypelloid pelvis were determined. CT sections were created in MPR imaging mode. Anterior obturator oblique (AOO) and inlet images were created for anterior column evaluation, while iliac oblique (IO) and outlet images were created for posterior column evaluation. The possibility of obtaining a linear corridor for acetabular columns was investigated by measuring corridor width and lengthon images of pelvic CTs. A linear corridor could not be obtained between the pubic tubercle and the supraacetabular region of 12 (30%) CTs in the anterior column of gynecoid pelvis group. The diameter of the anterior column corridor was below 5.5 mm in 10 (25%) of Gynecoid pelvis group, 5 (12.5%) of Anthropoid pelvis group, and 10 of Platypelloid pelvis group, , and all those scans belonged to the female gender. There was a statistically significant difference between pelvis types in terms of anterior and posterior column diameters (p <0.001). While the android pelvis type had the highest diameter and corridor length in both anterior column and posterior column measurements, the gynecoid pelvic type had the lowest diameter and corridor length. In the evaluations made according to gender, both anterior and posterior column diameters were larger and longer in males than in females (p <0.001). Pelvis type is an important factor which can affect anterior and posterior column diameter and length of acetabulum. Pelvic typing before acetabular surgery can help the surgeon determining the most appropriate patient position, surgical approach, and implant selection. Level of Evidence: Level 2..
... The indications for CRPIF remain vague and are based on nonuniform categorized factors, such as a suitable fracture morphology, extent of displacement, roof arc, assumed inevitable secondary hip replacement, comorbidities, compliance, higher age, and hospital-specific indications [12,13,17,[21][22][23][24]. These factors lead to sample sizes in the literature ranging from 12 to 80 patients [12,17,21,22,25,26] reporting on CRPIF, declining to 8-41 patients [13,18,23,24,27] considering solely percutaneous closed reductions without additional stab incisions or accessory windows [28]. In the authors' view, elderly patients with previous abdominal surgeries and several comorbidities and a related higher perioperative risk benefit from CRPIF. ...
Closed reduction and percutaneous internal fixation (CRPIF) for acetabular fractures was introduced as a less invasive alternative to open reduction and internal fixation (ORIF) for moderately displaced fractures. Currently, comparisons of ORIF and CRPIF outcomes are rare. Twenty-three patients treated with CRPIF were matched with patients treated with ORIF based on sex, age, and fracture classification. Surgery-dependent and -independent factors of the in-hospital stay, the conversion rate to total hip arthroplasty (THA), and quality of life were assessed. The ORIF group had a higher preoperative fracture step (p = 0.04) and gull wing sign (p = 0.003) compared with the CRPIF group. Postoperatively, the gap and step size were not significantly different between the groups (p > 0.05). CRPIF required less time (p < 0.0001) and transfusions (p = 0.009) and showed fewer complications (p = 0.0287). Four patients were converted to THA (CRPIF, n = 1; ORIF, n = 3; p = 0.155) because of posttraumatic osteoarthritis. Functional outcomes and pain were similar in both groups (p > 0.05). The present study revealed less blood loss and a lesser extent of reduction in patients treated with CRPIF than in those treated with ORIF. The rates of conversion to THA and functional outcomes did not differ between CRPIF and ORIF. CRPIF appeared to be a valuable treatment option for selected patients.
... Supine uoroscopy is often used for acetabular fractures involving the posterior column. If uoroscopy is used during the operation with the pelvis in the normal position, the ilium in the 45° oblique position, and the obturator foramen in the 45° oblique position [14], the "blind area" for uoroscopy will be generated in the posterior side of the posterior column due to the occlusion of the acetabular rim. Autopsy and MRI measurements have shown that 85% of the sciatic nerve is wholly or partially located in the "blind area" [15]. ...
Background: Research into minimally-invasive fixation of acetabular posterior column fracture has mostly focused on anatomic measurement through the ischial tuberosity in a retrograde manner, and few anatomic studies have been carried out on anterograde percutaneous Magic screws. The purpose of this paper was to discuss the entry point, entry direction and fixation range of Magic screws for fixation of acetabular posterior column fracture.
Method: Materialise’s Interactive Medical Image Control System (Mimics) 19.0 software was used to carry out three-dimensional (3-D) reconstruction based on the Computed tomography (CT) data of the pelvises of 100 cases. A virtual Magic screw was placed in the acetabular posterior column, and the screw entry point, entry direction, length, diameter, safety range and fixation range were determined. Osteotomy modeling was performed on the acetabular posterior column with virtual Magic screw fixation, and the changing law of the width of the screw channel was observed. The narrowest distance and position between the screw edge and the acetabulum were measured.
Results: The bone entry point of the Magic screw on the posterior side to the anterior inferior iliac spine and cephalad side to the acetabular top for the males were 33.32 ± 5.52 mm and 13.42 ± 3.68 mm, respectively; and those for females were 33.94 ± 5.43 mm and 9.11 ± 3.82 mm, respectively. The screw for males had a back rake angle of 57.37 ± 6.53° and a leaning inside angle of 52.12 ± 5.61°, with an angle of 15.16 ± 3.45° to the iliac wing. For females, those angles were 55.61 ± 7.94°, 51.53 ± 5.59° and 9.76 ± 3.69°, respectively. The maximum screw diameter was 6.97 ± 0.98 mm for males and 6.39 ± 0.85 mm for females. The screw length was 76.73 ± 9.20 mm for males and 63.64 ± 8.37 mm for females. The safety ranges of back rake angle and leaning inside angle of the 5.5 mm diameter screws for the males were 7.18 ± 3.32° and 9.42 ± 3.96°, respectively, and those of 5.2 mm diameter screws for females were 8.39 ± 2.83° and 10.37 ± 3.92°, respectively. For 60% of the male specimens, the screw fixation range was above the acetabular top, with a length of 60.45 ± 5.92 cm; and for 40% of the male specimens, the screw fixation range was below the acetabular top, with a length of 50.68 ± 6.49 cm. For females, 24% of the specimens were above the acetabular top, with a length of 52.19 ± 7.76 cm; and 76% of the specimens were below the acetabular top, with a length of 38.40 ± 4.35.
Conclusion: Percutaneous Magic screws provide a minimally-invasive fixation method for acetabular posterior column fracture with high surgical difficulty, and can be used to fix fractures located in the middle and upper segment of the posterior column.
Objectives:
There are multiple established patient positions for placement of a percutaneous retrograde posterior column screw for fixation of acetabulum fractures. The sciatic nerve is at risk of injury during this procedure, as it lies adjacent to the start point at the ischial tuberosity. The purpose of this study is to define how the position of the sciatic nerve, relative to the ischial tuberosity, changes with respect to the patient's hip position.
Methods:
In a cohort of 11 healthy volunteers, ultrasound was used to measure the absolute distance between the ischial tuberosity and the sciatic nerve. Measurements were made with the hip and knee flexed to 90 degrees to simulate supine and lateral positioning, and with the hip extended to simulate prone positioning. In both positions, the hip was kept in neutral abduction and neutral rotation.
Results:
The distance from the lateral border of the ischial tuberosity to the medial border of the sciatic nerve was greater in all subjects in the hip flexed position versus the extended position. The mean distance was 17 mm (range, 14-27 mm) in the hip extended position, and 39 mm (range, 26-56 mm) in the hip flexed position (P < .001).
Conclusion:
The sciatic nerve demonstrates marked excursion away from the ischial tuberosity when the hip is flexed compared with when it is extended. The safest patient position for percutaneous placement of a retrograde posterior column screw is lateral or supine with the hip flexed to 90 degrees.
