Novel within ring fixation using iliac screws and an iliosacral screw locking system technique for fragility fracture of the pelvis
- Department of Orthopaedic Surgery, Sanmu Medical Center, Chiba, Japan
- Department of Orthopedic Surgery, Seirei Yokohama Hospital, Kanagawa, Japan
- Department of Orthopaedic Surgery, Chiba University, Chiba, Japan.
Ryohei Sawada, Department of Orthopaedic Surgery, Sanmu Medical Center, Chiba, Japan.
DOI:10.25259/SNI_301_2022Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Ryohei Sawada1, Tetsuhiro Ishikawa1, Mitsutoshi Ota2, Joe Katsuragi1, Yasuhito Sasaki1, Masahiro Suzuki1, Tomotaka Umimura1, Yuki Nagashima1, Daisuke Hashiba1, Takuma Yoshimoto1, Naoki Yamoto1, Seiji Ohtori3. Novel within ring fixation using iliac screws and an iliosacral screw locking system technique for fragility fracture of the pelvis. 16-Sep-2022;13:421
How to cite this URL: Ryohei Sawada1, Tetsuhiro Ishikawa1, Mitsutoshi Ota2, Joe Katsuragi1, Yasuhito Sasaki1, Masahiro Suzuki1, Tomotaka Umimura1, Yuki Nagashima1, Daisuke Hashiba1, Takuma Yoshimoto1, Naoki Yamoto1, Seiji Ohtori3. Novel within ring fixation using iliac screws and an iliosacral screw locking system technique for fragility fracture of the pelvis. 16-Sep-2022;13:421. Available from: https://surgicalneurologyint.com/surgicalint-articles/11870/
Background: Surgical indications for fragility fracture of the pelvis (FFP) have been reconsidered recently, and the indications to perform surgery have increased. However, the optimal surgical method to obtain sufficiently strong fixation in elderly patients with minimal invasiveness is not yet clear. In this report, we present the case of a patient with FFP who was treated with a novel posterior within ring fixation technique using a combination of iliac screws and an implant that locks the original iliosacral (IS) screw in the sacrum.
Case Description: A 90-year-old man was diagnosed with FFP (Rommens classification: Type IIc) and hospitalized for conservative treatment. However, 6 weeks after the injury, pain reappeared in his right buttock and computed tomography showed additional fractures of the right subpubic branch and right sacrum (Rommens classification: Type IVb). The fracture was considered to have progressed from being stable to unstable, and surgical treatment was planned. To obtain strong fixation with minimal invasion, we performed posterior fixation using E.Spine Tanit (Euros, France) compact posterior thoracolumbar instrumentation, an implant that combines an IS screw with a sacral anchoring system. The patient started walking unaided 2 weeks after the surgery, suggesting a good outcome of this surgical approach to FFP.
Conclusion: We performed posterior fixation surgery for a patient with an unstable FFP that recurred and progressed after conservative treatment. We have achieved good results using a minimally invasive, strong, and within ring fixation technique.
Keywords: Fragility fracture of pelvis, Iliosacral screw, Pelvic fracture, Rommens classification, Spinopelvic fixation, Within ring fixation
The super-aging of society is a global trend, and the population of people aged 65 and over is expected to double between 2010 and 2040.[
FFP has been reported to have a good outcome after conservative treatment.[
There are several surgical methods to fix pelvic fracture; spinopelvic fixation, within ring fixation, and percutaneous screw fixation, but each has its own problems, such as the degree of fixation achieved and extent of invasiveness. Therefore, we focused on a system that is used as a distal anchor for long fixation in surgery for spinal deformity. The combination of iliac screws and an implant that locks the original iliosacral (IS) screw in the sacrum allows for within ring minimally invasive surgery and strong fixation. In this report, we present the case of a patient with FFP who was treated with a novel posterior within ring fixation technique using this system with a good postoperative outcome.
A 90-year-old man complained of the left thigh pain after he fell lightly on his buttocks during farm work. Before the injury, he was able to walk independently. His medical history includes asthma, postoperative inguinal hernia, and left total knee joint replacement. Plain radiographs and computed tomography (CT) showed fractures of the sacrum and pubis [
In this case, progression from stable (Rommens classification: Type IIc) to unstable fracture (Rommens classification: Type IVb) was observed after symptom relief with conservative treatment. FFP can be easily detected in pubic sciatic fractures on a plain radiograph, but posterior sacral fractures are usually difficult to diagnose without CT and require attention.[
There are three main surgical methods: spinopelvic fixation to extend the fixation area to the lumbar spine for stability, within ring fixation to keep the fixation in the pelvic ring, and percutaneous screw fixation. Spinopelvic fixation has been reported mainly in the form of crab-shaped fixation, triangular osteosynthesis, and the Galveston method. Due to its strong fixation by anchoring to the lumbar spine, the vertical shearing force of the pelvis can be suppressed, and vertical dislocation can be corrected intraoperatively. However, fixation between the healthy lumbar vertebrae and the pelvis should be avoided for pelvic ring injuries, and there are concerns about the extent of invasion, adjacent segment disease, and need for implant removal, even for elderly patients.[
Within ring fixation includes the plate fixation technique for the sacroiliac joint, sacroiliac rod fixation (SIRF), and transverse iliac rod fixation (TIRF), which have been reported to provide strong fixation without anchoring to the lumbar spine. However, plates are more invasive and should be avoided for the elderly, SIRF raises concerns about the fixation of S1 pedicle screws and the limited direction for inserting S1 pedicle screws on the injured side of the sacrum, and TIRF requires the addition of an IS screw, because the sacrum is not fixed [
Common percutaneous screw fixation methods include rami screws, IS screws, and transiliac transsacral (TITS) screws. While percutaneous screws are minimally invasive, the TITS has a narrow corridor for insertion, and the IS screw has inferior fixation strength, because the tip of the screw is in the sacral cancellous bone.[
Rommens et al. stated that the important points of surgical treatment in FFP are to focus on achieving stability rather than precise anatomical reduction and to use the least invasive technique possible.[
Within ring fixation using E.Spine Tanit
E.Spine Tanit is a pelvic fixation system consisting of a sacral connector and IS screw and is used as a pelvic anchor for long fixation in spinal deformity surgery [
First, this technique cannot be applied in cases, in which there is vertical shear dislocation and requires a procedure for correction. Second, it was difficult to control the depth of the sacral connector, which made it difficult to connect the iliac screws to the rods that connect them, so the connection took time in this case. Establishing a suitable method to connect each implant is warranted.
We performed posterior fixation surgery for a patient with an unstable FFP that recurred and progressed after conservative treatment. We achieved good results using a minimally invasive, strong, and within ring fixation technique.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
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