Significant displacements of the fractured or dislocated pelvic fragments on x-ray images are generally associated with pelvic instability. The indications for percutaneous pelvic surgery are controversial among orthopaedic trauma surgeons. The method cannot be used if intraoperative image intensification is inadequate because of morbid obesity or intraabdominal contrast agents. Safe insertion of an iliosacral screw is impossible in such patients and is determined by the preoperative radiological studies. The use of the technique is precluded in displaced fractures which are irreducible by closed means, sacral dysmorphism, and other unusual pelvic anatomical variations. Percutaneous fixation is recommended when a number of essential criteria are met and only after an accurate reduction has been achieved, avoiding residual displacement which can endanger the adjacent neural and vascular structures associated with compromised outcomes and function. Patients are allowed to start weight bearing within 2 weeks after percutaneous fixation and do not have to recover from a major operation. Blood loss is significantly reduced, and due to decreased tissue trauma and the lack of a large open wound, a lower risk of infection may be anticipated. It does not decompress the pelvic hematoma and therefore surgical stabilization is possible without the risk of additional hemorrhage.Įarly and accurate closed reduction in association with stable fixation utilizing percutaneous techniques may be an ideal treatment for specific disruptions of the pelvic ring, especially in polytrauma cases. In patients with severe comminution and osteopenia, the percutaneous technique is useful as a means of preserving bone stock. The soft-tissue planes remain undisturbed. Percutaneous techniques may offer a shorter surgical time, reduce exposure-related hazards and decrease soft-tissue disruption. The surrounding anatomical vicinity is characterized by vital and vulnerable structures, and therefore the percutaneous surgical approach becomes an attractive option for the treatment of these injuries. Unstable pelvic ring injuries, especially in polytraumatized patients, require anatomical reconstruction and stable fixation to allow for early function. Rationale: indications and contraindications The iliac brim screw and antegrade medullary ramus screw must be inserted carefully when used together since the initial implant‘s pathway may intersect/obstruct subsequent implant pathways. The iliac brim screw is used to stabilize the anterior iliac component on to the posterior iliac stable fragment. Different screws are used in the percutaneous treatment of a pelvic fracture. Apart from the percutaneous iliosacral screw, a few other types of screws have been described and eventually added to the orthopaedic armamentarium for the treatment of pelvic fractures, such as antegrade and retrograde intramedullary pubic ramus screws, iliac wing, and transverse screws ( Fig 14.1-1). Subsequently, percutaneous fixation with iliosacral screws has become increasingly common for treating complex injuries of the pelvic ring. Routt et al described percutaneous fixation with iliosacral screws, for sacroiliac dislocation, and sacral fractures, demonstrating it to be a safe, reproducible method which is biomechanically stable with reduced blood loss and infection. To overcome the complication of extensile surgical approaches, percutaneous fixation of the pelvis has been receiving increasing attention.
It therefore seems reasonable to consider less invasive alternatives whenever possible. Most of these complications are related to the surgical exposure itself, rather than to the initial injury. General principles-the role of minimally invasive osteosynthesis in pelvic fracturesĬonventional techniques of internal fixation have generally required extensive surgical exposure of the deep structures of the pelvis, which can be associated with problems of wound healing, damage to major vessels or nerves, and increased incidence of infection up to 25%.
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