Description of Standardized Planes and Angles for Percutaneous Supra-acetabular Screw Placement

Abstract

Background Percutaneous screw fixation for pelvic fractures has become a minimally invasive alternative to an open operation. The complex anatomy of the pelvis renders this procedure challenging. The objective of this study was to assess standardized angles and dimensions of safety zones within a 3 D computed tomography model for optimal supra-acetabular screw placement.

Methods Computed tomography scans of 107 patients that suffered major trauma without showing any bone injury of the pelvis were collected. Using a software-based analysis, raw computed tomography data were transformed into 3 D models to set standardized landmarks and determine the possible insertion corridor.

Results Screws not exceeding a length of 97 mm in females and 106.4 mm in males were, in 95% of the evaluated cases, insertable without cortical bone penetration. The safety zone was 6.6 mm for females and 7.9 mm for males. Screws not exceeding these diameters were safely insertable in 95% of the cases. For the midsagittal plane, the angle was 36.4 ± 5.1 on the left and 34.7 ± 2.9 on the right (p = 0.008). For the anterior pelvic plane, the angle was 31.3 ± 4.5° on the left and 34.0 ± 4.8° on the right (p = 0.008).

Conclusions Percutaneous fixation using supra-acetabular screws is a promising method to treat simple supra-acetabular fractures. These results may improve its safe utilization and could facilitate its broader clinical application.

Zusammenfassung

Hintergrund Die perkutane Schraubenosteosynthese hat sich bei Beckenfrakturen zu einer minimalinvasiven Alternative zum offen chirurgischen Vorgehen entwickelt, wobei die komplexe Anatomie des Beckens das Verfahren zu einer Herausforderung macht. Das Ziel der vorliegenden Arbeit ist es, standardisierte Winkel und Abmessungen des knöchernen Schraubenkanals, anhand von dreidimensionalen CT-Modellen zur Platzierung der supraazetabulären Schraube zu bewerten.

Methoden Es wurden Computertomographie-Scans von 107 Patienten rekonstruiert, die ein schweres Trauma erlitten, ohne dass eine Knochenverletzung des Beckens auftrat. Mithilfe einer softwarebasierten Analyse wurden CT-Rohdaten in 3 D-Modelle umgewandelt, um standardisierte Orientierungspunkte zu setzen und den möglichen Insertionskorridor zu bestimmen.

Ergebnisse Schrauben, die eine Länge von 97 mm bei Frauen und 106,4 mm bei Männern nicht überschritten, waren in 95% der ausgewerteten Fälle ohne Perforation der Kortikalis einbringbar. Die Sicherheitszone betrug 6,6 mm für Frauen bzw. 7,9 mm für Männer. Schrauben, die diese Durchmesser nicht überschritten, konnten in 95% der Fälle sicher eingebracht werden. Für die Mittelsagittalebene (MSP) betrug der Winkel 36,4 ± 5,1 links und 34,7 ± 2,9 rechts (p = 0,008). Für die vordere Beckenebene (APP) betrug der Winkel 31,3 ± 4,5° links und 34,0 ± 4,8° rechts (p = 0,008).

Schlussfolgerungen Die perkutane Fixierung mit supraazetabulären Schrauben ist eine vielversprechende Methode zur Behandlung einfacher supraazetabulärer Frakturen. Diese vorliegenden Ergebnisse können bei der Implantation als Referenzwerte dienen und eine sichere Verwendung erleichtern.

Schlüsselwörter

Trauma - Beckenfrakturen - supraazetabuläre Schraube - Beckenring - minimalinvasive Osteosynthese

Keywords

pelvis - pelvic ring fractures - screw insertion angle - supraacetabular screw

Publication History

Received: 24 October 2022

Accepted after revision: 06 June 2023

Article published online:
18 July 2023

• References

• 1 Routt ML, Swiontkowski MF. Operative treatment of complex acetabular fractures. Combined anterior and posterior exposures during the same procedure. J Bone Joint Surg Am 1990; 72: 897-904 (PMID: 2114408)
• 2 Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am 1996; 78: 1632-1645 (PMID: 8934477)
• 3 Alfonso NA, Ryan W, Baldini T. et al. Fixation of Transverse Acetabular Fractures With Precontoured Plates Alone Causes Fracture Malreduction: A Biomechanical Assessment. J Orthop Trauma 2020; 34: 89-94 DOI: 10.1097/BOT.0000000000001637. (PMID: 31567698)
• 4 Giannoudis PV, Grotz MRW, Papakostidis C. et al. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br 2005; 87: 2-9 (PMID: 15686228)
• 5 Kaempffe FA, Bone LB, Border JR. Open reduction and internal fixation of acetabular fractures: heterotopic ossification and other complications of treatment. J Orthop Trauma 1991; 5: 439-445 DOI: 10.1097/00005131-199112000-00009. (PMID: 1762005)
• 6 Simonian PT, Routt ML, Harrington RM. et al. Internal fixation of the unstable anterior pelvic ring: a biomechanical comparison of standard plating techniques and the retrograde medullary superior pubic ramus screw. J Orthop Trauma 1994; 8: 476-482 (PMID: 7869161)
• 7 Puchwein P, Enninghorst N, Sisak K. et al. Percutaneous fixation of acetabular fractures: computer-assisted determination of safe zones, angles and lengths for screw insertion. Arch Orthop Trauma Surg 2012; 132: 805-811 DOI: 10.1007/s00402-012-1486-7. (PMID: 22358222)
• 8 Trikha V, Kumar A, Mittal S. et al. Morphometric analysis of the anterior column of the acetabulum and safety of intramedullary screw fixation for its fractures in Indian population: a preliminary report. Int Orthop 2020; 44: 655-664 DOI: 10.1007/s00264-019-04428-5. (PMID: 31838545)
• 9 Zhang L, Zhang L, Si Q. et al. Experimental study on treatment of acetabular anterior column fractures: applyment of a minimally invasive percutaneous lag screw guide apparatus. BMC Musculoskelet Disord 2016; 17: 27 DOI: 10.1186/s12891-015-0846-1. (PMID: 26769591)
• 10 Shahulhameed A, Roberts CS, Pomeroy CL. et al. Mapping the columns of the acetabulum--implications for percutaneous fixation. Injury 2010; 41: 339-342 DOI: 10.1016/j.injury.2009.08.004. (PMID: 19733352)
• 11 Zhang L, Zhang W, Mullis B. et al. Percutaneous Anterior Column Fixation for Acetabulum Fractures, Does It Have to Be Difficult?-The New Axial Pedicle View of the Anterior Column for Percutaneous Fixation. J Orthop Trauma 2016; 30: e30-e35 DOI: 10.1097/BOT.0000000000000424. (PMID: 26284439)
• 12 Starr AJ, Reinert CM, Jones AL. Percutaneous fixation of the columns of the acetabulum: a new technique. J Orthop Trauma 1998; 12: 51-58 DOI: 10.1097/00005131-199801000-00009. (PMID: 9447519)
• 13 Bates P, Gary J, Singh G. et al. Percutaneous treatment of pelvic and acetabular fractures in obese patients. Orthop Clin North Am 2011; 42: 55-67 DOI: 10.1016/j.ocl.2010.08.004. (PMID: 21095435)
• 14 Chen X, Jia P, Wang Y. et al. A surface-based approach to determine key spatial parameters of the acetabulum in a standardized pelvic coordinate system. Med Eng Phys 2018; 52: 22-30 DOI: 10.1016/j.medengphy.2017.11.009. (PMID: 29269225)
• 15 Chang JK, Gill SS, Zura RD. et al. Comparative strength of three methods of fixation of transverse acetabular fractures. Clin Orthop Relat Res 2001; (392) 433-441 DOI: 10.1097/00003086-200111000-00057. (PMID: 11716419)
• 16 von Keudell A, Tobert D, Rodriguez EK. Percutaneous Fixation in Pelvic and Acetabular Fractures: Understanding Evolving Indications and Contraindications. Oper Tech Orthop 2015; 25: 248-255 DOI: 10.1053/j.oto.2015.08.007.
• 17 Giannoudis PV, Tzioupis CC, Pape HC. et al. Percutaneous fixation of the pelvic ring: an update. J Bone Joint Surg Br 2007; 89: 145-154 DOI: 10.1302/0301-620X.89B2.18551. (PMID: 17322425)
• 18 Gay SB, Sistrom C, Wang GJ. et al. Percutaneous screw fixation of acetabular fractures with CT guidance: preliminary results of a new technique. AJR Am J Roentgenol 1992; 158: 819-822 DOI: 10.2214/ajr.158.4.1546599. (PMID: 1546599)
• 19 Dekimpe C, Andreani O, De Dompsure RB. et al. CT-guided fixation of pelvic fractures after high-energy trauma, by interventional radiologists: technical and clinical outcome. Eur Radiol 2020; 30: 961-970 DOI: 10.1007/s00330-019-06439-7. (PMID: 31628504)
• 20 Caviglia H, Mejail A, Landro ME. et al. Percutaneous fixation of acetabular fractures. EFORT Open Reviews 2018; 3: 326-334 DOI: 10.1302/2058-5241.3.170054. (PMID: 29951272)
• 21 Chen KN, Wang G, Cao LG. et al. Differences of percutaneous retrograde screw fixation of anterior column acetabular fractures between male and female: a study of 164 virtual three-dimensional models. Injury 2009; 40: 1067-1072 DOI: 10.1016/j.injury.2009.01.014. (PMID: 19329113)
• 22 Chui KH, Chan CCD, Ip KC. et al. Three-dimensional navigation-guided percutaneous screw fixation for nondisplaced and displaced pelvi-acetabular fractures in a major trauma centre. Int Orthop 2018; 42: 1387-1395 DOI: 10.1007/s00264-017-3659-z. (PMID: 29063184)
• 23 Gras F, Marintschev I, Schwarz CE. et al. Screw- versus plate-fixation strength of acetabular anterior column fractures: a biomechanical study. J Trauma Acute Care Surg 2012; 72: 1664-1670 DOI: 10.1097/TA.0b013e3182463b45. (PMID: 22695438)
• 24 Guimarães RP, de Góes Ribeiro A, Ulson O. et al. Supra-acetabular fixation and sacroiliac screws for treating unstable pelvic ring injuries: preliminary results from 20 patients. Rev Bras Ortop 2016; 51: 132-137 DOI: 10.1016/j.rboe.2016.02.010. (PMID: 27069879)
• 25 Mouhsine E, Garofalo R, Borens O. et al. Percutaneous retrograde screwing for stabilisation of acetabular fractures. Injury 2005; 36: 1330-1336 DOI: 10.1016/j.injury.2004.09.016. (PMID: 16051241)
• 26 Starr AJ, Jones AL, Reinert CM. et al. Preliminary results and complications following limited open reduction and percutaneous screw fixation of displaced fractures of the actabulum. Injury 2001; 32: 45-50 DOI: 10.1016/S0020-1383(01)00060-2. (PMID: 11521706)
• 27 Sen M, Harvey EJ, Steinitz D. et al. Anatomical risks of using supra-acetabular screws in percutaneous internal fixation of the acetabulum and pelvis. Am J Orthop 2005; 34: 94-96 (PMID: 15789529)
• 28 Kahler DM. Tech Orthop 2003; 18: 174-183 DOI: 10.1097/00013611-200306000-00006.