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Vertically Unstable Pelvic Ring Injuries: Impact of Multilevel and Transsacral Fixation Strategy on Failure Rate
Lauren Luther1, Ridge Maxson, Andres F Moreno-Diaz
1Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN.
Objectives:
To evaluate outcomes of percutaneous pelvic fixation in the treatment of displaced vertically unstable pelvic ring injuries and identify fixation constructs that predict success.
Methods:
Design: Retrospective cohort study.
Setting:
Level I trauma center.
Patient Selection Criteria:
Patients ≥18 years old who underwent operative management of a vertically unstable pelvic ring injury (OTA/AO 61C.1-3) displaced ≥ 10 millimeters (mm) with sacroiliac (SI) or transsacral (TS) screws over a 24-year period. Exclusion criteria were spinopelvic dissociation, pathologic fracture, treatment with spinopelvic fixation or plate fixation of the posterior pelvic ring, and less than six months follow-up.
Outcome Measures And Comparisons:
The primary outcome was treatment failure, defined as ≥10 mm of radiographic displacement compared to initial post-operative imaging. Secondary outcomes included failure rates stratified by posterior pelvic ring injury type and rates of revision surgery. Outcomes were compared between constructs that included both Multilevel sacral fixation and Transsacral fixation (MAT) versus constructs that lacked one or both of these features; that is, constructs with either Single-level fixation or only SI screws (SS).
Results:
The cohort meeting inclusion criteria comprised sixty-seven patients: MAT fixation N=38 (71% male; median age 37 years, IQR 33-53) and SS fixation N=29 (62% male; median age 39 years, IQR 34-47). The posterior ring injury patterns included sacral fractures ( n=36, 53.7%), sacroiliac fracture dislocations (n=17, 25.3%), and sacroiliac dislocations (n=14, 20.9%). MAT fixation had a significantly lower rate of treatment failure compared to SS fixation (2.6% vs 48.3%, P<0.001). Rates of revision surgery were also significantly lower when MAT fixation was utilized (2.6% vs 31.0%, P= 0.002).
Conclusions:
In this cohort of vertically unstable pelvic ring injuries, fixation at multiple sacral levels with at least one TS screw was associated with a significantly lower treatment failure rate (2.6%) compared to single-level fixation or SI screw-only fixation (48.3%). When multilevel transsacral fixation cannot be achieved due to patient anatomy or injury, adjunctive fixation strategies should be considered.
Level Of Evidence:
Therapeutic Level III.
