Date: Sun, 1 Apr 2001 15:02:11 +0100

From: Nuno Craveiro Lopes

Subject: Pelvic ring disruption Tile C type

Dear all,

I have included at my home page,  a clinical case demonstrative of the treatment of pelvic ring disruption Tile C type with Ilizarov frame and minimal invasive internal fixation as we do at our Department.

Click here to see this case at  or if you want to review the other cases to through the main page and click presented and published papers about experimental and clinical research.   Your visit is welcomed!

Best regards,

Nuno Craveiro Lopes
Almada, Portugal


Reply at: Orthopaedic Trauma Association forum

Date: Mon, 02 Apr 2001 07:32:12 -0500

From: Adam Starr

Dr Lopes,

I'm not sure I'd call that "minimally invasive". Those wires look like they're invading that guy's belly. Wouldn't a Pfannenstiel approach and symphysis plate have been simpler? And easier to tolerate?

Tough to judge the reduction at the left SI joint without pre- and post-op inlet/outlet and AP views.

Adam Starr
Dallas, Texas

Date: 04/02 12:54 PM

From: Nuno Craveiro Lopes

Dear Adam,

Now a days we use only 2 pins in each arch and do a pre-assembly of the frame. To apply the exfix and percut screw in a traction table with II control is a 30 minute procedure, without blood loss and risk of infection (Pfannenstiel approach and symphysis plate, has a infection rate of about 10-15% as you know).

Furthermore it is very well tolerated, the patient can walk the next day, you can do progressive complementary adjustements at outclinic basis to do the "fine tunning" of the reduction. Is this not minimally invasive?

Best regards

Nuno Craveiro Lopes
Almada, Portugal

Date: Mon, 02 Apr 2001 15:29:12 -0400

From: Kevin Pugh

Questions:

1. Any biomechanical data to suggest that this frame/posterior screw is better than a percutaneous placement of a more traditional uniplanar frame with posterior fixation? In the pictures and films on your web site, it appears that you have 4 half pins in this patient.

2. How can the reduction of the fracture be "fine tuned" with a screw accross the SI joint in the back? I would think that this would require the screw to bend to accomodate the adjustment. Are you doing the reduction with the frame prior to inserting the screw?

3. Can you supply pre/post op inlet and outlet views? It appears that the Left SI joint is still superior on the film labeled JP 2/99 (see relationship to adjacent sacral foramina). It does look better on your film after the fixator is removed.

4. Can the patient sit in this frame? How do your general surgeons feel about it?

KP

Kevin J. Pugh, MD
Director of Orthopaedic Trauma
The Ohio State University

Date: Tue, 3 Apr 2001 20:39:31 +0530

From: Vineesh Mathur

I wouldn't be very aggressive in making the patient walk with that frame. Infection and pin loosening would reach unacceptable levels withing the normal span of six to eight weeks.

Vineesh Mathur


Date: Mon, 02 Apr 2001 12:33:26 -0700

From: Chip Routt

Please share your reference for the quoted infection rate after symphyseal plate fixation.

Your patient's symphyseal and posterior pelvic malreductions appear to have minimal impact on squatting activities at one year.

Thanks-


Date: Tue, 3 Apr 2001 23:14:43 +0100

From: Nuno Craveiro Lopes

My dear Chip,

Please share your reference for the quoted infection rate after symphyseal plate fixation.

Those numbers refers to the rate of infection of internal fixation on Tile C (Malgaigne type fracture, with horizontal and vertical combined instability), where urethral and bladder rupture can go up to 50%, namely on straddle fractures.

Rupture of the Pubic Symphysis: Diagnosis, Treatment and Clinical Outcome. Klaus Weber, MD; Bernd Vock, MD; Wolfgang Mčller, MD; Andreas Wentzensen, MD http://www.kfshrc.edu.sa/annals/196/99-015A.html

Early open reduction and internal fixation of the disrupted pelvic ring. Goldstein A; Phillips T; Sclafani SJ; Scalea T; Duncan A; Goldstein J; Panetta T; Shaftan G J Trauma 1986 Apr;26(4):325-33.

The (short) experience of my Department on symphyseal plating on the first 2 cases of Tile C with urethral rupture, was one in two infection rate. That's why we begun to use Ilizarov dynamic fixation ( not static exfix ) plus ilio-sacral percutaneous cannulated screw.

Your patient's symphyseal and posterior pelvic malreductions appear to have minimal impact on squatting activities at one year.

I d'ont doubt of your superb expertise with the scalpel on those cases, but if you consider this a malreduction, please let me know were your trash can is!

Best regards,

Nuno Craveiro Lopes
Almada, Portugal


Date: Tue, 03 Apr 2001 16:50:11 -0700

From: Chip Routt

Yes, unfortunately I'd classify those as malreductions.

Twelve years ago-no way.

Now-yes.

Maybe check your postoperative CT scan and see.

It doesn't mean that it's no good, they're just malreduced.

Most clinicians know that malreduction doesn't always equal bad result...but an excellent reduction is a great starting point after operation.

Thanks, but no room for your Xrays in my trash can! I've got plenty!

Keep on-

Chip