Pelvic Fx Forum

Case 1

Presented by: (Michael J. Brennan),Sat, 30 Dec 1995 09:44:41 -0700 (MST)

          Looking for input.An orthopedic friend dropped by the office to bounce some films off me.  A 40yo male in MCA 2 weeks ago    L SI disruption with comminution of sacral ala    wide sym. pubis diastasis with comminuted R sup. ramus    Malgaigne type     neuro intact, bladder and bowel ok    stabilized with std. ext fix and sacral bars    initial X-rays ok, but then displaced with ex fix cutout    now in skeletal txn- improved but not great    skin inflammed at old pin sites and marginal posteriorly    I feel ORIF would require ilioinguinal approach to get fixation to    stable R pelvic brim for curved ant recon plate across sym pubis.      Another option may be use of the Mears quadrilateral ant frame with    double pin sites each side.  The existing posterior instrumentation     may then act as a tension band.Appreciate any constructive comments or experience with Mears frame.Thanks, have a great new year.Mike BrennanPhx, AZ

Reply at: Orthopaedic Trauma Association forum


************************Date: Sat, 30 Dec 1995 12:20:48 -0500From: barrick@CLARK.NETMike,It sounds like the exfix approach has failed, so that trying again witha Mears frame does not sound attractive.  The patient is probably oneof those immense people in which the exfix is not strong enough.I would use the extended Pfannestiel approach (which was describedby some one at the first Pelvic Congress in 1992).  When working on one side, the surgeon stands on the opposite side so that he/she canreach up to the ilium under the femoral vascular bundle.  It works wellwithout having to make the incision over the iliac crest.  You have to watch the communciating braches of the femoral vein...FredE. Frederick Barrick MDDirector of Orthopaedic TraumaFairfax Regional Trauma CenterFalls Church, VA********************Date: Sun, 31 Dec 1995 09:54:05 -0600From: Jeffrey Anglen I agree with Fred that internal fixation is probably the way to go, sinceexternal fixation has failed once.  I have no experience with quadrilateralframes.I haven't used the extended Pfannenstiel approach, but have used theilioinguinal for cases such as you describe, and have been quitesatisfied with the exposure.  It may take a little longer, but it pays off in not having to struggle to see as far laterally as you need.  I feel more comfortable having good control of the vessels.***************************Date: Sun, 31 Dec 1995 11:13:06 -0500From: OTS1@aol.comI believe that the approach is known as the STOPPA approach and was firstused by urologists. It lets you get into the true pelvis and thequadrilateral surface. Drs. Cole and Bolhoffner have reported their resultswith this at the OTA I believe in 1993. You should call and speak to them.                                             Roy  Sanders                                           (****************************Date: Sun, 31 Dec 1995 11:52:08 -0600From: Jeffrey Anglen It was at the 94 OTA in LA.*****************************Date: Sun, 31 Dec 1995 16:00:36 -0500From: (Bill Burman)>I believe that the approach is known as the STOPPA approach and was first>used by urologists. It lets you get into the true pelvis and the>quadrilateral surface. Drs. Cole and Bolhoffner have reported their results>with this at the OTA I believe in 1993. You should call and speak to them.Published CORR 305 p 112 1994AB  - Between March 1991 and December 1992 the authors surgically      treated 55 acetabular fractures using a modified Stoppa anterior      intrapelvic extensile approach. Indications for utilization of      this approach included displaced anterior column or wall      fractures, transverse fractures, T shaped fractures, both column      fractures and anterior column or wall fractures associated with a      posterior hemitransverse component. The approach involves a      transverse skin incision 2 cm above the pubic symphysis followed      by a midline split of the rectus abdominis. Access to the      intrapelvic aspect of the pelvis and acetabulum is gained by      retraction of the muscular, neurovascular and urological      structures. This modified Stoppa approach affords excellent      visualization of the pelvic ring, facilitating the development      and utilization of improved reduction and plating options.      Patients were followed for an average of 17.7 months. All      fractures united 6-12 weeks postoperatively. Radiographic grades      were excellent (64%), good (25%), fair (7%) and poor (4%).      Fixation and subsequent reduction were lost in 1 patient. Two      transient obturator nerve palsies were diagnosed. There was 1      infection and 1 inguinal hernia. Posttraumatic arthritic changes      were noted in 6 patients within the first postoperative year.      There was no significant heterotopic ossification, major vascular      injury iatrogenic palsy or intraarticular hardware placement.      Clinical results were excellent (47%), good (42%), fair (9%) and      poor (2%). The modified Stoppa incision offers the experienced      trauma surgeon a new approach for fixation of displaced      acetabular fractures. The approach offers improved reduction and      fixation possibilities and may decrease the rate of complications      associated with extrapelvic or extensile approaches.AU  - Cole JDAU  - Bolhofner BRTI  - Acetabular fracture fixation via a modified Stoppa limited      intrapelvic approach. Description of operative technique and      preliminary treatment results.SO  - Clin Orthop 1994 Aug;(305):112-23************************Date: 2 Jan 1996 09:04:01 -0800From: "Chip Routt" These sacral/SI combos are tough. Cut your potential losses now. Thefollowing plan success depends on time since injury...early-good....late-poor. Remove the implants posteriorly with the patient still in traction. Culture &Gram stain it and close it. Flip to the front still in traction. Excise the old pin sites to bone and irrigate torrentially. Next a Pfannenstiehl for a perfect reduction and plate symphyseal fixation.Manually stress the ramus under direct or fluoro visualization (or both). Iframus instability exists then either retrograde screw the ramus (if possible) or extend the Pfannenstiehl to a Stoppa or ilioinguinal (if needed) exposure.With the patient still supine and in traction, assess by fluoro the posterior"indirect realignment". If acceptable and the sacral anatomy allows (ie isnot dysplastic), then secure with 1-2 iliosacral screws. Lag if the alarinvolvement spares the neuro foramina and L5 zones, or fully threaded ifiatrogenic nerve injury is a threat from over-compression. Sometimes,you can "squeeze it just right" with the #1 screw as a lag watching on the outlet image and monitoring with spontaneouis EMG,  then "lock it up" with #2as a fully threaded screw. The iliosacral screw(s) must span the sacralbody and preferably reach into the contralateral ala (110-140mm length)to be durable for this pattern. The screws should also lock their threads.If the reduction posteriorly is no good after the symphyseal/ramusfixation/reduction then the patient is flipped again to prone for openreduction and fixation du jour. -Chip*************************From: "Steve Olson, MD" Subject: Re: problem caseSorry, limited experience with the Mears frame.I would approach the anterior ring through a pfannenstiel.  The pubicramis can be addressed as well through this approach.  Often reducingthe pubic symphysis will significantly reduce the ramus fracture if theanterior soft tissues are intact.Bad pin sites can be managed by a formal excision of the pin tract tobone with or without closure depending on the soft tissues.  Anilioinguinal can be done in a delayed manner if needed.My preference for significant displacement at the SI joint is for posterioropen reduction, ala Letournel, when the posterior tissues are in goodcondition.  I prefer iliosacral screws, with the addition of a posteriortension band plate, tunneled submuscularly for significant associatedcomminution.  In this case if restoration of the anterior ring is not enoughwith the sacral bars, and the posterior soft tissues are marginal for anopen reduction, a supplemental percutaneous iliosacral screw mayprovide enough stability.All of the above presuposes the surgeon is familiar with pelvic surgery. SA Olson**********************************Date: Thu, 04 Jan 1996 11:39:49 -0700 (MST)From: TDECOSTE@medusa.unm.eduRegarding the pelvic ring disruption case posted 12-30-95.  I havetried a variety of external fixation systems including pins placedat the anterior inferior iliac spine without a lot of success.  I havealso tried traction in patients whom I felt were unfixable but haveexperienced late loss of reduction even after 12 weeks of tractionin the hospital.  However not every patient who heals with residual displacement doespoorly and not every patient with internal fixation has a complication free excellent outcome.Good luck.Tom DeCoster***************************Date: Sun, 7 Jan 1996 11:09:58 -0500From: (Bill Burman)I have been reading Cole JD, Bolhofner BR; Acetabular fracture fixationvia a modified Stoppa limited intrapelvic approach. Description ofoperative technique and preliminary treatment results;Clin Orthop 1994 Aug;(305):112-23.The authors state :"By extending the Stoppa approach posteriorly along the brim and elevating theiliopectineal and obturator fascias, medial wall, dome and quadrilateral plateexposure is accomplished. Further posterior dissection with elevation of theexternal iliac vessels allows exposure of the sacroiliac joint and lateralsacral ala."In 55 consecutive acetabular fractures, the average EBL was 773 cc. There weretwo transient obturator nerve palsies but no vascular injuries.This is impressive. I have recently helped Schurman and Maloney of Stanfordprepare a CD-ROM presentation of THRA acetabular revision surgery with anemphasis on the uro-neuro-vascular tiger country within the pelvic brim.Within the "Pelvic Fx" forum of the HWB page (,I have taken the liberty of superimposing a vascular map from a standardanatomy text {image 3} on a line art representation {image 2} of a pelvic brimreconstruction plate from the Cole, Bolhofner article. Placement of the moreposterior screws seems challenging. 

Click images to enlarge.
1) 2) 3)

A picture {image 1 -Keating et al; Structures at risk from medially placedacetabular screws, JBJS 72A p 510 Fig 3} that is more depressing than image3 is also posted. As crowded as the neurovascular spaghetti appears to be,the accessory obturator artery from the inferior epigastric artery, the vasdeferens and the ureter have been left out (presumably to simplify thepicture).Also, I believe these diagrams make the following article impressive reading :Routt ML Jr; Simonian PT; Grujic LThe retrograde medullary superior pubic ramus screw for thetreatment of anterior pelvic ring disruptions: a new technique.Department of Orthopaedics, Harborview Medical Center, Seattle, WA Source:J Orthop Trauma 1995 Feb;9(1):35-44Abstract:"Retrograde medullary screws were used in 26 patients withunstable pelvic ring injuries to stabilize the superior publicramus fractures. The posterior pelvic ring fractures anddislocations were fixed with iliosacral screws. The retrogradescrews were inserted after closed manipulative reductions of thesuperior pubic ramus fractures in 15 patients and after openreduction in nine patients. We were unable to insert the screw intwo patients due to anatomical variations. One screw wasmisplaced superior to the pubic ramus and noted only on thepostoperative computed tomography scan. Another patientexperienced symptomatic screw disengagement that requiredreoperation. All fractures healed and no infections developed.Blood loss was minimal for the percutaneous procedures. Thetechnique provides stability to the anterior pelvic ring withoutthe need for extensile surgical exposures. The complications ofboth anterior pelvic external fixation and plating are avoided,yet this technique has its own potential problems. The procedureis described in detail, and the early results and complicationsare documented in our first 26 patients."