Use of 3D Fluoroscopy to Assist in the Reduction and Fixation of Pelvic and Acetabular Fractures: A Safety and Quality Case Series.

SUMMARY: Multidimensional fluoroscopy has been increasingly used in orthopaedic trauma to improve the intraoperative assessment of articular reductions and implant placement. Owing to the complex osteology of the pelvis, cross-sectional imaging is imperative for accurate evaluation of pelvic ring and acetabular injuries both preoperatively and intraoperatively. The continued development of fluoroscopic technology over the past decade has resulted in improved ease of intraoperative multidimensional fluoroscopy use in pelvic and acetabular surgery. This has provided orthopaedic trauma surgeons with a valuable tool to better evaluate reduction and fixation at different stages during operative treatment of these injuries. Specifically, intraoperative 3D fluoroscopy during treatment of acetabulum and pelvis injuries assists with guiding intraoperative decisions, assessing reductions, ensuring implant safety, and confirming appropriate fixation. We outline the useful aspects of this technology during pelvic and acetabular surgery and report its utility with a consecutive case series at a single institution. The added benefits of this technology have improved the ability to effectively manage patients with pelvis and acetabulum injuries.

Imaging of Pelvic and Acetabular Trauma: Part 2, Soft-Tissue Findings.

Pelvic ring injuries and acetabular fractures can be complex and challenging to treat. Orthopaedic trauma surgeons scrutinize pelvic radiographs and accompanying CT images for the osseous details that help create a thorough patient-specific preoperative plan. While the osseous details are incredibly important, the surrounding soft-tissue structures are equally as critical and can have a tremendous effect on both the patient and the surgeon. These findings may change surgery timing, dictate the need for additional surgeons or multidisciplinary teams, and determine the treatment sequence. The structures and potential clinical findings reviewed and demonstrated through example images should be sought out during physical examination and correlative preoperative imaging review. Combining all the available osseous and nonosseous information with a detailed approach helps the surgeon predict potential pitfalls and adjust surgical plans before incision. Maximizing the accuracy of the preoperative planning process can streamline treatment algorithm development and ultimately contribute to the best possible clinical patient outcome.

Posterior Wall Acetabulum Fracture with a Persistent Sciatic Artery: A Case Report.

CASE: We report the case of a patient who sustained a left posterior wall acetabular fracture with an ipsilateral persistent sciatic artery (PSA). The PSA was diagnosed preoperatively on lower extremity computed tomography angiogram. He was treated with open reduction internal fixation through a Kocher-Langenbeck approach. The PSA and sciatic nerve were identified and protected throughout the case. There were no neurovascular complications. CONCLUSION: PSA in the setting of posterior wall acetabulum fractures has not been reported previously. Orthopaedic surgeons who treat these injuries should be aware of PSA anatomic variants so that they can be identified and protected during surgery.

Morbid obesity and short-term complications following acetabular fracture surgery: A comparative cohort study.

INTRODUCTION: Obesity is an epidemic facing the United States affecting nearly 40% of the population (93.3 million adults). The objective of this study was to compare early perioperative complications in patients with a normal BMI to patients who are pre-obese, obese, and morbidly obese. MATERIALS AND METHODS: The study was conducted at a Level-I trauma center. Patients were separated into 4 groups based on their BMI. Group 1 had a BMI < 25 (normal), Group 2 had a BMI between 25-29.9 (pre-obesity), Group 3 had a BMI between 30-39.9 (obese), and Group 4 had a BMI ≥40 (morbidly obese). Outcome variables included total operative time (OT), estimated blood loss (EBL), length of stay (LOS), and early medical and surgical complications. A comparison between groups was performed for each outcome variable and surgical complication. RESULTS: We identified 333 patients and the number of patients in Groups 1-4 were 86, 96, 121, and 30, respectively. The average BMI for Groups 1-4 was 22.3, 27.3, 35.9, and 44.9, respectively (p < 0.001). OT, EBL, and LOS did not differ between groups or between the surgical approach utilized. There were no significant relationships when comparing complication rates between groups. Patients in Group 4 experienced significantly more PE compared to patients in Group 2 (p=0.01). Additionally, patients in Group 4 experienced a significantly more PE than patients in Groups 1 and 2 combined (p<.01). The relative risk of having a PE if BMI is ≥40, compared to a BMI <30 is 18.40 (95% CI = 1.98 - 171.13). The PEs were not fatal in all cases. CONCLUSIONS: In the treatment of the obese and morbidly obese with acetabular fractures, we find that these cohorts are not at a greater risk of wound complications or infection. The higher rate of pulmonary embolism seen in the morbidly obese should be considered when evaluating these patients for appropriate thromboembolic prophylaxis.

Quantification of the upper and second sacral segment safe zones in normal and dysmorphic sacra.

OBJECTIVES: To quantify the obliquity and dimensions of the upper and second sacral segment iliosacral screw safe zones and to determine the differences between normal and dysmorphic sacral morphology. DESIGN: Retrospective cohort. SETTING: University Level I trauma center. PATIENTS/PARTICIPANTS: Fifty patients with pelvic computed tomography scans. INTERVENTION: All sacra were characterized as normal or dysmorphic based on plain pelvic radiographs and previously described criteria. Multiple computed tomography scan reconstructions were viewed and manipulated simultaneously with 6 degrees of freedom to allow for custom visualization in any plane. MAIN OUTCOME MEASUREMENTS: In each patient, a unique reconstruction plane was created perpendicular to the safe zone axis. The narrowest safe zone cross-sectional area was measured. Next, on simulated pelvic outlet and inlet views, safe zone obliquity and width were measured. Finally, the space available for a transverse screw was assessed. Measurements were performed for both upper and second sacral segment. Values for normal and dysmorphic safe zones were compared. RESULTS: Sacral dysmorphism was identified in 22 patients. In these sacra, the upper sacral segment safe zone cross-section was 36% smaller than in normal sacra (P < 0.001). No transverse screws could be placed, but accommodating for the caudal to cranial obliquity (30° versus 21° in normals, P < 0.001) and posterior to anterior obliquity (15% versus 4% in normals, P < 0.001) of the safe zone, an iliosacral screw at least 75 mm in length could be placed safely in 91% of patients. A transverse screw could be placed in 75% of normal sacra. In the second segment safe zone, the cross-sectional area was more than twice as large in dysmorphic sacra compared to normals (220 mm versus 109 mm, P < 0.001). The obliquity was not different on either the inlet or outlet views between groups. A transverse screw could be placed at this level in 95% of those with dysmorphic sacra and in only 50% of normal sacra. CONCLUSIONS: Sacral dysmorphism occurred in 44% of patients in this consecutive series. Many anatomic differences were consistently found between the two morphologies with clinical relevance to iliosacral screw placement. Specifically, the dysmorphic upper sacral segment safe zone is significantly smaller and more obliquely oriented but is still large enough to accommodate an iliosacral screw in nearly all patients. The second sacral segment safe zone is approximately transversely oriented in both sacral types but is more than twice as large in dysmorphic sacra. This segment may be a primary fixation opportunity in patients with sacral dysmorphism.

Percutaneous pelvic fixation using working portals in a circumferential pelvic antishock sheet.

Unstable pelvic ring injuries are associated with an increased mortality rate, most commonly from severe hemorrhage. Circumferential pelvic antishock sheeting has proven effective for rapidly stabilizing the pelvic ring and has become an integral part of resuscitation protocols. Acute antishock sheet placement frequently results in patient hemodynamic stabilization and an accurate pelvic reduction. In these situations, we describe a technique of maintaining the pelvic sheet position for continued use as a reduction aid and using working portals to insert definitive percutaneous pelvic implants.