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Use of calcaneal plates in the treatment of posterior pelvic ring injuries and displaced iliac blade fractures- A case series

Published:December 29, 2022DOI:https://doi.org/10.1016/j.jcot.2022.102091

      Abstract

      Introduction

      The operative fixation of pelvic ring injuries and associated acetabulum fractures presents a challenging scenario to most of the orthopaedic trauma surgeons. Current development of anatomically contoured reconstruction (ACR) plates gained popularity in fixing complex pelvic ring fractures. This study was done to assess the functional and radiological outcomes using of lateral wall stainless steel (LWSS) calcaneal plates in posterior pelvic ring injuries and displaced iliac blade fractures.

      Materials and methods

      Retrospectively selected eight cases of pelvic ring injuries planned for fixing posterior pelvic instability and iliac blade fractures using LWSS plates. Mean follow-up was 18 months (Range 12–26 months).

      Results

      Average time for radiological bony union achieved in 18 weeks (Range 13–22). Seven patients returned to their normal work. Average Majeed score was 60 (Range 50–68). Mean duration of surgery was 160 min (Range 120–200).

      Conclusion

      This technique can be routinely used as supplementary fixation for posterior pelvic ring instability and iliac blade fractures. LWSS calcaneal plates showed no screw breakage or implant failure. Further this technique was cost effective in developing countries with limited resources.

      Keywords

      1. Introduction

      Pelvic injuries are the sequence of high energy injury, despite this fact, some elderly patients sustain injuries from low energy trauma due to prevalence of osteoporosis and the management requires a multidisciplinary team approach.
      • Lange R.H.
      • Hansen S.T.
      Pelvic ring disruptions with symphysis pubis diastasis. Indications, technique, and limitations of anterior internal fixation.
      ,
      • Hopf J.C.
      • Krieglstein C.F.
      • Müller L.P.
      • Koslowsky T.C.
      Percutaneous iliosacral screw fixation after osteoporotic posterior ring fractures of the pelvis reduces pain significantly in elderly patients.
      There are many classification systems formulated to classify pelvic ring injuries. Tile classification is based on the stability of the pelvic rings and aids in understanding the need for surgical intervention namely type A injuries (A1, A2) which are stable and can be treated conservatively; type B (B1 to B3) injuries include vertically stable but rotationally unstable injuries and type C (C1 to C3) injuries are rotationally and vertically unstable.
      • Tile M.
      Fractures of the pelvis.
      Young and Burgess classification is the widely used system based on mechanism of injury, described into four types. Lateral compression (LC) injuries result from side-impact injury by motor vehicle collisions leading to rami fractures with sacral impaction and iliac wing fracture posteriorly. Sacral impaction fractures in LC Ⅰ injuries, fracture dislocation of the iliac wing through the sacroiliac (SI) joint leading to iliac wing fracture or ‘crescent’ fracture in LC Ⅱ injuries and LC Ⅲ injuries (wind-swept pelvis) are composite injuries of LC Ⅰ and LC Ⅱ with opening of opposite hemi-pelvis at SI joint. Anteroposterior compression (APC) injuries also called ‘open book’ injuries results from the rotation of one or both hemipelvis hinging over SI joints. APC Ⅰ injury results in isolated symphysis injury with less than 2.5 cm symphysis diastasis. APC Ⅱ injury results in failure of sacrotuberous, sacrospinous and anterior SI ligaments with more than 2.5 cm symphysis diastasis. APC Ⅲ injuries results from prolonged external rotation force leading to disruption of the posterior sacroiliac ligaments with completely unstable SI joint.
      • Burgess A.R.
      • Eastridge B.J.
      • Young J.W.
      • et al.
      Pelvic ring disruptions: effective classification system and treatment protocols.
      Pelvic injuries are commonly associated with acetabular fractures presenting with difficult fracture reductions.
      • Gänsslen A.
      • Pohlemann T.
      • Paul C.
      • Lobenhoffer P.
      • Tscherne H.
      Epidemiology of pelvic ring injuries.
      Urethral and bladder injuries are common in pelvic injuries. Pelvic bleeding is the most devastating complication in pelvic injuries primarily managed by damage control orthopaedics with aggressive resuscitation like blood transfusion, pelvic binders, pelvic packing and external fixation.
      • Bjurlin M.A.
      • Fantus R.J.
      • Mellett M.M.
      • Goble S.M.
      Genitourinary injuries in pelvic fracture morbidity and mortality using the National Trauma Data Bank.
      • Hsu S.D.
      • Chen C.J.
      • Chou Y.C.
      • Wang S.H.
      • Chan D.C.
      Effect of early pelvic binder use in the emergency management of suspected pelvic trauma: a retrospective cohort study.
      • Scaglione M.
      • Parchi P.
      • Digrandi G.
      • Latessa M.
      • Guido G.
      External fixation in pelvic fractures.
      Stable pelvic injuries with rotational stability are treated by pelvic binders like pneumatic anti-shock garments and military anti-shock trousers.
      • Hsu S.D.
      • Chen C.J.
      • Chou Y.C.
      • Wang S.H.
      • Chan D.C.
      Effect of early pelvic binder use in the emergency management of suspected pelvic trauma: a retrospective cohort study.
      External fixators are indicated in minimal anterior pubic diastasis, but unstable pelvic injuries must be fixed internally with anatomically contoured pelvic plates, percutaneous screw fixation for sacroiliac stabilization.
      • Scaglione M.
      • Parchi P.
      • Digrandi G.
      • Latessa M.
      • Guido G.
      External fixation in pelvic fractures.
      • Tornetta P.
      • Dickson K.
      • Matta J.M.
      Outcome of rotationally unstable pelvic ring injuries treated operatively.
      • Matta J.M.
      Indications for anterior fixation of pelvic fractures.
      • Matta J.M.
      • Tornetta P.
      Internal fixation of unstable pelvic ring injuries.
      • Routt M.L.C.J.
      • Nork S.E.
      • Mills W.J.
      Percutaneous fixation of pelvic ring disruptions.
      Unstable pelvic injuries require multiple plates for fixation which generally bestowed with a financial burden to the patients and hospital. Further in developing countries with limited medical resources, the availability of ACR pelvic plates is a daunting task. There are very few studies stating use of newer implants in pelvic ring injuries. Current trend tends towards development of minimally invasive procedures. But our study gives importance towards open surgery with minimal risk of radiation to the operating surgeon. We have a hypothesis that calcaneal plate gives good reduction to posterior pelvic ring injury and displaced iliac blade fractures due to their larger surface area and varying pattern of pelvic injuries. Therefore, primary objective of this study was to the evaluate efficiency of calcaneal plates in terms of clinical and radiological results.

      2. Materials and methods

      This is a retrospective, consecutive case series between May 2018 to April 2021. Eight patients with pelvic ring injuries and acetabular fractures were selected from a level 1 trauma centre. This study is approved by institution review board (IERB number 03/2018-19/108). Informed consent was taken from all patients. All patients were assessed for haemodynamic stability. Stable patients were subjected to primary diagnostic modalities like history, clinical examination, x-rays (inlet view, outlet view, iliac oblique and obturator oblique view) and CT scan of the pelvis. All stable and unstable pelvic injuries (OTA 61A, 61B and 61C) and displaced acetabular fractures (OTA 62A, 62B and 63C) were included. Patients with suprapubic catheter and wounds over pelvis and abdomen were excluded. There were 4 acetabular fractures, 3 knee injuries and 2-foot injuries associated with pelvic injuries. All patients were operated by single surgeon (ZH). There were 6 males and 2 females with mean age of 49 years (Range 32–64). The mean follow-up period was 18 months (Range 12–26 months). [Table 1, Table 2].
      Table 1Demographic table (n = 8).
      Sl no.Age (years)sexFracture type (classification) Young Burgess TileAssociated fracturesDuration (minutes)FixationMajeed scoreComplications
      145MLC ⅡA2Posterior wall and anterior column of acetabulum140Both anterior and posterior pelvis66Superficial infection
      232MAPC ⅡC1Ipsilateral sub-trochanteric femur and Lateral condyle tibia120Both anterior and posterior pelvis50Subcutaneous haematoma
      338FVertical shearC1Patella fracture130Posterior pelvis60Superficial infection
      452MAPC ⅡC1Metatarsal fracture180Both anterior and posterior pelvis72
      564FLC ⅡC1Anterior column of acetabulum164Posterior pelvis52
      656MAPC ⅡC1Metatarsal fracture200Both anterior and posterior pelvis68
      744MLC ⅡC1Anterior column of acetabulum and patella fracture192Both anterior and posterior pelvis54Subcutaneous haematoma
      860MVertical shearC1Anterior wall of acetabulum152Both anterior and posterior pelvis58Subcutaneous haematoma
      Table 2Demographic table (continued).
      Sl no.Classification (Young Burgess)Follow-up (months)Bony union (weeks)Postoperative reduction (Matta and Tornetta)
      1LC Ⅱ1520Excellent
      2APC Ⅱ1216Good
      3Vertical shear2613Excellent
      4APC Ⅱ2420Excellent
      5LC Ⅱ1821Excellent
      6APC Ⅱ2217Good
      7LC Ⅱ1421Excellent
      8Vertical shear1318Excellent

      2.1 Operative procedure

      All of the surgical procedures were performed under general anaesthesia or spinal anaesthesia with the patients lying in a semi-decubitus position. 8 cm long curved incision over the iliac crest. The skin and subcutaneous tissue were incised. Iliacus muscle was detached by blunt dissection and soft tissue close to the periosteum was dissected to expose the site of fracture or dislocation. The displacement or dislocation was reduced first: the vertical displacement of the sacroiliac joint was reduced by traction and rotational displacement by compressing the iliac wing (for open-book fracture) or distracting (for closed-book fracture). For vertically displaced pelvic fractures, longitudinal traction to affected limb and further flexing knee (30°–60°) and hip flexion (20°–40°) was used to reduce the fracture. For lateral compression pelvic fractures one schanz screw near anterior superior iliac spine (ASIS) or anterior inferior iliac spine (AIIS) was inserted to reduce the fracture. An appropriate calcaneal plate was used to maintain the reduction. The plate was pre-contoured, but it was not necessary to strictly match with the iliac anatomy. The contoured calcaneal plate was placed along the displaced ilium or anterior to sacroiliac joint at the affected side. Before and after fixation of the screws, intraoperative fluoroscopy (anteroposterior, inlet and outlet views) was used to assess the reduction and fixation. If the reduction and fixation were successful, the incision was irrigated and sutured. The fascia was sutured first, and then the subcutaneous tissue and skin were closed. For some cases complicated by unstable anterior pelvic fracture, internal fixation with a reconstruction plate was performed in addition. Following the order of reduction, anterior pubic diastasis was fixed and then push pull test was performed to assess posterior ring stability under fluoroscopic guidance. Push pull test was done by applying a manual axial load to the affected extremity after fixing anterior pelvis and SI instability is fixed.
      • Sagi H.C.
      • Coniglione F.M.
      • Stanford J.H.
      Examination under anesthetic for occult pelvic ring instability.
      We have used simple cortical screws, as it is difficult to place locking screws with help of locking sleeves in pelvic area (see Fig. 1).

      2.2 Postoperative protocol

      Immediate reduction was assessed as per Matta and Tornetta for pelvis injuries. Postoperative fracture displacement on radiograph was termed excellent (<4 mm), good (5–10 mm), fair (10–20 mm) and poor (>20 mm).
      • Matta J.M.
      Indications for anterior fixation of pelvic fractures.
      (Fig. 2, Fig. 3) Patients administered with intravenous antibiotics for 5 days. Deep vein thrombosis prophylaxis was given with injection clexane (subcutaneous) and discharged with oral aspirin. Suture removal was done after 14 days during the postoperative period. Patients were allowed for partial weight-bearing at 6 weeks and full-weight bearing at 3 months (Fig. 4). Regular physiotherapy was initiated with help of trained physiotherapists. All the patients were followed up at regular intervals every 3 months. Patients were assessed for Majeed score (pain-30, work-20, sitting-10, standing-36, sexual intercourse-4), ISS (injury severity score) and complications.
      • Score Majeed
      Fig. 1
      Fig. 1Diagrammatic representation of application of calcaneal plate in SI joint disruption (a) and displaced iliac blade (b).
      Fig. 2
      Fig. 2Case 1, a) and b) preoperative x-ray and 3DCT scan showing Young Burgess LC Ⅱ injury with anterior wall of acetabulum fracture, c) Immediate postoperative x-ray image showing LWSS calcaneal plate fixing iliac blade and ACR plates stabilising anterior wall of acetabulum and anterior pubic instability.
      Fig. 3
      Fig. 3Case1, a) X-ray at 3rd month postoperative period showing stable reduction with no screw loosening, b) X-ray at 12th month postoperative period showing complete bony union.
      Fig. 4
      Fig. 4Case1, Clinical images at 20th month follow-up a) showing normal limb active straight leg raising, b) showing single leg weight bearing on normal side, c) showing decreased active straight leg raising of injured side, d) showing single leg weight bearing on affected side, e) showing cross leg sitting f) showing squatting position.

      3. Results

      In our study 6 patients suffered an injury due to a motor vehicle accident and 2 patients due to fall from height. The mean systolic blood pressure on arrival was 99 mmHg (86–110 mmHg). All patients required blood transfusion within 2 days of admission. All patients operated within 2 days after haemodynamic stabilization. As per Young Burgess 3 patients had LC Ⅱ injury, 3 patients had APC Ⅱ injury and 2 patients had vertical shear fractures. As per Tile's classification 7 patients had C1 injury and 1 patient had A2 injury [Table 1, Table 2]. In this study 6 patients had fixation of both anterior and posterior pelvis, 2 patients had posterior fixation alone. 2 patients were operated for associated acetabulum fractures. Among group of patients who were operated with anterior pelvic fixation, 4 patients were operated with ACR symphysis pubic plates and 2 patients with ACR pelvic plates. One patient had revision surgery due to the presence of screws inside SI joint. The order of fixation was anterior pelvis and then posterior pelvis. The associated fractures were also treated accordingly. The mean operative blood loss was 707 ml (Range 250 ml–1500 ml). In our study, none of the patients was associated with urinary or bladder injuries and hip dislocations. The average ISS score was 24 (Range 10–40). The mean duration of surgery was 160 min (Range 120–200). 6 patients had excellent reduction postoperatively and 2 patients had good reduction postoperatively. Mean Majeed score was 60 (Range 50–68). 7 patients returned to their previous work. 2 patients had residual pain on exertion. The average time for the bony union was 18 weeks (13–22). There was no case of screw breakage or implant loosening due to delayed weight bearing. 2 patients had superficial infection but resolved on treatment with oral antibiotics. 3 patients had subcutaneous haematoma at the medial aspect of the thigh which resolved completely with compression bandages. No cases of iatrogenic nerve injury.

      4. Discussion

      Pelvic injuries are complex injuries which are also seen in the aging population due to osteoporosis and are difficult to manage due to poor bone architecture. These cases render orthopaedic trauma surgeons challenging scenario. Currently various techniques are described in the treatment of pelvic injuries such as external fixation, percutaneous screw fixation, open reduction and internal fixation with anatomically contoured recon plates. External fixation of pelvic injuries was done using specialised clamps particularly in open book pelvic injuries with skin lacerations over pelvis or bladder injuries. Percutaneous screw placement has better outcomes compared to open procedures specially in decreased blood loss and duration of surgery, but excellent reduction was achieved in open reduction and plating.
      • Scaglione M.
      • Parchi P.
      • Digrandi G.
      • Latessa M.
      • Guido G.
      External fixation in pelvic fractures.
      • Tornetta P.
      • Dickson K.
      • Matta J.M.
      Outcome of rotationally unstable pelvic ring injuries treated operatively.
      • Matta J.M.
      Indications for anterior fixation of pelvic fractures.
      • Matta J.M.
      • Tornetta P.
      Internal fixation of unstable pelvic ring injuries.
      • Routt M.L.C.J.
      • Nork S.E.
      • Mills W.J.
      Percutaneous fixation of pelvic ring disruptions.
      Calcaneal plates have a large surface area, multiple screw options, easy availability and bending capacity similar to reconstruction plates provide good fixation to comminuted iliac blade fractures and wider coverage to SI joint. Few authors advise external fixation to pubic diastasis and internal fixation to the posterior pelvic ring. In our study, to provide good cosmesis, we performed internal fixation to pubic diastasis. Further external fixation renders unstable fixation.
      • Kellam J.F.
      The role of external fixation in pelvic disruptions.
      ,
      • Cabanela M.E.
      Fractures of the pelvis and acetabulum.
      In our study we used a single plate for pubic diastasis though some authors advise double plating. None of the patients suffered plate breakage, screw loosening and loss reduction in our study.
      • Lange R.H.
      • Hansen S.T.
      Pelvic ring disruptions with symphysis pubis diastasis. Indications, technique, and limitations of anterior internal fixation.
      ,
      • Simonian P.T.
      • Routt M.L.
      • Harrington R.M.
      • Tencer A.F.
      Box plate fixation of the symphysis pubis: biomechanical evaluation of a new technique.
      ,
      • Webb L.X.
      • Gristina A.G.
      • Wilson J.R.
      • Rhyne A.L.
      • Meredith J.H.
      • Hansen S.T.
      Two-hole plate fixation for traumatic symphysis pubis diastasis.
      (Fig. 5, Fig. 6) Bony G et al. in their study used locking calcaneal plate in the treatment of acetabulum fractures to buttress quadrilateral plate.
      • Boni G.
      • Pires R.E.
      • Sanchez G.T.
      • Dos Reis F.B.
      • Yoon R.S.
      • Liporace F.A.
      Use of a stainless -steel locking calcaneal plate for quadrilateral plate buttress in the treatment of acetabular fractures.
      In this study there was no screw or plate malposition, this provides added advantage of our procedure compared to percutaneous screw placement. In percutaneous screw placement neurovascular injuries are more common, which is not seen in our study.
      • Giannoudis P.V.
      • Tzioupis C.C.
      • Pape H.C.
      • Roberts C.S.
      Percutaneous fixation of the pelvic ring: an update.
      • Lindahl J.
      • Hirvensalo E.
      Outcome of operatively treated type-C injuries of the pelvic ring.
      • Routt M.L.
      • Simonian P.T.
      • Mills W.J.
      Iliosacral screw fixation: early complications of the percutaneous technique.
      • Templeman D.
      • Schmidt A.
      • Freese J.
      • Weisman I.
      Proximity of iliosacral screws to neurovascular structures after internal fixation.
      Duration of surgery was 160 min in our study. In contrary, Lindhavl et al. reported a duration of 98 min for posterior pelvic fixation by SI screw and Kobbe et al. reported a duration of 101 min in minimally invasive trans-iliac posterior plating.
      • Lindahl J.
      • Hirvensalo E.
      Outcome of operatively treated type-C injuries of the pelvic ring.
      ,
      • Kobbe P.
      • Hockertz I.
      • Sellei R.M.
      • Reilmann H.
      • Hockertz T.
      Minimally invasive stabilisation of posterior pelvic-ring instabilities with a transiliac locked compression plate.
      Sagi et al. reported in their study anterior plating for posterior pelvis injury showed increased stability and no displacement with high satisfactory results.
      • Sagi H.C.
      • Coniglione F.M.
      • Stanford J.H.
      Examination under anesthetic for occult pelvic ring instability.
      Ming Li et al. reported average blood loss was 195 ml, 66% patients had excellent outcome according to Matta and Tornetta radiological evaluation and no mortality, infections, nerve injury, deep vein thrombosis like complications were seen in cannulated iliac screw combined with reconstruction plate in pelvic fractures. In contrast 75% patients had excellent outcome according to Matta radiological evaluation and average blood loss was 707 ml in our study. Our study showed better radiological outcome but blood loss was more which was compensated by intraoperative blood transfusion.
      • Li M.
      • Huang D.
      • Yan H.
      • Li H.
      • Wang L.
      • Dong J.
      Cannulated iliac screw fixation combined with reconstruction plate fixation for Day type II crescent pelvic fractures.
      Our study was limited by small number of patients, selection bias, relatively short follow-up, and lack of comparative group. Therefore, we need further investigation with randomised controlled trials and biomechanical studies with larger study sample.
      Fig. 5
      Fig. 5Case 1, a) and b) 3DCT cut section showing bony union at 20th month, c) X-ray at 20th month post-operative period showing complete union of iliac blade and acetabulum, d) 3DCT image at 20th month follow-up.
      Fig. 6
      Fig. 6Case 2, Postoperative x-ray showing LCSS plate stabilising SI joint instability and ACR pelvic plates (6 holes) stabilising pubic diastasis.

      5. Conclusion

      Calcaneal plates in SI joint instability with pubic diastasis plating was an effective treatment with minimal risk of iatrogenic neurovascular injuries. We think that our technique may be a good supplementary fixation in posterior pelvic instability and iliac blade fractures. And further studies are required for bilateral posterior instability and large multi-centric studies to substantiate our results.

      Ethics approval

      Informed consent was obtained from all individual participants included in the study.

      Funding

      The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

      Author contributions

      All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Zakir Hussain and Siddharath Parmeshwar. The first draft of the manuscript was written by Siddharath Parmeshwar and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

      Consent to participate

      The authors affirm that human research participants provided informed consent for publication of the images.

      Patient declaration statement

      All appropriate consents from patients were obtained by the authors.

      Financial support and sponsorship

      Nil.

      Declaration of competing interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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