Iliosacral Screws Indications. What Injuries Are Amenable? CRPFPP Indications Injured Zones 11/18/2013

Transcription

1 Iliosacral Screws Indications ML Chip Routt Jr MD UT Houston Orthopedics Houston, Texas What Injuries Are Amenable? Sacroiliac Sacral Iliac Combination CRPFPP Indications Injured Zones SI Joint Sacral Combination U-H-Y 1

2 CRPFPP Indications Injured Zones Zones CRPFPP Indications All Ages Adults Kids CRPFPP-Indications-Resuscitation Acute Reduction Support Quick Safe Temporary Definitive 2

3 CRPFPP Indications - Urgent Manipulator Frame Screws Stability CRPFPP Indications - Polytrauma TSFO SSTNO Get Off the Algorithm Manipulate-Support 3

4 CRPFPP Indications - Polytrauma TSFO SSTNO Get Off the Algorithm Manipulate-Support CRPFPP Indications - Instability Common Biomechanics Anterior Posterior Each Site Supportive CRPFPP Indications - Instability Displacement Deformity Manipulate Support 4

5 CRPFPP Indications - Tissues Open Degloving Necrosis Flank Abdomen Other CRPFPP Indications - Obesity Abdomen Buttock Flank CRPFPP - Indications - Obesity Res Ipsa Loquitur Stability Minimal Exposure 20 5

6 CRPFPP - Indications - Chronic Instability Postpartum Old Trauma Pain Arthritic Nonunion Insufficiency CRPFPP Indications - Chronic Trauma CRPFPP Indications - Chronic Trauma 6

7 CRPFPP Indications - Pathological Tumor Primary Metastatic CRPFPP Indications - Pathological Radiation Necrosis U-Type Sacral CRPFPP Indications - Insufficiency Senior Frailty Medications Low Lumbar Spine Surgery 7

8 CRPFPP Indications - Insufficiency Fortify Fill Anterior & Posterior All Sites CRPFPP Indications - Acetabular Combination SI Sacral Others CRPFPP - Contraindications Complete SI ManipRed Failure Tunnel Debris Others 8

9 Summary Posterior Pelvis Lateral Iliac Cortex Osteology Reduction 9

10 The Iliosacral Screw: Anatomy, Equipment, & Technique Jonathan Eastman, MD University of California, Davis Disclosures I have no disclosures Learning Objectives Understand upper sacral segment anatomy Recognize variability Appreciate osseous fixation pathways Realize importance of preoperative planning Safely and reproducibly place iliosacral screws 1

11 Pelvis usf.edu Spectrum of Anatomy Normal Dysmorphic Spectrum of Anatomy Normal Dysmorphic Miller and Routt. JAAOS

12 Spectrum of Anatomy Normal Dysmorphic Osseous Fixation Pathways Bishop and Routt. J Trauma Acute Care Surg 2012 Osseous Fixation Pathways Normal 3

13 Osseous Fixation Pathways Dysmorphic Variable Sagittal Plane Alignment Consistent Extraosseous Anatomy Staying Within the Vestibule L5 Nerve Root - Lateral ala - High and anterior S1 Nerve Root - Central ala - Low and posterior Common Iliac Vessels - Medial Ala - High and Anterior Carlson et al. JOT

14 Preoperative Planning Intraoperative Fluoroscopy Outlet View Graves and Routt. J Trauma 2011 Preoperative Planning Inlet View 5

15 Preoperative Planning Outlet View Preoperative Planning AP Rollover View Lateral View Miller and Routt. JAAOS

16 Lateral View Miller and Routt. JAAOS 2012 Reduction is a Prerequisite Reduction is Mandatory 7

17 Reduction is Mandatory Reduction is Mandatory Reduction is Mandatory 8

18 Iliosacral Screw Technique Equipment Needed 1.6 mm Kirschner wire 4.5 mm cannulated drill Threaded guidewire Cannulated screws - Fully threaded - Partially threaded Washer Patient Positioning Supine Lumbosacral bump - Two blankets in midline Prep low and posterior 9

19 Start Site Inlet Outlet Drill Insertion and Orientation Drill Advancement Inlet Outlet 10

20 Verify on Lateral View Advance Into Sacral Body Inlet Outlet Evaluate Drill Path 11

21 Advance Wire to Final Position Inlet Outlet Measure Depth Screw Insertion 12

22 Verify No Screw Intrusion Inlet AP Rollover Final Position Inlet Outlet Conclusion Knowledge of anatomy is paramount Understand posterior ring variability Preoperative planning vital Reduction mandatory Execute screw placement safely and reproducibly 13

23 Thank You! UCDavis Trauma 14

24 Posterior Pelvic Ring Injuries: Exposure & Techniques Clifford B. Jones, MD, FACS Michigan State University/CHM Orthopaedic Associates of Michigan Grand Rapids Medical Education Partners (GRMEP) Grand Rapids, MI Posterior Pelvic Ring Injuries: Exposure & Techniques Clifford B Jones, MD The following relationships exist: Partial Owner: Midtowne Surgical Center Grants: OTA, NIH, DOD Boards non reimbursed: OTA, MAOA, AOA OTB Posterior Pelvic Ring ORIF Indications SI Joint Fracture/Dislocation Posterior Ilium Fractures Sacral Fractures/Dislocations +/- foraminal encroachment Late Reduction/Fixation (>5days) 1

25 Contraindications Degloving Injuries Vascular Injuries s/p Interventional Radiology Posterior Pelvic Ring Approaches Supine Anterior, Iliac Window Prone Posterior, Paramedian Posterior, Midline Posterior Pelvic Ring Approaches Supine Anterior, Iliac Window Prone Posterior, Paramedian Posterior, Midline 2

26 Anterior Supine: Posterior Ring Indications SI Disruptions SI Joint Fracture/Dislocations (Crescent Fx) Iliac Fractures Iliac Window Indications SI disruptions & Fx/Dislocations (crescent) Ilium & Iliac wing fx Associated acetabular fx Technique Incision 2 cm distal to iliac crest Elevate external oblique muscle Extend anteriorly past ASIS Identify and release lateral femoral cutaneous (LFC) n +/- release inguinal ligament Extend posteriorly dividing internal oblique muscle Dissect deep to sciatic notch & posterior SI joint Insert blunt Homan retractor into notch careful of sciatic n. Insert blunt Homan posteriorly and cephalad to SI joint 3

27 Supine Anterior Iliac Window Lateral Femoral Cutaneous Nerve Lumbosacral Plexus Sciatic Nerve Supine Anterior Iliac Window Limit Dissection to 2.0cm Careful of Notch Retractor Placement Supine Anterior Iliac Window Iliac Window of Illoinguinal Approach Inner Pelvic Table Blunt Homan Retractor Inner Notch Sharp Homan Retractor Intact Anterior Sacrum Pillow Under Knee Relax Iliopsoas 4

28 Supine Anterior Clamp Placement King Tong Clamp Supine Anterior Clamp Placement Clamp Placement Limited By Obesity & Edema SI Joint Dislocation ORIF Anteriorly (Screws) 24 M, MVC Hypotensive No Motor LE 5

29 Injury Pelvis Injury CT Angio Bilateral Internal Iliac Attempted ExFix Reduction of SI Joint INtrao Intraop Clamp Placement 6

30 Post Op CT Final Imaging SI Joint Dislocation ORIF Anteriorly (Plates) 3.5 mm Plates Fixation 7

31 SI Joint Dislocation ORIF Anteriorly (Plates) 42 F, Snowmobile Unstable Pelvic Ring Initial Sheeting in Field Hypotensive Traction applied Good Intraop Reduction SI Joint Dislocation ORIF Anteriorly (Plates) Resuscitation in SICU Post Op CT Malreduction of SI L5 Nerve Root 8

32 SI Joint Dislocation ORIF Anteriorly (Plates) Return for ORIF Open 5 Days Later Fixation of Rt High Root Ramus & SI Put Screws Into Bone Iliac Wing Fx 9

33 Posterior Pelvic Ring Approaches Supine Anterior, Iliac Window Prone Posterior, Paramedian Posterior, Midline Posterior Indications SI Disruptions SI Joint Fracture/Dislocations (Crescent Fx) Sacral Fractures Late (ie > 5 days) Reductions Fixation Failure ReDo s Posterior Approaches Prone Laminectomy rolls Spine table with anterior ex-fix Eye protection (blindness 1/10,000) +/- distal femoral traction Seal rectum & perineum 10

34 Set Up Exposure: Skin Incision Historical reports of unacceptably high infection rates % - Kellam, OCNA 1987, 18, More recent reports demonstrate acceptable rates - 3.4% - Stover, CORR (8) Contraindications Degloving Injuries Vascular Injuries s/p Interventional Radiology 11

35 Paramedian Stover, CORR, 2012 SI Joint Fracture Dislocation Crescent Fracture, Posterior ORIF SI Joint Fracture Dislocation Crescent Fracture, Posterior ORIF Tension Band Plate 12

36 SI Joint Fracture Dislocation Crescent Fracture, Posterior ORIF Small Sacral Safe Zone Small Crescent Fragment SI Joint Fracture Dislocation Crescent Fracture, Posterior ORIF SI Dislocation 13

37 Approach cephalad caudad Sacral Fractures: Approach and Reduction Posterior Open Approach Midline vs Paramedian Vertical Paramedian Clean fracture directly Accurately reduce Strategic clamp applications Avoid over compression 14

38 Sacral Fractures: Approach and Reduction Posterior Open Approach Midline vs Paramedian Vertical Paramedian Intraoperative traction Clamp from spinous process to PSIS Schantz pin into PSIS Use the inferior (tension) read Posterior Sacral Fracture Clamp Placement Sacral Malreduction and Iliosacral Screws Reilly et al, JOT,

39 Sacral Malreduction and Iliosacral Screws Reilly et al, JOT, 2003 Displacement Decreased X-S Area 5mm 30% 10mm 56% 15mm 81% 20mm 90% Can t place 2 screws in 50% of 15mm, 66% of 20mm Can t place 1 screw in 17% of 15mm, 20% of 20mm ICD L5 Reduction Lateral - GSNs ICDs - Ala - L5 Root Pantaloon - S1 Root Safe Zone S1 Start Site-Aim-Length Sacral Fractures: Fixation Options SI screws (1 vs 2) Transiliac plate Tension band plate Dorsal plate Sacral bars Transiliac screw Lumbopelvic Fixation 16

40 Sacral Fracture ORIF Posterior (Screws) 62 F MVA Stable Hemodynamically Sacral Fracture ORIF Posterior (Screws) Sacral Fracture ORIF Posterior (Screws) 17

41 Sacral Fracture ORIF Posterior (Screws) Dorsal Plating of Transverse Sacral Fxs Sacral Fracture Posterior ORIF (Plates) 45 M Fall & Drunk Sacral Numbness Inability to Void 18

42 Sacral Fracture Posterior ORIF (Plates) Dorsal Midline Decompression Dorsal Plating Transiliac Dorsal Plating Similar concept Requires reduction Open technique Trans vs Dorsal Same location as bars 19

43 Lumbopelvic Fixation (LPF) Small Safe Zones Sacral Foraminal Encroachment Extensive Sacral Comminution Associated L5/S1 Facet Injury LPF Indications Comminuted Sacral Fx Intraforaminal Sacral Fx requiring decompression (ie osseous removal) Small Safe Zone inadequate for SI screw Extension into L5 S1 Articulation (Facet Fx) Revision Sacral Surgery with osteotomy requiring a reduction (Cephalad to Caudad) technique Pelvic for LPF Imaging Sciatic Buttress Iliac Oblique Rollover Outlet Obturator Oblique 20

44 Sacral Alar Iliac Pelvic Fixation Sciatic Buttress Sacral alar iliac pelvic fixation Standard Illiac Fixation Trajectory Sacral Alar Illiac Fixation Trajectory Kebaish Spine

45 32 yo male, logging injury Triangular Fixation WBAT 22

46 After Healing Lumbopelvic Fixation 17 F, MVA Hypotensive Left LE Sciatic Nerve Palsy 23

47 Lumbopelvic Fixation L5/S1 Facet Injury Small Safe Zone Marked Comminution Lumbopelvic Fixation Lumbopelvic Fixation 24

48 65 M, Sacral Alar Fracture Pubic Symphysis Plating 3 Months Post Op SI screw Loosening Cephalad Migration PS Plate Breakage 25

49 Posterior Injury Subtle Instability Neglected Posterior Pelvic Ring ORIF Appropriate Fracture Selection All Fracture Patterns early or late Caution with: 1. Degloving & 2. Interventional Radiology Appropriate Approach Supine (Anterior) - iliac Prone (Posterior) midline vs. paramedian Appropriate Implant Insertion Screw, Plate, Lumbopelvic, Combo Coordinated with Clamp Placement Appropriate Layered & Skin Closure 26

50 Percutaneus Pelvic Fixation: Avoiding Complications James Krieg, MD Philadelphia, PA Consultant to Acumed Disclosures Complications Errant screw placement Neurologic damage Vascular damage Loss of fixation Inappropriate placement Inadequate fixation 1

51 Errant screw placement Knowledge of anatomy Safe screw corridors Reduction Why are they dangerous? Where are they dangerous? 2

52 How to avoid screw errors Know anatomy 3

53 How to avoid screw errors Know anatomy Lateral view How to avoid screw errors Know anatomy Lateral view Tactile feedback Follow wires advance How to avoid screw errors Know anatomy Lateral view Tactile feedback Follow wires advance Reduction 4

54 Failures of fixation Error in technique Error in judgement Technical Errors Screw intrusion Screws generate force by converting rotational movement into translation/compression Force generated by screw threads countered by head Prevent screw head intrusion Use a washer Fluoro to assess screw insertion 5

55 Correct screw intrusion Semitubular plate Technical tip: Long screws, fully threaded screws Technical tip: Long screws, fully threaded screws 6

56 Errors in judgement: Inadequate fixation Summary Imaging, planning, anatomy Technical tips to avoid errant screws Multiple screws, long, fully threaded Judgment in indications, planning to avoid failures of fixation 7