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Background and purpose: Cannulated screws are standard implants for percutaneous fixa-tion of posterior pelvis ring injuries. The choice of whether to use these screws in combination with a washer is still undecided. The aim of this study was to evaluate the biomechanical competence of S1-S2 sacroiliac (SI) screw fixation with and without using a washer across three different screw designs. Material and Methods: Twenty-four composite pelvises were used and an SI joint injury type APC III according to the Young and Burgess classification was simulated. Fixation of the posterior pelvis ring was performed using either partially threaded short screws, fully threaded short screws, or fully threaded long transsacral screws. Biomechanical testing was performed under progressively increasing cyclic loading until failure, with monitoring of the intersegmental and bone-implant movements via motion tracking. Results: The number of cycles to failure and the corresponding load at failure (N) were significantly higher for the fully threaded short screws with a washer (3972 ± 600/398.6 ± 30.0) versus its counterpart without a washer (2993 ± 527/349.7 ± 26.4), p = 0.026. In contrast, these two parameters did not reveal any significant differences when comparing fixations with and without a washer using either partially threaded short of fully threaded long transsacral screws, p ≥ 0.359. Conclusions: From a biomechanical perspective, a washer could be optional when using partially threaded short or fully threaded long transsacral S1-S2 screws for treatment of posterior pelvis ring injuries in young trauma patients. Yet, the omission of the washer in fully threaded short screws could lead to a significant diminished biomechanical stability.

Background/Purpose Posterior pelvis ring injuries represent typical high-energy trauma injuries in young adults. Joint stabilization with two cannulated sacroiliac (SI) screws at the level of sacral vertebrae S1 and S2 is a well-established procedure. However, high failure- and implant removal (IR) rates have been reported. Especially, the washer recovery can pose the most difficult part of the IR surgery, which is often associated with complications. The aim of this biomechanical study was to evaluate the stability of S1-S2 fixation of the SI joint using three different screw designs. Methods Eighteen artificial hemi-pelvises were assigned to three groups ( n  = 6) for SI joint stabilization through S1 and S2 corridors using either two 7.5 mm cannulated compression headless screws (group CCH), two 7.3 mm partially threaded SI screws (group PT), or two 7.3 mm fully threaded SI screws (group FT). An SI joint dislocation injury type III APC according to the Young and Burgess classification was simulated before implantation. All specimens were biomechanically tested to failure in upright standing position under progressively increasing cyclic loading. Interfragmentary and bone-implant movements were captured via motion tracking and evaluated at four time points between 4000 and 7000 cycles. Results Combined interfragmentary angular displacement movements in coronal and transverse plane between ilium and sacrum, evaluated over the measured four time points, were significantly bigger in group FT versus both groups CCH and PT, p  ≤ 0.047. In addition, angular displacement of the screw axis within the ilium under consideration of both these planes was significantly bigger in group FT versus group PT, p  = 0.038. However, no significant differences were observed among the groups for screw tip cutout movements in the sacrum, p  = 0.321. Cycles to failure were highest in group PT (9885 ± 1712), followed by group CCH (9820 ± 597), and group FT (7202 ± 1087), being significantly lower in group FT compared to both groups CCH and PT, p  ≤ 0.027. Conclusion From a biomechanical perspective, S1-S2 SI joint fixation using two cannulated compression headless screws or two partially threaded SI screws exhibited better interfragmentary stability compared to two fully threaded SI screws. The former can therefore be considered as a valid alternative to standard SI screw fixation in posterior pelvis ring injuries. In addition, partially threaded screw fixation was associated with less bone-implant movements versus fully threaded screw fixation. Further human cadaveric biomechanical studies with larger sample size should be initiated to understand better the potential of cannulated compression headless screw fixation for the therapy of the injured posterior pelvis ring in young trauma patients.

Introduction : Superior and inferior ramus fractures, termed straddle fractures, are high-energy fractures often accompanied by unstable pelvic ring injuries. However, consensus is lacking regarding indications for surgical treatment or fixation methods. We aimed to compare clinical and radiological outcomes of unilateral ramus fixation (URF) and bilateral ramus fixation (BRF) for straddle fractures with unilateral posterior pelvic ring injuries. Materials and methods We enrolled 118 patients (73 males, 45 females; mean age, 47 years) diagnosed with straddle fractures between March 2015 and December 2021 with > 1 year of follow-up. Patients were divided into URF ( n  = 60) and BRF ( n  = 58) groups based on the anterior pelvic ring fixation method. Preoperative factors including body mass index, diabetes, smoking, injury mechanism, injury severity score, American Society of Anesthesiologists classification system, Tile classification, and Young and Burgess classification were compared. Intraoperative blood loss, operation time, postoperative bone union rate, complications, and the need for additional surgeries were analyzed. Results There were no statistically significant preoperative differences between the two groups. However, the URF group showed a significantly lower mean operative time and blood transfusion requirement (63 min and 2 units, respectively) than the BRF group (104 min and 3 units, respectively) (both p  < 0.001). Postoperatively, bone union was achieved in 57 (95.0%) and 56 (96.6%) patients in the URF and BRF groups, respectively. Complications occurred in 17 (28.3%) and 14 (24.1%) patients in the URF and BRF groups, respectively, with additional surgeries needed in 3 (5.0%) patients in the URF group and 2 (3.4%) patients in the BRF group. Conclusions Unilateral anterior fixation can provide sufficient stability and clinical effectiveness in the surgical treatment of straddle fractures in areas with posterior pelvic ring injuries. Compared with bilateral anterior fixation, unilateral fixation significantly reduces operation time and blood loss, making it a viable fixation method for straddle fractures.

Posterior pelvic ring injuries (i.e., sacro-iliac joint dislocations, fracture-dislocations, sacral fractures, pelvic non-unions/malunions) are challenging injury patterns which require a significant level of surgical training and technical expertise. The modality of surgical management depends on the specific injury patterns, including the specific bony fracture pattern, ilio-sacral joint involvement, and the soft tissue injury pattern. The workhorse for posterior pelvic ring stabilization has been cannulated iliosacral screws, however, trans-sacral screws may impart increased fixation strength. Depending on injury pattern and sacral anatomy, trans-sacral screws can potentially be more beneficial than iliosacral screws. In this article, the authors will briefly review pelvic mechanics and discuss their rationale for ilio-sacral and/or trans-sacral screw fixation.

Background This study investigated the clinical efficacy of Double INFIX for the treatment of unstable pelvic fractures. Methods We performed a retrospective analysis of 23 patients with unstable pelvic fractures treated using the Double INFIX minimally invasive technique. The cohort included five cases of Tile B1 type, eight cases of B2 type, six cases of B3 type, three cases of C1 type and one case of type C2. Pre- and postoperative evaluations included standardised pelvic serial films and three-dimensional CT scans. Key observational indicators were fracture reduction quality (assessed using Matta’s criteria), fracture healing, functional recovery (evaluated with the Majeed function assessment criteria), and incidence of complications. Results The mean follow-up duration was 24.48 ± 1.78 months. The average fracture healing time was 4.00 ± 1.41 months, and the average time for removal of fixation was 7.43 ± 1.75 months. Repeat imaging at 12 months postoperatively using Matta’s criteria showed eight cases with excellent results (52.17%), 13 cases with good results (34.78%), three cases with fair results (13.04%), and no cases with poor results. The combined excellent and good rate was 86.96%, whereas the fair rate was 13.04%. The average Majeed hip joint function score at the final follow-up was 95.04 ± 1.72. Postoperative complications included meralgia paresthetica in two cases (8.7%) and sacrococcygeal discomfort in three patients when lying flat. Conclusion Double INFIX is a minimally invasive treatment technique with adequate clinical efficacy for managing unstable pelvic fractures.

Background To analyze the perioperative bleeding and hidden blood loss (HBL) of sacroiliac screw minimally invasive treatment of pelvic posterior ring injury and explore the influential factors of HBL after operation for providing reference for clinical treatment. Method A retrospective analysis was conducted on data from 369 patients with posterior pelvic ring injuries treated with sacroiliac screws internal fixation at our hospital from January 2015 to January 2022. The research was registered in the Chinese Clinical Trial Registry in July 2022 (ChiCTR2200061866). The total blood loss (TBL) and HBL of patients were counted, and the factors such as gender, age, and surgical duration were statistically analyzed. The influential factors of HBL were analyzed by multiple linear regression. Results The TBL was 417.96 ± 98.05 ml, of which the visible blood loss (VBL) was 37.00 ± 9.0 ml and the HBL was 380.96 ± 68.8 ml. The HBL accounted for 91.14 ± 7.36% of the TBL. Gender, surgical duration, fixed position, and fixed depth had significant effects on the HBL ( P  < 0.05). Conclusions The HBL was the main cause of anemia after minimally invasive treatment of posterior pelvic ring injury with a sacroiliac screw. Gender, surgical duration, fixed position, and fixed depth were closely related to the occurrence of HBL. In clinical treatment, we should consider these influential factors and take effective measures to reduce the impact of HBL on patients.

Background: The management of lateral compression type 1 (LC-1) pelvic fractures remains controversial. Posterior fixation alone has traditionally been practiced without clearly defined indications for supplementary anterior stabilization. Direct comparative evidence between posterior-only and combined anterior–posterior fixation remains scarce. This study evaluated whether institutional criteria reliably identify patients who benefit from additional percutaneous anterior fixation. Methods: A retrospective cohort study was conducted at a level I trauma center and included adults with LC-1 fractures treated exclusively by percutaneous fixation. Combined anterior–posterior fixation was performed when predominant anterior pain and radiographic compromise indicated instability. Primary outcomes were pain trajectory (Numeric Rating Scale), inpatient opioid use, physiotherapy clearance, and ward mobility. Results: Thirty-seven patients were analyzed (combined = 14; posterior-only = 23). Preoperative pain was higher in the combined group (median 7 vs. 6; median difference 1 [95% CI 0 to 2]; p = 0.0036). Postoperatively, pain scores were lower in the combined group at 1–6 weeks (median difference −1 [95% CI −2 to 0]; p < 0.05). Opioid consumption was reduced (193 mg vs. 312 mg; median difference −200 mg [95% CI −280 to −120]; p < 0.001), and physiotherapy clearance occurred earlier (4 vs. 7 days; median difference −3 [95% CI −5 to −1]; p = 0.020). Conclusion: Our current indications to perform combined fixation were associated with favorable early outcomes in pain control and physiotherapy clearance among patients with LC-1 fractures showing anterior compromise. These results support a selective combined approach, though interpretation must remain cautious given the small retrospective cohort. Further prospective studies are warranted to validate these findings and refine patient selection.

Objective There are many advantages to stabilize the posterior pelvic ring injuries with a transiliac‐transsacral (TITS) screw percutaneously. To identify the correct entry point and insert a guidewire accurately for a TITS screw, we propose a method of specifying the optimal entry point, and introduce a technique of enabling freehand placement of a guidewire with fluoroscopic guidance. Methods In this retrospective study, 116 patients who underwent pelvic CT scans and pelvic lateral radiographs at our institution from January 2020 to April 2022 were enrolled. The optimal entry point for a TITS screw was formulated in the strict mid‐sagittal CT plane, and then transferred to the pelvic lateral radiograph relying on the sacral cortexes which were easily visible even in the poor fluoroscopy. The relative position of this point to other anatomical markers was checked to confirm its feasibility as an entry point. With the method to locate the entry point, 18 patients suffered the posterior pelvic ring injuries were treated with TITS screws through hammering a reverse Kirschner wire (K‐wire) to insert a guidewire assisted by a canula, followed by the validation of the screw placement accuracy. Results The transferred point in radiograph was consistently beneath the sacral alar slope, and located posteroinferior to the iliac cortical density (ICD) and anterosuperior to the sacral nerve root tunnel in all 116 patients. In clinical practice, 18 TITS screws were successfully placed in 18 patients without cortex violation. The average operative time for each screw was 20.11 ± 6.29 min, with an average of 14.11 ± 6.81 fluoroscopic shots per screw. At the 3‐month follow‐up, fracture healing was confirmed in all patients. The average Majeed score was 89.61 ± 6.90 at the final follow‐up. Conclusions It's feasible to identify an entry point for a TITS screw based on the sacral cortexes, and hammering a reverse K‐wire assisted by a percutaneous kyphoplasty (PKP) canula is a safe and practical technique for guidewire insertion. This study introduced an approach for the freehand placement of a TITS screw with fluoroscopic guidance. The sacral cortexes, which are easily visible even in the poor fluoroscopy, served as the reference for identifying an entry point. For accurate guidewire insertion, a reverse K‐wire was hammered into the cancellous bone assisted with a PKP canula.

Background Posterior pelvic ring injuries are challenging for surgeons to treat adequately due to difficulties with reduction and stabilization. Surgical intervention is a beneficial option to protect neurological structures and provide sufficient stability for early mobilization. The gull wing plate (GWP) is a pre-contoured anatomical locking plate with six screws, and its design is unique among posterior transiliac tension-band plates. The purpose of this study was to investigate clinical results of the GWP. Methods Patients who had an unstable posterior pelvic ring injury and underwent internal fixation with GWP were retrospectively analyzed at a trauma center. Demographic data, fracture type, perioperative data, and radiological evaluation with computed tomography (CT) were collected. Clinical outcomes were graded using the functional independence measure (FIM) and Majeed outcome score. Results Twenty-six patients were enrolled (mean age, 54 years), and the mean follow-up period was 23 months. The mean Injury Severity Score was 24 points, and internal fixation was performed 6.6 days post-trauma. CT evaluation showed the lateral surface angle of the uninjured ilium was approximately 68°. The GWP pre-contoured anatomical design closely matched this angle. The mean FIM and Majeed score were 119 and 76 points, respectively, which were graded as excellent ( n  = 14), good ( n  = 9), or fair ( n  = 3). Conclusions With the retrospective single-center data available, the GWP seems to be a minimally-invasive alternative, provides reliable stability of the posterior pelvic ring and allows for rehabilitation within normal ranges.

IntroductionBetween 2005 and 2017, the number of closed reduction and internal fixation of pelvic ring injuries increased by 1116%. Percutaneous fixation is currently the only minimally invasive technique that can stabilize the posterior elements of the pelvis. The purpose of this study was to investigate the utility of the inlet obturator oblique view (IOO) with the hypothesis that the IOO view will improve the accuracy of sacroiliac and transsacral screw placement in the S1 or S2 body and improve the accuracy of assessing whether the implant is fully seated against the outer cortex of the ilium.Materials and methodsTen male pelvic training models were used. Thirty-six screw configurations were inserted by a fellowship trained orthopedic trauma surgeon in appropriately and inappropriately placed sacroiliac and transsacral screw configurations. These configurations were imaged using fluoroscopy in different planes and saved for survey.ResultsFourteen orthopedic professionals reviewed 313 fluoroscopic images. Interrater reliability demonstrated marked improvement in assessment of whether the screw head was seated against the outer cortex of the ilium with the IOO view (kappa = 0.841, without IOO kappa = 0.027). There was a statistically significant difference in overall accuracy (p value < 0.001, OR = 1.57, 95% CI = 1.35–1.84) and whether the screw head was seated (p value < 0.001, OR = 8.14, 95% CI = 5.52–11.99) when compared with and without the IOO view (accuracy with IOO view: 85%, accuracy without IOO view: 78.26%; screw seated with IOO view: 93.93%, screw seated without IOO view: 65.54%). There was no significant difference (p value 0.465, OR = 1.13, 95% CI = 0.82–1.55) determining if the screw was in a safe position (safe with IOO view: 84.64%, safe without IOO view: 83.04%).ConclusionsOur findings demonstrate that misinterpretation of sacroiliac and transsacral screw placement can occur with the standard fluoroscopic imaging. We suggest the addition of the IOO view increases the overall accuracy of screw placement and whether the screw head is fully seated against the outer table of the ilium. This in turn can improve fixation and potentially improve patient outcomes and decrease adverse events.