INFIX-safe and effective surgical option for complex fracture patterns of the anterior pelvic ring: A prospective single center study
Introduction
Pelvic fractures are high energy injuries with disruption of the anterior and posterior bony and/or ligamentous structures. Fracture pattern dictates the type of implants and fixation strategy. Posterior injury is usually addressed with iliosacral screws, recon plates, or a combination based on fracture morphology whereas anteriorly a simple injury pattern like a diastasis (in APC injuries) can be fixed with symphyseal plating through pffenensteil incision. The challenge to reduction and fixation is of complex fracture patterns of the anterior ring (bilateral superior pubic rami and inferior pubic rami fractures, comminuted fractures, segmental fractures which remain unstable after posterior fixation). Such cases need extensile anterior approach like a modified Stoppa's or bilateral ilioinguinal approach to address the injury. These extensile approaches are obviously associated with increased operative time, blood loss and increased risk of infection.
Definitive external fixation for anterior ring injuries, which is usually reserved for cases with urogenital injuries and open injuries with inadequate soft tissue coverage can also be used for such complex fracture patterns of anterior ring.1,2,3 However, it is associated with various complications like pin site infection rates (2%–40%), limited access to the abdomen, decreased patient mobility, along with aseptic loosening and are not accepted well by patients.3
Procedures comprising of pedicle screws fixed into the ilium on either side and connected to each other with subcutaneous rod, with or without fixation into the symphyseal region are described as the pelvic bridge or INFIX technique. This procedure is an MIO technique (Minimally invasive osteosynthesis) and has potential benefits like fewer soft tissue infections, better pain control, better patient mobilization and hence faster rehabilitation. This procedure could be of potential use in complex fracture patterns of anterior pelvic ring and avoid morbidity due to decreased intraoperative time and blood loss compared to conventional techniques.4
As the procedure is an MIO technique relying upon indirect reduction technique and therefore functional reduction, its utility in achieving reduction, maintaining reduction, and achieving bony union needs to be evaluated.
The present study was conducted to evaluate the subcutaneous pedicle screw–bar fixation (INFIX) as a minimally invasive procedure for unstable pelvic ring injuries with complex fracture patterns of the anterior ring, in the respects of its feasibility, merits, limitations, safety, and complications in the Indian population.
Section snippets
Materials and methods
Study Design and Setting- This study was a prospective analysis of patients presenting with pelvic fractures to a tertiary care center (single center) between Jan 1, 2018 to Dec 31, 2018.
Participants- All cases were screened by 2 pelvic surgeons independently and assessed for need of anterior INFIX. In case of conflicting decision, a close discussion between both surgeons was done and a consensus was arrived upon. The basis for selection of patients was primarily the fracture morphology with
Results
A total of 112 patients presented with pelvic fractures during the study duration, of which 12 patients were selected for INFIX application (Baseline data illustrated in Table 1). The mean age of the patients was 37.08 ± 15.65 years with an average follow up of 6 months. According to Young and Burgess classification, 1 patient was classified as LC2 type, 6 patients as LC3 injury pattern type, 3 patients as VS type and 2 patients fell into combined mechanism type. Tile's anterior pelvic
Discussion
Pelvic injuries are complex injuries with disruption of multiple bony and/or ligamentous components both anteriorly and posteriorly. Initially most anterior injuries were left unattended after posterior stabilization. Over time the importance of addressing anterior injury has been evolving and emphasized.7,8 Commonly used methods for anterior fixation include plating, percutaneous screws and external fixator. Anterior plating is considered as method of fixation for symphyseal injuries.4
Conclusion
INFIX and percutaneous iliosacral screws combined together is a biomechanically stable and effective minimally invasive surgical technique for definitive management of complex pelvic ring injuries in presence of anterior comminution. It is capable of achieving good fracture reduction with good functional and radiological outcomes leading to better patient satisfaction. The vital structures which are in close proximity to implant are not at risk if safe surgical technique is followed as shown by
Source of funding
Nil.
Declaration of competing interest
None.
References (24)
- et al.
Surgical complications and implications of external fixation of pelvic fractures
Injury
(1997) - et al.
Midterm radiologic and functional outcomes of minimally-invasive fixation of unstable pelvic fractures using anterior internal fixator (INFIX) and percutaneous iliosacral screws
J Clin Orth Trauma
(2017) - et al.
“Anterior subcutaneous pelvic internal fixator (INFIX), Is it safe?” A cadaveric study
Injury
(2016) - et al.
Anterior subcutaneous internal fixation of the pelvis− what rod-to-bone distance is anatomically optimal?
Injury
(2017) - et al.
Distraction external fixation in lateral compression pelvic fractures
J Orthop Trauma
(2000) - et al.
Internal fixation in pelvic fractures and primary repairs of associated genitourinary disruptions: a team approach
J Trauma Acute Care surg
(1996) - et al.
INFIX versus plating for pelvic fractures with disruption of the symphysis pubis
Int Orthop
(2017) - et al.
Fractures of the pelvis
- et al.
Outcome of operatively treated unstable posterior pelvic ring disruptions
Clin Orthop Relat Res
(1996) - Tonetti J. Management of recent unstable fractures of the pelvic ring. An update Conference supported by the Club...
OTA highlight paper predicting future displacement of nonoperatively managed lateral compression sacral fractures: can it be done?
J Orthop Trauma
Minimally invasive treatment of unstable pelvic ring injuries with modified pedicle screw–rodfixator
J Int Med Res
Cited by (5)
Functional outcomes of the anterior subcutaneous internal pelvic fixator (INFIX) technique for pelvic ring injuries: A case series
2021, InjuryCitation Excerpt :In a multicenter study, Vaidya et al. [3] evaluated the function of patients undergoing INFIX and reported that 100% of their patients could sit, stand, and walk with the device in place. Sharma et al. [23] reported an overall Majeed score of 92.6 points and an average IPS of 93.9 points. Steer et al. [1] reported an average IPS of 79.7, ranging from 52 to 100.
Progress in minimally invasive techniques for pelvic fractures
2023, Chinese Journal of Orthopaedic TraumaArterial angioembolisation versus pre-peritoneal pelvic packing in haemodynamically unstable patients with complex pelvic fractures: a meta-analysis
2023, European Journal of Trauma and Emergency Surgery