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The application of percutaneous fixation techniques with pelvic

and acetabular fractures.

Rami Mosheiff

Percutaneous fixation of pelvic and

acetabular fractures

Unstable pelvic-ring injuries call for anatomical reconstruc- unsafe exposures. Additionally, some of the screw pathways,
tion and stable fixation to allow for early function. As the routinely used in percutaneous pelvic surgery, can be used
surrounding anatomical vicinity contains vital vulnerable in acetabular fracture fixation. The learning curve achieved
structures, the percutaneous surgical approach becomes an during pelvic surgery procedures can be utilized for more de-
attractive treatment option minimizing exposure, blood loss, manding acetabular surgery.
risk of infection, and protecting vital structures. To safely
apply percutaneous reduction and fixation techniques, a thor- Implementation Implementation of percutaneous pelvic
ough understanding of the complex three-dimensional pelvic and acetabular fracture surgery occurs in three stages: un-
anatomy and radiology is necessary. This knowledge is more derstanding the fracture and preoperative planning; indirect
complex than that required for long bone fixation. reduction techniques; and percutaneous fixation.

Indications Although percutaneous pelvic surgery is contro- Preoperative planning Although 3-D CT has considerably
versial [1], this approach has gained popularity due to the fol- improved the understanding of fracture patterns it has not
lowing: yet allowed the percutaneous placement of plates or improved
reduction techniques. Currently, the control of screw orienta-
• A pelvic-ring fracture is not an intraarticular fracture re- tion is possible only with fluoroscopy so strict pre-operative
quiring a perfect reduction so a “near anatomical” recon- planning is mandatory in percutaneous pelvic and acetabular
struction is accepted without significantly affecting the surgical treatment to avoid complications. Recently, computer
clinical outcome. programs have been developed enabling the performance of
• The percutaneous approach complements the more “open” virtually all steps of the real surgical procedure including de-
traditional method by minimizing the open approach in termination of the safe zones for fixation, precise planning of
certain areas where it can be safely implemented. screw dimensions, and pre-checking of the percutaneous op-
tion as an alternative to open approach (Figs 1–4) [2–3].
The percutaneous fixation of acetabular fractures has a com-
pletely different approach. This is a weight-bearing joint so Reduction A precise closed reduction is a prerequisite for
anatomical reconstruction is recommended and inaccuracy in percutaneous pelvic fixation and even more so for acetabular
reduction and/or fixation will result in a compromised out- fractures. As a consequence, there are three indications for
come. In certain circumstances, it is acceptable to achieve sec- percutaneous pelvic fixation: minimally displaced pelvic or
ondary congruency while avoiding the use of extensile and acetabular fractures, displaced fractures with a feasible closed

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 expert zone clinical topic 31

1a 1b

2 3

Fig 1a–b A computerized preoperative planning device (SQ Pelvis

software) enables complete virtual operation on the model acquired
from real patient data (CT). Using 3-D viewing tools, the virtual model
of a fractured acetabulum is built. Following reduction, fixation can
be undertaken. The direction and length of the screws is controlled by
turning the pelvis (a) or by making the bones more transparent (b).

Fig 2 Percutaneous screw insertion by means of computerized

fluoroscopic navigation system enables the simultaneous use of
several radiographic projections. This system has the potential to
significantly reduce radiation exposure and operative time, while
allowing the surgeon to achieve maximum accuracy.

Fig 3 Three-dimensional fluoroscopy allows the acquisition of CT-like

images during surgery by taking about 100 fluoroscopic x-ray images at
1° intervals with a motorized isocentric C-arm. The navigation images
4 consist of both CT and fluoroscopic x-ray images. The advantages
being that complex fractures can be better visualized and that CT
images, prior to and following reduction, can be taken.

Fig 4 Immediate postoperative x-ray. Closed disruption of left side of

pelvic ring with vertical displacement through left sacroiliac joint. The
patient was hemodynamically unstable on arrival.

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 32 1 | 08

5a 5b

Fig 5a–b Preoperative x-ray (a) and CT image (b).

reduction, and complex fractures in which a combination of Fixation Conventional fluoroscopy is used most frequently
closed and open reduction is necessary. It is quite clear that in percutaneous pelvic fixation. However, it provides only a
the development of closed reduction techniques is pertinent two-dimensional image and requires multiple images in dif-
for achieving a breakthrough in this field. Recently, innova- ferent projections to determine the correct point of entry and
tive table–skeletal pelvic fixation frames have been devised to trajectory of the screw resulting in prolonged exposure for the
secure the normal side of the pelvis to the table so as to more patient and surgical team screw position error and the need
effectively apply the reduction maneuvers to the displaced for a proficient and available radiology technician. The intro-
hemipelvis [4] (Figs 5–7). duction of computerized navigational systems may overcome
many of the previous objections to this technique [7–8]. Sev-
Intraoperative control Intraoperative rather than postopera- eral studies have already demonstrated higher precision, de-
tive confirmation of the reduction and fixation can save pa- creased radiation exposure and lower revision rates with the
tients and surgeons from uncertainty relating to the quality of use of navigation techniques for percutaneous screw fixation
reduction and implant position. The introduction of operative around the pelvis and acetabulum (Fig 1).
3-D imaging (SireMobil IsoC-3-D, Siemens Medical Solutions,
Erlangen, Germany), combines the capabilities of routine in- Summary The goals in the treatment of pelvic and acetabu-
traoperative fluoroscopy with resultant axial cuts, 2-D and lar fractures are achieving anatomic reduction of articular le-
3-D reformations. This unique imaging modality can help the sions (sacroiliac joint, acetabulum) followed by stable fixation.
surgeon assess the acetabulum and the posterior pelvic ring Only the experienced pelvic and acetabular surgeon has the
anatomy intraoperatively [5–6]. The persisting disadvantage surgical judgment and experience to decide if it is possible to
of 3-D fluoroscopes is a limited image size, however newer achieve these goals with a percutaneous procedure. If the dif-
modifications will allow superior image quality, increased ficulties entailed in integrating the new technology despite
field of view, higher spatial resolution, and soft-tissue visibil- its initial cumbersomeness is accomplished then the advanced
ity as well as the elimination of the need to rotate around a preplanning capabilities, improved accuracy of implant place-
fixed point (isocentricity). ment, significant reduction in radiation exposure, and cre-
ation of a powerful educational and quality control tool will
be available.

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 expert zone clinical topic 33

6 7a

Fig 6 After external fixation and arterial embolization.

Bibliography

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three-dimensional model to evaluate the intraosseous space available for
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(ISO-C-3D) image based computer assisted navigation in trauma surgery: Fig 7 The Starr frame assists with closed anatomical correction of
A preliminary report. Injury ; 39:39–43. the deformity. The device is based on table–skeletal pelvic fixation:
7. Mosheiff R, Khoury A, Weil Y, et al (2004) First generation securing the normal side of the pelvis to the table and maneuvering
computerized fluoroscopic navigation in percutaneous pelvic surgery. the other hemipelvis. After reduction, percutaneous sacro-illiac
J Orthop Trauma; 18(2):106–111. fixation can easily be achieved (Courtesy of Adam J. Starr, MD).
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and acetabular surgery – expectations, success and limitations. Injury ;
38(4):450–462.

Rami Mosheiff
Hadassah University Medical Center
Jerusalem, Israel
ramim@hadassah.org.il

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