Veterinary Surgery, 20, 2, 91-96, 1991

Stabilization of Bilateral Sacroiliac FracturerLuxations

in Small Animals with a Single Transsacral Screw

Bilateral sacroiliac fracture-luxations in four dogs and four cats weighing 3.5 kg to 30.9 kg
were reduced and stabilized with a single 3.5 mm, 4.5 mm, or 6.5 mm transsacral screw.
Alignment of the drill bit was visual in six cases and assisted by the use of an aiming device
in two cases. Seven animals were reevaluated at months 3 to 6. No significant screw loosening
or loss of reduction had occurred. Although no intraoperative complications were encountered
with visual drill bit alignment, use of an aiming device for transsacral drilling is strongly rec-
ommended.

AINFUL AND debilitating displacement of the pelvis
P can result from multiple pelvic fractures, pelvic frac-
tures with sacroiliac fracture-luxations, or bilateral sacro-
iliac fracture-luxations. In one retrospective study of sa-
croiliac fracture-luxations in dogs, 23% (2 1/92) were bi-
lateral.' At the New York State College of Veterinary
Medicine. sacroiliac fracture-luxation was diagnosed in
132 dogs and cats from January 1977 to January 1989.
The lesion was bilateral in 46% (34/74) of the cats and
26% ( 15/58) of the dogs.*
Conservative treatment and several methods of surgical
stabilization have been described for small animals with
sacroiliac fracture-l~xation.*-~ Fixation with a screw
placed in lag fashion is generally regarded as supenor to
Steinmann pin or Kirschner wire fixation. In a retrospec-
tive study in dogs, however, premature screw loosening
occurred in 38% of the dogs with lag fixation.' Premature
screw loosening was correlated with screws placed in lo-
cations other than the first sacral body and screws tra-
versing less than 60% of the sacral width.' If lag fixation
is used bilaterally in small animals with bilateral sacroiliac
fracture-luxation, less than optimal screw placement is
inevitable because the first sacral body is so small. Sta-
bilizing bilateral sacroiliac fracture-luxations with a single
transsacral screw was developed to decrease the postop-
erative complications of premature screw loosening and
loss of reduction. The purpose of this report is to describe
the technique and document the use of single transsacral
screw stabilization in eight small animals.
Materials and Methods
Bilateral sacroiliac fracture-luxations in four dogs
weighing 12.7 kg to 30.9 kg and four cats weighing 3.5
kg to 7.0 kg were stabilized with a single transsacral screw.
All the animals had unilateral or bilateral pelvic fractures
and other musculoskeletal injuries. The animals were
anesthetized, prepared for aseptic surgery over the dorsum
of the lumbosacral region. and placed symmetrically in
sternal recumbency on a form-fitting vacuum-activated
positioner.? The animals were positioned in moderate
coxofemoral extension (Fig. I ).
A separate dorsal approach was made to each sacroiliac
joint.' In three dogs and three cats, reduction of the first
sacroiliac joint was accomplished by inspection and su-
perimposition of the sacral and ilia1 cartilaginous C-shaped
auricular surfaces.' The reduced sacroiliac joint was com-
pressed with speed lock reduction forceps, and a Kirschner
wire was inserted across the joint caudal to the center of
the C-shaped auricular surfaces for temporary fixation

* Kaderly RE. llnpublished data. t Vac-Pac. Kirschner-Collison. Aherdeen Maryland.

From the Department of Clinical Sciences, Cornell University, College of Veterinary Medicine, Ithaca, New York.
Presented at the Twenty-Fifth Annual Meeting, American College of Veterinary Surgeons, February 23, 1990.
The author thanks Paula Bensadoun for the illustrations.
Reprint requests: Robert Kaderly, DVM, PhD, Department of Clinical Sciences, Cornell University, College of Veterinary Medicine, Ithaca, NY
14853.
91
92 BILATERAL SACROILIAC FRACTURE-LUXATIONS
,
Fig, , A cat positioned in sternal recumbency for separate dorsal
approaches to each sacroiliac joint.
Fig. 2. The first (right) sacroiliac joint is reduced, compressed with
reduction forceps, and stabilized temporarily with a Kirschner wire.
Fig. 3. On the nonreduced (left) side, a drill bit is placed in the center
of the auricular cartilage of the sacrum and aligned visually for trans-
sacral drilling. (Inset) After drilling, a tap is used to cut threads in the
transsacral drill hole.
(Fig. 2). A drill bit was aligned in the center ofthe auricular
surface of the sacrum on the nonreduced side and directed
perpendicular to the palpable line of lumbar spinous pro-
cesses and parallel to the surface of the operating table
(Fig. 3). The drill bit was advanced carefully until its tip
emerged from the lateral surface of the reduced ilial wing.
The length of the drilled hole through the sacrum, one
sacroiliac joint, and one ilial wing was measured. The
measurement was increased to include the nonreduced
ilia1 wing and sacroiliacjoint, and a washer; a screw several
Fig. 4. The second (left) sacroiliac joint is reduced and stabilized by
insertinga screw through the glide hole in the ilia1 wing into the trans-
sacral hole. Lag compression is accomplished at the second sacroiliac
joint by tighteningthe screw; the first sacroiliac joint is stabilized when
the screw tip passes through the (right) ilia1 wing. The Kirschner wire
is removed.
 KADERLY
Fig. 5. As an alternative to visual drill bit alignment, an aiming device
is used to align the drill bit for transsacral drilling. The aiming device
is centered in the sacral auricular surfaces and the transsacral hole is
drilled before reduction of either sacroiliac joint.
millimeters longer was selected. A tap was used to cut
threads in the transsacral drill hole and reduced ilia1 wing
(Fig. 3, insert). A glide hole was drilled in the center of
the auricular surface of the nonreduced ilia1 wing, the
screw with a washer was placed through the nonreduced
ilia1 wing, and the second sacroiliac joint was reduced.
The screw was advanced through the sacral body and op-
posite ilia1 wing and seated firmly (Fig. 4).Adequate screw
length was confirmed by observing several millimeters of
screw threads emerging from the lateral surface of the
opposite ilia1 wing. The Kirschner wire for temporary fix-
ation of the first sacroiliac joint was removed.
In one dog and one cat, an alternate method of trans-
sacral screw placement was used. Before reduction of the
first sacroiliac joint, an aiming device$ was centered bi-
laterally in the C-shaped auricular cartilages of the sacrum
(Fig. 5). A drill bit was inserted in the aiming device and
the transsacral hole was drilled. One sacroiliac joint was
reduced and fixed temporarily with a Kirschner wire, and
the drill bit was advanced through the reduced dial wing.
The remaining steps were as previously described. The
incisions were closed.
All animals were evaluated at week 2, and seven animals
were reevaluated by physical and radiographic examina-
tion between months 3 and 6 .
Results
No complications occurred during any of the surgical
procedures. Adequate reduction of all sacroiliacjoints and
Screw 'lacement sacral bodies were
4 Combined Aiming Device Set, Synthes. Paoli, PA.
93
Fig. 6. Preoperative pelvic radiographs of an 8-year-old domestic
shorthair cat (animal 1) with bilateral sacroiliac luxations and fractures
of the pubis and right ischiurn.
documented radiographically (Figs. 6, 7). On day 1, all
animals seemed to be more comfortable, and seven ani-
mals in which transsacral screw stabilization reestablished
continuity of the weight-bearing column between the pel-
vic limbs and axial skeleton were able to stand and am-
bulate. One animal with a unilateral comminuted ace-
tabular fracture requiring excision arthroplasty did not
begin ambulating until day 3. Physical examination of all
animals at week 2, and physical and radiographic ex-
amination of seven animals at months 3 to 6, revealed
no evidence of sacroiliac instability or loss of reduction.
One dog (animal 6) was able to ambulate well and both
sacroiliac joints were stable at week 2, but it was lost to
further follow-up. Loss of reduction was not visible in the
follow-up radiographs of any sacroiliac joint. In two cats
(animals I , 4)the joint space compressed only with forceps
appeared slightly wider at months 3 and 3%, respectively.
Discussion
Sacroiliac fracture-luxation may be treated nonsurgi-
cally if displacement is minimal. Bilateral sacroiliac frac-
Fig. 7. Postoperative pelvic radiographs of animal 1 . Reduction and
fixation with a single transsacral screw have reestablished the weight-
bearing column between the pelvic limbs and axial skeleton.
94 BILATERAL SACROILIAC FRACTURE-LUXATIONS

TABLE 1. Dogs and Cats with Bilateral Sacroiliac Luxations that, in v i v a a single large screw could be placed more
Stabilized with a Transsacral Screw accurately in the sacral body and was less likely to loosen
Animal Weight Screw Size Screw Length than two inaccurately placed smaller screws.'" When sa-
No. Species/Breed (kg) (mm) (mm) croiliac fracture-luxations require bilateral surgical sta-
1 DSH 3.5 3.5 36 bilization, the sacral body is not large enough to receive
2 DSH 3.9 4.0 36 the strongest fixation reported-two large screws across
3 DSH 4.1 4.0 36 each sacroiliac joint. No significant improvement in the
4 DSH 7.0 4.5 40 strength of repair was found with the addition of a
5 Cocker spaniel 12.7 6.5 65
6 American Eskimo 14.1 4.5 64
Kirschner wire to single-screw fixation."
7 Poodle 18.0 6.5 70 Successful transsacral screw fixation requires accurate
8 Labrador retriever 30.9 6.5 85 drilling. Proper alignment must be maintained for the
drill bit to remain in solid bone. Dorsoventral malalign-
DSH-Domestic shorthaired cat.
ment could cause the drill bit to exit ventrally into the
pelvic cavity or dorsally into the spinal canal. Craniocau-
ture-luxations often result in significant displacement of dal malalignment could cause the drill bit to enter the
the ilia, narrowing of the pelvic canal, and loss of the L7-S 1 intervertebral disc or the weaker bone of the second
weight-bearing column between the hind limbs and the sacral vertebra. Minor malalignments are insignificant if
axial skeleton. In these instances, surgical stabilization the center of the auricular surface of the sacrum is used
helps diminish patient discomfort and permits earlier as a starting point for transsacral drilling. Slow power
ambulation. Dorsolateral or ventrolateral surgical ap- drilling or short interrupted bursts of power provide an
proaches to the sacroiliacjoint6.*with the animal in lateral opportunity for rechecking drill bit alignment and reassure
recumbency preclude bilateral reduction and fixation. the surgeon that drilling is progressing in solid bone. The
With the patient in sternal recumbency, exposure of the aiming device facilitates proper drill bit alignment and
auricular surfaces of the sacroiliac joint through a dorsal significantly reduces the risk of damage to neurovascular
approach' facilitates precise reduction of unilateral or bi- structures; its use is strongly recommended. In future
lateral sacroiliac fracture-luxations, and proper implant cases, use of the 4.5 mmll or 3.5 mmll cannulated screw
location can be consistently achieved. systems for placing a cannulated transsacral screw may
Previously described fixation methods included crossed be superior to the methods and materials described
Steinmann pins,' a Kirschner wire and a screw placed in here.
lag f a ~ h i o n two
, ~ screws placed in lag f a ~ h i o n ,or
~ . one
~ The thread diameter of a transsacral screw should be
large screw placed in lag fashion.'.' For bilateral sacroiliac more than half the size of the auricular cartilage. The
fracture-luxations, the fixation technique on one side was appropriate screw diameter can be estimated from an an-
usually repeated on the opposite side. A transverse bolt5 imal's size (Table 1). The author's guidelines for selecting
through the ilial wings has been suggested for additional the appropriate screw diameter are given in Table 2. Be-
~tability.~.' cause the bone of the sacral body and ilial wing is soft,
Two reports support the conclusion that single trans- cancellous screws are preferable to cortical screws placed
sacral fixation is effective for bilateral sacroiliac fracture- in lag fashion. In cats and small dogs, the author prefers
luxations. In the review of canine sacroiliac fracture-lux- the 4.0 mm fully threaded cancellous screw (coarse threads
ations in which 38% of the screws placed in lag fashion
loosened prematurely, only 12% of the screws within the I' DHSO Basic Set, Synthes, Paoli. PA.

sacral body loosened and only 7% of the screws traversing ll Small Cannulated Screw Instrument and Implant Set, Synthes, Paoli.
PA.
more than 60% ofthe sacral width loosened.' The authors
concluded that one large screw properly placed in the body
of the sacrum adequately stabilized the sacroiliac joint
and was effective in minimizing premature implant loos- TABLE 2. RecommendedScrew Diameters'
ening and loss of reduction. In an in v i m investigation According to Patient Size
of the shear, torsional, and bending strengths of various Screw Diameter Patient Size
unilateral sacroiliac fracture-luxations, fixation strength
2.7 mm Cortical Very small toy breeds, kittens
was maximized by using the largest screw diameter pos- (0.5-2 kg)
sible." Although two accurately placed small screws were 3.5 mm Cortical or 4.0 mm Small dogs, cats (2.0-4.0 kg)
stronger than a single large screw, the authors suggested Cancellous
4.5 mm Cortical Medium size dogs (4.0-12 kg)
6.5 mm Cancellous Large, giant dogs (>12 kg)
5 Richards Osteoporotic Bone Bolt, Richards Medical Co, Memphis,
TN. Outside thread diameter.
 KADER LY 95

Fig. 8. Ventrodorsal radiographs of a canine pelvis with a properly placed transsacral screw. A. Conventional positioning superimposes the
image of the screw over the sacral canal. B. With an angled beam, accurate positioning of the screw across the sacroiliac joints and sacrum is
documented

and 2.0 mm core) over the 3.5 mm cortical screw (fine
threads and 2.5 m m core). Fully threaded screws require
a glide hole in the ilium to accomplish lag compression
at the sacroiliac joint, but partially threaded screws do
not. A stainless steel washer prevents the screw head from
sinking into the ilium during final tightening, particularly
in immature animals with soft bone.
Compression of the sacroiliac joints is desirable to in-
crease frictional forces that add stability to the fixation.
If the joint is anatomically reduced, interdigitation of ad-
jacent bony projections helps prevent rotational instabil-
ity. Because placing a screw in lag fashion provides more
compression than reduction forceps, the more unstable
joint should receive the lag compression. For greater
compression of the forceps-compressedjoint, a transsacral
bolt with washer and nut§ or a nut# tightened on the
exposed tip of a transsacral screw could be used. A glide
hole in each ilia1 wing would be necessary if a washer and
nut were to be used for greater compression. However,
# Nut for 4.5rnrn Cortex Screw, Synthes, Paoli. PA.
more compression than that afforded by reduction forceps
may not be necessary, since no loss of reduction was iden-
tified in this study. Widening of the forceps-compressed
sacroiliac joint in follow-up radiographs of two cats may
have been artifacts caused by slightly different positioning.
Both joints of all animals reevaluated at months 3 to 6
remained reduced. Additional followups were not con-
sidered necessary since only 6 to 8 weeks are probably
adequate for healing and recovery of mechanical strength
of the dorsal and ventral sacroiliac ligaments and joint
capsule.’
Postoperative radiographic interpretation of the lo-
cation of a transsacral screw is complicated by two fac-
tors. Routine ventrodorsal positioning of the pelvis re-
sults in radiographic superimposition of a properly lo-
cated transsacral screw over the sacral canal. An angled-
beam view through the pelvic canal is needed to doc-
ument the position of a transsacral screw within the
sacral body (Fig. 8). On a lateral radiographic view, the
metallic washer obscures the precise axial alignment of
the screw.
96 BILATERAL SACROILIAC FRACTURE-LUXATIONS

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