The use of the transpedicular spinal system and titanium mesh cage in surgical treatment of post‑traumatic pelvic deformity: a case study and a brief literature review

Introduction. The problem of treating chronic unstable pelvic injuries is characterized by the complexity of delayed one-step or staged reduction, difficulties in choosing the technology and treatment options, complexity of selecting criteria for evaluating planning along with the effectiveness of treatment. The use of spinal systems to perform reduction manipulations and fixation of the pelvis is described in few clinical observations. Therefore, the assessment of the effectiveness of the sequential use of various fixation systems in one patient was regarded by the authors as a rare opportunity and determined the purpose of the study.

Purpose. Demonstration of the possibilities of various osteosynthesis methods and their combination in reconstructive surgery of the pelvis in a case of its severe chronic injury.

Materials and methods. We present a clinical case and a brief analysis of the literature. A case of a patient with post-traumatic pelvic deformity and imbalance syndrome as a leading component of pelvic ring deformity is presented by us. The effectiveness of reconstruction options, including those with the use of spinal systems, was analyzed. The treatment was assessed with radiological study methods (X-ray and CT) with balance evaluation on a digital platform and functional scores for the quality of life.

Results. Correction of frontal deformity of the pelvis was achieved with compensation for a relative shortening of the left lower extremity, restoration of the center of rotation of the hip joints, and relief of pain in the lumbar region. The functional state according to the Majeed score system and clear radiological signs of stabilization of the pelvic ring while maintaining the position of the acetabulum in the frontal plane prove the effectiveness of hybrid osteosynthesis with the use of spinal fixation systems.

Conclusion. The leading syndromic complexes are instability with clinical manifestations of non-union and pain along with an imbalance syndrome, manifested by a gross deformation of the pelvic ring. Syndromic evaluation determines the tactics of surgical treatment while a detailed planning of the sequence of intervention, choice of the level of osteotomy, combination of osteosynthesis options using spinal fixation systems provide the solution of reconstructive pelvic surgery tasks in one session.

1. Shlykov I.L., Kuznetsova N.L. Algoritm vybora metoda operativnogo lecheniia bolnykh s posttravmaticheskimi deformatsiiami tazovogo koltsa [Algorithm of selecting the technique of surgical treatment of patients with pelvic ring posttraumatic deformities]. Genij Ortopedii, 2010, no. 2, pp. 70-73. (in Russian)

2. Tile M., Kellam J., Helfet D., eds. Fractures of the pelvis and acetabulum. 3rd Edition. Lippincott, Williams & Wilkins. 2003. 600 p.

3. Cherkes-Zade D.I. Lechenie povrezhdenii taza i ikh posledstvii: ruk. dlia vrachei [Treatment of the pelvis injuries and their consequences: guide for physicians]. M., Meditsina, 2006, 191 p. (in Russian)

4. Grishchuk M.E., Puseva N.V. Tishkov V.Iu., Vasilev V.Iu. Operativnoe lechenie nesvezhikh i zastarelykh dvustoronnikh rotatsionno-nestabilnykh povrezhdenii taza (obzor literatury) [Surgical treatment of stale and long-standing bilateral rotationally unstable pelvic injuries (review of the literature)]. Biulleten Vostochno-Sibirskogo Nauchnogo Tsentra Sibirskogo Otdeleniia Rossiiskoi Akademii Meditsinskikh Nauk, 2010, no. 5 (75), pp. 222-232. (in Russian)

5. Martel I.I., Shvedov V.V. Vozmozhnosti vneshnei fiksatsii po printsipam Ilizarova pri zakrytom vosstanovlenii formy i stabilnosti tazovogo koltsa u bolnykh s zastarelymi povrezhdeniiami taza [Possibilities of external fixation according to Ilizarov principles for closed restoration of pelvic ring shape and stability in patients with advanced pelvic injuries]. Genij Ortopedii, 2013, no. 2, pp. 5-9. (in Russian)

6. Sergeev S.V., Ananin D.A., Grishanin O.B. Dinamicheskaia plastina dlia fiksatsii perednego polukoltsa taza pri nestabilnykh povrezhdeniiakh tazovogo koltsa [A dynamic plate for fixing the anterior pelvic semi-ring in case of unstable injuries of the pelvic ring]. Klinicheskii Opyt Dvadtsatki, 2013, no. 4 (20), pp. 57-62. (in Russian)

7. Tripathy S.K., Goyal T., Sen R.K. Nonunions and malunions of the pelvis. Eur. J. Trauma Emerg. Surg., 2015, vol. 41, no. 4, pp. 335-342. DOI: 10.1007/s00068-014-0461-0

8. Giannoudis P.V., Psarakis S., Kanakaris N.K., Pape H.C. Biological enhancement of bone healing with bone morphogenetic protein-7 at the clinical setting of pelvic girdle non-unions. Injury, 2007, vol. 38, no. Suppl. 4, pp. S43-S48. DOI: 10.1016/s0020-1383(08)70008-1

9. Lindahl J. Delayed and late reconstructions of the pelvis. Suom. Ortop. Traumatol., 2011, vol. 34, no. 1, pp. 43-48.

10. Borozda I.V. Sistematizatsiia znanii po biomekhanike tazovogo koltsa [Systematization of knowledge in biomechanics of the pelvic ring]. Dalnevostochnyi Meditsinskii Zhurnal, 2009, no. 2, pp. 129-132. (in Russian)

11. Runkov A.V., Kutepov S.M., Stelmakh K.K. Antoniadi Yu.V. Ustranenie travmaticheskikh deformatsii taza // lechenie povrezhdenii i zabolevanii kostei taza [Elimination of traumatic pelvic deformities]. Materialy iubileinoi mezhdun. nauch.-prakt. konf. travmatologov-ortopedov “Novye tekhnologii v lechenii povrezhdenii i zabolevanii oporno-dvigatelnoi sistemy” [Proceedings of Anniversary International Scientific-and-Practical Conference of Traumatologists and Orthopedists]. Ekaterinburg, 2001, pp. 48-50. (in Russian)

12. Kanakaris N.K., Angoules A.G., Nikolaou V.S., Kontakis G., Giannoudis P.V. Treatment and outcomes of pelvic malunions and nonunions: a systematic review. Clin. Orthop. Relat. Res., 2009, vol. 467, no. 8, pp. 2112-2124. DOI: 10.1007/s11999-009-0712-2

13. Ziran B.H., Chamberlin E., Shuler F.D., Shah M. Delays and difficulties in the diagnosis of lower urologic injuries in the context of pelvic fractures. J. Trauma, 2005, vol. 58, no. 3, pp. 533-537. DOI: 10.1097/01.ta.0000152561.57646.80

14. Shchetkin V.A., Chernyshev A.S., Ivanov P.A., Fain A.M., Chukina E.A., Vorontsova Iu.A. Metodika rannei reabilitatsii u patsientov s povrezhdeniem tazovogo koltsa [The technique of early rehabilitation in patients with the pelvic ring damage]. Fizioterapiia, Balneologiia i Reabilitatsiia, 2013, no. 4, pp. 13-16. (in Russian)

15. Tiliakov A.B., Valiev E.Iu., Ubaidullaev B.S. Primenenie sterzhnevogo apparata vneshnei fiksatsii v kompleksnom lechenii nestabilnykh perelomov kostei taza pri sochetannoi travme [The use of a rod device for external fixation in the complex treatment of unstable fractures of pelvic bones in case of concomitant injury]. Zhurnal im. N.V. Sklifosovskogo «Neotlozhnaia Meditsinskaia Pomoshch», 2014, no. 2, pp. 32-37. (in Russian)

16. Smirnov A.A., Pavlov D.V. Operativnoe lechenie nestabilnykh povrezhdenii taza i ikh posledstvii [Surgical treatment of unstable pelvic injuries and their consequences]. Meditsinskii Almanakh, 2012, no. 5, pp. 148-151. (in Russian)

17. Shlykov I.L., Kuznetsova N.L. Kompleksnoe lechenie bolnykh s nestabilnymi perelomami taza na osnove lechebno-diagnosticheskikh algoritmov [Complex treatment of patients with unstable pelvic fractures on the basis of treatment and diagnostic algorithms]. Sistemnaia Integratsiia v Zdravookhranenii, 2009, no. 4, pp. 3-9. (in Russian)

18. Bignardi C., Terzini M., Aprato A., Audenino A.L., Costa P., Massai D., Massè A., Zanetti E.M. Pelvic manipulator for fractures reduction. International Journal of Mechanical Engineering and Technology, 2018, vol. 9, no. 3, pp. 570-580.

19. Wu X., Li Y., Sun X., Wang J., Zhao C., Yang M., Zhu S., Cao Q., Wu H., Wang M. Modeling of unstable pelvic fractures for 20° sagittally rotated pelvic displacement. Med. Eng. Phys., 2015, vol. 37, no. 11, pp. 1076-1081. DOI: 10.1016/j.medengphy.2015.08.015

20. Dimitriou R., Giannoudis P.V. Pelvic fractures. Surgery (Oxford), 2012, vol. 30, no. 7, pp. 339-346.

21. Eckardt H., Egger A., Hasler R.M., Zech C.J., Vach W., Suhm N., Morgenstern M., Saxer F. Good functional outcome in patients suffering fragility fractures of the pelvis treated with percutaneous screw stabilisation: Assessment of complications and factors influencing failure. Injury, 2017, vol. 48, no. 12, pp. 2717-2723. DOI: 10.1016/j.injury.2017.11.002

22. Zamzam M.M. Unstable pelvic ring injuries. Outcome and timing of surgical treatment by internal fixation. Saudi Med. J., 2004, vol. 25, no. 11, pp. 1670-1674.

23. Kanezaki S., Rommens P.M. Bilateral nonunion of the sacrum in a long-term paraplegic patient treated with trans-sacral bar and spinopelvic fixation. Arch. Orthop. Trauma Surg., 2015, vol. 135, no. 3, pp. 345-349. DOI: 10.1007/s00402-014-2143-0

24. Witvliet M.J., Ping Fung Kon Jin P.H., Goslings J.C., Luitse J.S., Ponsen K.J. Historical treatment results of pelvic ring fractures: a 12-year cohort study. Eur. J. Trauma Emerg. Surg., 2009, vol. 35, no. 1, pp. 43-48. DOI: 10.1007/s00068-008-7107-z

25. Akbar M., Arshad R.M., Hanif M., Rana R.E. Treatment of open book pelvic fractures: Comparison between internal and external fixation. Pakistan Journal of Medical and Health Sciences, 2012, vol. 6, no. 3, pp. 662-665.

26. Iorio J.A., Jakoi A.M., Rehman S. Percutaneous Sacroiliac Screw Fixation of the Posterior Pelvic Ring. Orthop. Clin. North Am., 2015, vol. 46, no. 4, pp. 511-521. DOI: 10.1016/j.ocl.2015.06.005

27. Blum L., Hake M.E., Charles R., Conlan T., Rojas D., Martin M.T., Mauffrey C. Vertical shear pelvic injury: evaluation, management, and fixation strategies. Int. Orthop., 2018, vol. 42, no. 11, pp. 2663-2674. DOI: 10.1007/s00264-018-3883-1

28. Dienstknecht T., Pfeifer R., Horst K., Sellei R.M., Berner A., Zelle B.A., Probst C., Pape H.C. The long-term clinical outcome after pelvic ring injuries. Bone Joint J., 2013, vol. 95-B, no. 4, pp. 548-553. DOI: 10.1302/0301-620X.95B4.30804

29. Hessmann M.H., Rickert M., Hofmann A., Rommens P.M., Buhl M. Outcome in pelvic ring fractures. Eur. J. Trauma Emerg. Surg., 2010, vol. 36, no. 2, pp. 124-130. DOI: 10.1007/s00068-010-1042-0

30. Acklin Y.P., Marco G., Sommer C. Double locking plate fixation of sacral fractures in unstable pelvic ring C-type injuries. Oper. Orthop. Traumatol., 2015, vol. 27, no. 1, pp. 74-79. DOI: 10.1007/s00064-014-0307-2

31. Vanderschot P., Daenens K., Broos P. Surgical treatment of post-traumatic pelvic deformities. Injury, 1998, vol. 29, no. 1, pp. 19-22. DOI: 10.1016/s0020-1383(97)00111-3

32. Rousseau M.A., Laude F., Lazennec J.Y., Saillant G., Catonné Y. Two-stage surgical procedure for treating pelvic malunions. Int. Orthop., 2006, vol. 30, no. 5, pp. 338-341. DOI: 10.1007/s00264-006-0089-8

33. Lee K.J., Min B.W., Oh G.M., Lee S.W. Surgical correction of pelvic malunion and nonunion. Clin. Orthop. Surg., 2015, vol. 7, no. 3, pp. 396-401. DOI: 10.4055/cios.2015.7.3.396

34. Mears D.C., Velyvis J. Surgical reconstruction of late pelvic post-traumatic nonunion and malalignment. J. Bone Joint Surg. Br., 2003, vol. 85, no. 1, pp. 21-30. DOI: 10.1302/0301-620x.85b1.13349

35. Matta J.M., Dickson K.F., Markovich G.D. Surgical treatment of pelvic nonunions and malunions. Clin. Orthop. Relat. Res., 1996, no. 329, pp. 199- 206. DOI: 10.1097/00003086-199608000-00024

36. Wright J.L., Nathens A.B., Rivara F.P., MacKenzie E.J., Wessells H. Specific fracture configurations predict sexual and excretory dysfunction in men and women 1 year after pelvic fracture. J. Urol., 2006, vol. 176, no. 4, Pt. 1, pp. 1540-1545. DOI: 10.1016/j.juro.2006.06.044

37. Gautier E., Rommens P.M., Matta J.M. Late reconstruction after pelvic ring injuries. Injury, 1996, vol. 27, no. Suppl. 2, pp. B39-B46.

38. Cano-Luís P., Giráldez-Sánchez M.Á., Andrés-Cano P. Pelvic post-traumatic asymmetry: Assessment and sequenced treatment. EFORT Open Rev., 2018, vol. 3, no. 5, pp. 335-346. DOI: 10.1302/2058-5241.3.170069

39. Keating J. Delayed reconstruction of pelvic fractures. Orthop. & Trauma. Mini-symposium: Pelvic Fractures, 2005, vol. 19, no. 5, pp. 362-372. DOI: 10.1016/j.cuor.2005.09.006

40. Van den Bosch E.W., Van der Kleyn R., Van Zwienen M.C.M.A., Van Vugt A.B. Nonunion of unstable fractures of the pelvis. Eur. J. Trauma, 2002, vol. 28, pp. 100-103. DOI: https://doi.org/10.1007/s00068-002-1188-x

41. Taguchi T., Kawai S., Kaneko K., Yugue D. Surgical treatment of old pelvic fractures. Int. Orthop., 2000, vol. 24, no. 1, pp. 28-32. DOI: 10.1007/s002640050007

42. Oliver C.W., Twaddle B., Agel J., Routt M.L. Jr. Outcome after pelvic ring fractures: evaluation using the medical outcomes short form SF-36. Injury, 1996, vol. 27, no. 9, pp. 635-641. DOI: 10.1016/s0020-1383(96)00100-3

43. Kurz S., Pieroh P., Lenk M., Josten C., Böhme J. Three-dimensional reduction and finite element analysis improves the treatment of pelvic malunion reconstructive surgery: a case report. Medicine (Baltimore), 2017, vol. 96, no. 42, pp. e8136. DOI: 10.1097/MD.0000000000008136

44. Oransky M., Tortora M. Nonunions and malunions after pelvic fractures: why they occur and what can be done? Injury, 2007, vol. 38, no. 4, pp. 489- 496. DOI: 10.1016/j.injury.2007.01.019

45. Khabibianov R.Ia., Galeev I.G. Artrodezirovanie kresttsovo-podvzdoshnogo sochleneniia [Arthrodesis of the sacroiliac joint]. Prakticheskaia Meditsina, 2014, no. 4-2 (80), pp. 152-155. (in Russian)

46. Guimarães J.A.M., Rocha V.M.D., Barcellos A.L.L. Osteotomia sacroilíaca posterior: uma opção ao acesso ilioinguinal na reconstrução pélvica em lesões inveteradas [Posterior sacroiliac osteotomy: an alternative to the ilioinguinal approach for pelvic reconstruction in misalignment lesions]. Rev. Bras. Ortop., 2017, vol. 52, no. Suppl. 1, pp. 63-68. DOI: 10.1016/j.rboe.2017.08.010. (in Brazilian)

47. Taller S., Srám J., Lukás R., Krivohlávek M. Paklouby pánve [Nonunions or malunions of pelvic fractures]. Acta Chir. Orthop. Traumatol. Cech., 2009, vol. 76, no. 2, pp. 121-127. (in Czech)

48. Fang C., Alabdulrahman H., Pfeifer R., Tarkin I.S., Pape H.C. Late reconstruction of severe open-book deformities of the pelvis – tips and tricks. Int. Orthop., 2017, vol. 41, no. 9, pp. 1777-1784. DOI: 10.1007/s00264-017-3549-4

49. Blohm D., Madsen F., Jensen J. Pelvisfrakturer – en opgørelse af operationsresultater of baekken "nonunion" og "malunion" [Fractures of the pelvis- -a survey of" nonunion" and" malunion" surgical results]. Ugeskr. Laeger., 2000, vol. 162, no. 47, pp. 6413-6415. (in Danish)

50. Hessmann M.H., Ingelfinger P., Hofmann A., Rommens P.M. Sekundär- und Späteingriffe nach Beckenring- und Azetabulumfrakturen [Secondary and late interventions after fractures of the pelvic ring and aetabulum]. Trauma und Berufskrankheit, 2007, vol. 9, no. 2, pp. S172-S178. DOI: 10.1007/s10039-006-1138-7 (in German)

51. Nicodemo A., Capella M., Deregibus M., Massè A. Nonunion of a sacral fracture refractory to bone grafting: internal fixation and osteogenic protein-1 (BMP-7) application. Musculoskelet. Surg., 2011, vol. 95, no. 2, pp. 157-161. DOI: 10.1007/s12306-011-0131-x

52. Zhang L.-C., Lan X., Zhang L., Tao Sh., Zhang Q., Liang X.-D., Guo Y.-Z., Tang P.-F. Internal fixation with different implants for the treatment of old pelvic fractures. Chinese Journal of Tissue Engineering Research, 2013, vol. 17, no. 9, pp. 1703-1710. DOI: 10.3969/j.issn.2095-4344.2013.09.027

53. Zhdanov A.S., Gubin A.V. Sposob rekonstruktsii taza pri slozhnykh posttravmaticheskikh deformatsiiakh [The way of pelvis reconstruction for complex posttraumatic deformities]. Patent RF no. 2637283, А61В 17/56, 2016. (in Russian)