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Re: APC III pelvis advice
Sam Agnew 29 Сентябрь 2006, 08:03
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Jeff
Thanks for posting this case and generating the thought processes therein, could you please explain the rationale behind dual plating of the symphysis? is this per your routine-if so why, and if not why did you feel it was necessary?
The mal-alignment that you indicated by the arrow in your photo of the ilium, do you have some idea as to how that occurred? was the crescent component locked in such a manner that it could not be moved?
I would recc. immediate revision of the subtroch mal-reduction, was there a reason for not doing that at the same setting and save the patient the now 3rd operation?
Thanks again
SGA
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Re: APC III pelvis advice
Jeff Brooks 29 Сентябрь 2006, 08:08
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Sam -- great questions.
I'll address the question about 1 vs 2 symphyseal plates first, as it relates directly to the other question about the ilium. I'd love to hear Chip's thoughts on this since he's studied this quite a bit in his lab.
I know folks like MacAvoy et.al. studied 1 v 2 symph plates in cadaveric single-limb stance and couldn't detect a difference in stability between 1 v 2 plates (JOT 1997 11(8): 590-3). I think they
used a curved 6 hole sup vs same plus anterior 4 hole. Chip & Dr.
Simonian evaluated the "box plate" (2 4.5 2-hole interlocked) and showed that no other combo of 1 or 2 plates was as rigid, and amongst the 1 vs 2 plate constructs none was superior (1 vs 2 plates). (J Orthop Trauma. 1994 Dec;8(6):483-9.) They also subsequently looked at several new plates including Zimmer's (then) new biplanar plate and (in an APC model) couldn't show a significant advantage of dual plating (J Trauma. 1996 Sep;41(3):498-502. ) ........
But there is some evidence that I know of (although not as much) that maybe 2 plates is more stable - Hearn et.al. studied 12 combos of
fixation with SI dislocation and symphyseal disruption (Tile, Helfet & Kellam p 123 describes this non-medline-listed study), and the combo of 2 plates with any form of posterior fixation gave the greatest ring stiffness but only significant when compared with transiliac bars, not SI screws. (I think Schied & Kellam also found supportive evidence for dual-plating around 10-15 yrs ago, but I don't have that ref)
So, there I was with the aforementioned info on my mind, and my R iliac wing was a little malreduced. I think it's in residual extension and some external rotation, explaining the 5-6mm gap/step
on the posterior R iliac wing. (When I loooked at the inlet fluoro, the L obturator foramen was more visible than the R obt foramen, as was the R ischial spine) so it's not as stable as if it were
anatomic, despite all the metal. This came from hesitance to take down all the posterior paraspinals to really see the R posterior crest (where the malreduction is best seen on the iliac oblique view), and I could see the entire iliac fossa and most of the crest anyway.
Finally, the L SI joint seemed wide, even after closing it with c-clamp and iliosacral screw, so I added the extra 4 hole symphyseal plate anteriorly (even though to my knowledge unproven). That was the thinking and sequence of events that lead to the 2 symph plates shown. Note that the 4 hole recon is a locking plate (non-locked in medial 2 holes before locked screws in holes 1 & 4) -- fertile ground for debate on that I'm sure!
I'd love to hear others' comments on that sequence of events and decisions.
1) If the R ilium was a little malreduced, why not take off the plates and redo it anatomically, then the malreduction/rotation isn't transmitted around to the L SI joint, right?
a. --What about balancing the risks of the above of (longer surgery, more blood loss, higher infection rate, etc) that such revision would
have necessitated? (as it was the skin-to-skin time was long enough at~6hrs)
2) Is a wide L SI joint enough to open & plate, or struggle with longer for perc reduction?
3) Maybe I should have reduced & fixed the L SI joint before any of the rest so as not to be the late victim of crescent malrediuction?
4) After all, isn't the L SI the reduction of the three that is most critical to be anatomic?
a. -- Isn't the pt at risk of SI joint/low back pain necessitating SI fusion if SI joint is off?
Thanks to all who have commented/suggested/questioned.
Jeff
PS - as for the femur -- I had an idea about the malreduction in flexion, varus & ext rotation after seeing my colleague's postop fluoros from the nailing. I first recognized the actual magnitude of the malrotation after transferring the pt to the OR table for ORIF of his pelvis, and did not have consent for revision, among other
issues. I've since spoken with the first surgeon (who did the femur nailing) and we will address that, probably together, ASAP, but before the pt leaves the hospital.
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Re: APC III pelvis advice
Отправитель: Sam Agnew 01 Октябрь 2006, 19:55
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Jeff
You certainly had a lot of confusing-confounding information to deal with while trying to devise this surgical tactic. I have almost always found it more logical and anatomically easier to perform the reduction beginning with the exit point of the injury-in this case the force started in the R ilium and progressed to and thru the (L) SI-to my assessment from the available history and radiographs, therefore empirically I would have reduced and stabilized the (L) side first and proceed to the point of impact (R) side in a sequential manner.
I am still confused by your logic espousing dual plating as you offer more evidence to the contrary then in support of it. Can you comment on the surgical dissection required to place two orthogonal plates and the gestalt as to how this could be good?
thanks again for the case
Samuel G. Agnew MD FACS
Orthopaedic Trauma
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Re: APC III pelvis advice
Отправитель: Jeff Brooks 01 Октябрь 2006, 20:23
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Thank you Sam, for your comments. I'm grateful for this forum and exchange of ideas. What did people do before the internet, digital x rays, and email?!?
Interesting point about order of fixation. Thought-provoking.
Indeed there seems to be more evidence to the contrary re-dual plating, but in my opinion the limited anterior dissection isn't that much more (if at all), as I had already placed the pelvic reduction clamp anteriorly on 2 screws, and just placed the plate in those screw holes then added 1 more screw on either side. And, to my knowledge (which I admit is limited as I'm not as experienced as many who take care of these injuries), there is little or no harm to adding a second plate anteriorly.
Jeff
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