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Re: APC III pelvis advice
послал Chip Routt 01 Октябрь 2006, 10:56
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Reduction sequencing can be complicated. It looked like on a few views that his left sided SI joint was actually completed disrupted but not so badly
displaced...on a few other views, it looked not so bad...usually the worst look is the reality.
Double plating of symphyseal injuries was initially advocated at a time when operative treatment of pelvic ring disruptions was quite difficult. There were no malleable plates designed to fit the pelvis but rather large fragment implants (and later some small fragment implants) were used. One early symphyseal operative recommendation was a 2 holed narrow DCP attached using 6.5mm cancellous screws. Remember, intraoperative C-arm imaging was primitive as were most surgeons' operative pelvic experiences. The posterior ring was something to be avoided and most described high complication rates with open posterior fixations.
Orthoganol (biplanar, "double") symphyseal plating was devised/advocated as a treatment method to "overpower" the symphysis in order to avoid posterior pelvic operative techniques. The anatomy was difficult, the experiences were minimal, the implants didn't fit, the published results of operative posterior fixation were frightening, intraoperative imaging was poor quality, correlating the pelvic osteology with intraoperative imaging was undescribed, and so on.
At the time, some experts recommended to just make the symphysis more rigid and the posterior ring injury could then be nursed along without surgery.
Mechanical testing of double symphyseal plating then was performed and found to have superior results to single plating...and the legend was born.
Some sustain it.
Here's the hook...the mechanical testing was performed with wide implant separation which applied a superior implant and a separate caudal, anterior implant. In clinical practice, the amount of soft tissue stripping needed to apply such a caudal, anterior plate (similar to the mechanical testing model) is quite extensive and impractical. What results are 2 so-called orthoganol implants which are placed without much distance between
them... the surgeon adds more fixation sites but loses the mechanical power achieved in the lab tests by implant separation.
Next came improved fluoroscopic imaging, more surgical experiences, osteology correlations which people understood and descibed, implants designed to fit the pelvis, mechanical and clinical data indicating the superiority of anterior and posterior ring injury site fixations, percutaneous techniques, cannulated implants, and on and on.
"Double" plating is what it is... at this point in time for most routine symphyseal injuries with associated posterior ring injuries, surgeons recognize that a single 6-8 holed 3.5mm pelvic reconstruction plate applied to the bone with well oriented screws and combined with stable posterior
ring fixation will yield clinically sufficient stability.
People worry though because they don't do it very often, they've seen some lecture somewhere that shows failures, they don't make the disconnect
between lab data/implant location and clinical data/reality of implant locations, among 400 other reasons... so most of us do what we know how to
do.
We've all had symphyseal failures using one plate, two plates, custom plates, etc...the symphysis is hard to hold and anterior fixations need a buddy in the back to help.
We tested many injuries and fixation constructs in our lab...Peter Simonian and Allan Tencer drove this research... but even our own info is clouded by the fact that cadaveric pelvic research is quite difficult because of the donor age/bone quality, modeling/simulating loading, etc.
So we're back to anecdote as always.
Here's what I know...
1. I've done one double plating in my life.
2. Early symphyseal failures very rarely occur, especially when the posterior injury is supported with some form of fixation.
3. Later symphyseal implant failures are not uncommon, are typically asymptomatic, and are usually unknown by the patient until they see the
follow up film... no great surprise, the symphysis has normal motion... implants fatigue.
4. Pelvic reduction sequencing is a complicated and multi-factoral process.
5. Pelvic surgery is hard but successful if performed early, if the reduction is very accurate, when the fixation is stable and durable, and when complications are avoided.
There's plenty more to discuss about your patient and what was done... if he heals without fixation failure or other complication, then it¹ll be fine-
Chip
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