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Sacral Non-Union
Ортопедия и травматология Отправлено David P. Zamorano 23 Август 2007, 00:29
Looking for advice.
This is a 48 yo non-smoking female s/p MCC 10 months ago. I do not have the initial injury films. She underwent ORIF as shown on attached file.
She is having continued pain in low back/sacral region. Worse with sitting and prolonged walking. Has had pain since surgery. All of her wounds have healed uneventfully. Also has right hip pain laterally. No groin pain. Not aggravated with ROM of the hip. Infection work-up has been negative.

Any thoughts on the broken plate on the pelvic brim and the non-union on the anterior column. Doesn't seem like she's have pain from there.

Suggestions on treatment of sacral nonunion.

Thanks
dave
David P. Zamorano, MD
Director, Orthopaedic Trauma Service
UCI Medical Center

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    Re: Sacral Non-Union
    Chip Routt 23 Август 2007, 23:06
    Maybe remove the disengaged iliosacral screw first to see if she improves?

    I can't see the axial CT images well enough to detail the potential sacral issues....can you magnify them?

    Chip
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    • Re: Sacral Non-Union
      Отправитель: David Zamorano 25 Август 2007, 21:05


      Here is a magnified view. Sorry about the quality but the CT was scanned into our system.

      dave

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      • Re: Sacral Non-Union
        Отправитель: Chip Routt 25 Август 2007, 21:08
        Thank you...it might help to remove the disengaged and other iliosacral screws then insert longer lag screws into the upper sacral segment and if anatomically feasible into the second sacral segment as well.

        You could do it percutaneously and even add an electrical stimulation device if that seems reasonable.

        At this point, I'd ignore the right pubic root issue if asymptomatic.

        If simple measures such as those above fail, then you could remove it all, take down the sacral fracture site, refix with alternate techniques, and bone graft.

        Chip

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    Re: Sacral Non-Union
    Maxim Agalakov 26 Август 2007, 12:18
    Remove IS screwes, then perform weight-bearing x-rays standing on one leg.
    In case of instability, drilling of the zone of sacral nonunion and another screw fixation may lead to fracture consolidation and pain relief.

    Late hardware failure usually is asymptomatic but nonunion of the anterior column may sometimes simulate low back pain. In this situation just wait and give NSAIDS.


    Huegli RW, Messmer P, Jacob AL, Regazzoni P, Styger S, Gross T.
    Delayed union of a sacral fracture: percutaneous navigated autologous cancellous bone grafting and screw fixation. : Cardiovasc Intervent Radiol. 2003 Sep-Oct;26(5):502-5.

    Delayed or non-union of a sacral fracture is a serious clinical condition that may include chronic pain, sitting discomfort, gait disturbances, neurological problems, and inability to work. It is also a difficult reconstruction problem.
    Late correction of the deformity is technically more demanding than the primary treatment of acute pelvic injuries. Open reduction, internal fixation (ORIF), excision of scar tissue, and bone grafting
    often in a multi-step approach are considered to be the treatment of choice in delayed unions of the pelvic ring. This procedure implies the risk of neurological and vascular injuries, infection, repeated failure of union, incomplete correction of the deformity, and incomplete pain relief as the most important complications. The lesion was successfully treated percutaneously in a single step procedure using CT navigation for drilling of the delayed union, autologous bone grafting, and screw fixation.
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