mmcandrew at siumed
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Sep 30, 2006, 8:08 PM
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Re: [ORT-L] APC III pelvis advice
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we are getting old. historical perspective is painful but
enlightening. please continue to remind us.
thanks
Chip Routt wrote:
> 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 it'll be fine-
>
> Chip
>
>
>
>
>
>
>
>
>
> 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
>
> On Sep 30, 2006, at 1:00 AM, Sam Agnew wrote:
>
> 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
> On Thursday, September 28, 2006, at 08:51PM, Jeff Brooks
> <jjbrooksmd@gmail.com> wrote:
>
>
>
>
> <<Original Attached>>
> <<Original Attached>>
>
>
>
>
> Samuel G. Agnew MD FACS
> Orthopaedic Trauma
>
> In case the initial .ppt didn't go through (the Mac/PC issue)
> I attached the injury films and selected CT cuts as a .pdf.....
>
> 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.
>
>
>
>
>
> On Sep 28, 2006, at 6:49 PM, Sam Agnew wrote:
>
> 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
>
>
>
> Jeffrey J Brooks, MD
> Orthopaedic Surgery & Sports medicine center
> 1290 summer street, #4400
> Stamford, ct 06905
> (203) 323-7331
>
>
>
>
>
>
>
> Jeffrey J Brooks, MD
> Orthopaedic Surgery & Sports medicine center
> 1290 summer street, #4400
> Stamford, ct 06905
> (203) 323-7331
>
>
>
>
>
>
>
>
> M.L. Chip Routt, Jr.,M.D.
> Professor-Orthopedic Surgery
> Harborview Medical Center
> 325 Ninth Avenue
> Box 359798
> Seattle, WA 98104-2499
> phone 206-731-3658
> FAX 206-731-3227
> --
>
(This post was edited by christian on Jan 24, 2007, 3:08 PM)
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