Aktuelle minimalinvasive operative Konzepte für Insuffizienzfrakturen des Sakrums

Zusammenfassung

Insuffizienzfrakturen des hinteren Beckenrings nehmen an Häufigkeit zu und stellen eine relevante Herausforderung für unser Gesundheitssystem dar. Zur Sicherung der Diagnose sollte ergänzend zu den konventionellen Röntgenaufnahmen eine Computertomografie und ggf. eine Magnetresonanztomografie erfolgen. Bei Versagen konservativer Therapieregime zeigen kleinere Serien minimalinvasiver operativer Therapieansätze vielversprechende Ergebnisse. Ziel dieser Übersichtsarbeit ist es, die aktuell eingesetzten Techniken der minimalinvasiven operativen Versorgung von Insuffizienzfrakturen des Sakrums aufzuführen und die jeweiligen Vor- und Nachteile darzulegen. Dies sind aktuell die Sakroplastie, die perkutane iliosakrale Verschraubung S I oder S I/S II, die transsakrale Verschraubung u. a. mithilfe des transsakralen „bar“ und von posterior horizontalen sowie lumbopelvinen Stabilisierungen. Im Allgemeinen hängt die Entscheidungsfindung zur Therapie vom klinischen Erscheinungsbild, der Frakturmorphologie und den Erfahrungen der behandelnden Chirurgen ab.

Schlüsselwörter

hinterer Beckenring - Sakrumfraktur - Insuffizienzfraktur - minimalinvasive Versorgung - Fragilität

Publication History

Article published online:
27 July 2021

• References/Literatur

• 1 Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: Recommendations for surgical treatment. Injury 2013; 44: 1733-1744
• 2 Abe H, Nakamura M, Takahashi S. et al. Radiation-induced insufficiency fractures of the pelvis: evaluation with 99 mTc-methylene diphosphonate scintigraphy. AJR Am J Roentgenol 1992; 158: 599-602
• 3 Lapina O, Tiskevicius S. Sacral insufficiency fracture after pelvic radiotherapy: a diagnostic challenge for a radiologist. Medicina (Kaunas) 2014; 50: 249-254
• 4 Dasgupta B, Shah N, Brown H. et al. Sacral insufficiency fractures: an unsuspected cause of low back pain. Br J Rheumatol 1998; 37: 789-793
• 5 Grangier C, Garcia J, Howarth NR. et al. Role of MRI in the diagnosis of insufficiency fractures of the sacrum and acetabular roof. Skeletal Radiol 1997; 26: 517-524
• 6 Deschamps Perdomo A, Tome-Bermejo F, Pinera AR. et al. Misdiagnosis of sacral stress fracture: an underestimated cause of low back pain in pregnancy?. Am J Case Rep 2015; 16: 60-64
• 7 Finiels H, Finiels PJ, Jacquot JM. et al. [Fractures of the sacrum caused by bone insufficiency. Meta-analysis of 508 cases]. Presse Med 1997; 26: 1568-1573
• 8 Weber M, Hasler P, Gerber H. Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine 1993; 18: 2507-2512
• 9 Schindler OS, Watura R, Cobby M. Sacral insufficiency fractures. J Orthop Surg (Hong Kong) 2007; 15: 339-346
• 10 Burge R, Dawson-Hughes B, Solomon DH. et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 2007; 22: 465-475
• 11 Richards AM, Coleman NW, Knight TA. et al. Bone density and cortical thickness in normal, osteopenic, and osteoporotic sacra. J Osteoporos 2010; 504078
• 12 Linstrom NJ, Heiserman JE, Kortman KE. et al. Anatomical and biomechanical analyses of the unique and consistent locations of sacral insufficiency fractures. Spine 2009; 34: 309-315
• 13 De Smet AA, Neff JR. Pubic and sacral insufficiency fractures: clinical course and radiologic findings. AJR Am J Roentgenol 1985; 145: 601-606
• 14 Schildhauer TA, Josten C, Muhr G. Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weight-bearing. J Orthop Trauma 2006; 20 (1 Suppl.): S44-S51
• 15 Leung KS, Chien P, Shen WY. et al. Operative treatment of unstable pelvic fractures. Injury 1992; 23: 31-37
• 16 Dehdashti AR, Martin JB, Jean B. et al. PMMA cementoplasty in symptomatic metastatic lesions of the S1 vertebral body. Cardiovasc Intervent Radiol 2000; 23: 235-237
• 17 Marcy PY, Palussiere J, Descamps B. et al. Percutaneous cementoplasty for pelvic bone metastasis. Support Care Cancer 2000; 8: 500-503
• 18 Garant M. Sacroplasty: a new treatment for sacral insufficiency fracture. J Vas Interv Radiol 2002; 13: 1265-1267
• 19 Heo DH, Park CK. Percutaneous Sacroplasty for Non-neoplastic Osteoporotic Sacral Insufficiency Fractures. Pain Physician 2017; 20: 89-94
• 20 Frey ME, Warner C, Thomas SM. et al. Sacroplasty: A Ten-Year Analysis of Prospective Patients Treated with Percutaneous Sacroplasty: Literature Review and Technical Considerations. Pain Physician 2017; 20: E1063-E1072
• 21 Andresen R, Radmer S, Andresen JR. et al. Comparison of the 18-month outcome after the treatment of osteoporotic insufficiency fractures by means of balloon sacroplasty (BSP) and radiofrequency sacroplasty (RFS) in comparison: a prospective randomised study. Eur Spine J 2017; 26: 3235-3240
• 22 Andresen R, Radmer S, Andresen JR. et al. Clinical Improvement and Cost-effectiveness of CT-guided Radiofrequency Sacroplasty (RFS) and Cement Sacroplasty (CSP) – a Prospective Randomised Comparison of Methods. Z Orthop Unfall 2019; 157: 524-533
• 23 Yang SC, Tsai TT, Chen HS. et al. Comparison of sacroplasty with or without balloon assistance for the treatment of sacral insufficiency fractures. J Orthop Surg (Hong Kong) 2018; 26: 2309499018782575
• 24 Krappinger D, Kaser V, Kammerlander C. et al. Inter- and intraobserver reliability and critical analysis of the FFP classification of osteoporotic pelvic ring injuries. Injury 2019; 50: 337-343
• 25 Mendel T, Noser H, Kuervers J. et al. The influence of sacral morphology on the existence of secure S1 and S2 transverse bone corridors for iliosacroiliac screw fixation. Injury 2013; 44: 1773-1779
• 26 Laux CJ, Weigelt L, Osterhoff G. et al. Feasibility of iliosacral screw placement in patients with upper sacral dysplasia. J Orthop Surg Res 2019; 14: 418
• 27 Hilgert RE, Finn J, Egbers HJ. [Technique for percutaneous iliosacral screw insertion with conventional C-arm radiography]. Unfallchirurg 2005; 108: 954-960
• 28 Höch A, Pieroh P, Henkelmann R. et al. In-screw polymethylmethacrylate-augmented sacroiliac screw for the treatment of fragility fractures of the pelvis: a prospective, observational study with 1-year follow-up. BMC Surg 2017; 17: 132
• 29 Hopf JC, Krieglstein CF, Müller LP. et al. Percutaneous iliosacral screw fixation after osteoporotic posterior ring fractures of the pelvis reduces pain significantly in elderly patients. Injury 2015; 46: 1631-1636
• 30 Eckardt H, Egger A, Hasler RM. et al. 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; 48: 2717-2723
• 31 Osterhoff G, Ossendorf C, Wanner GA. et al. Percutaneous iliosacral screw fixation in S1 and S2 for posterior pelvic ring injuries: technique and perioperative complications. Arch Orthop Trauma Surg 2011; 131: 809-813
• 32 Zwingmann J, Hauschild O, Bode G. et al. Malposition and revision rates of different imaging modalities for percutaneous iliosacral screw fixation following pelvic fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2013; 133: 1257-1265
• 33 Camino Willhuber G, Zderic I, Gras F. et al. Analysis of sacro-iliac joint screw fixation: does quality of reduction and screw orientation influence joint stability? A biomechanical study. Int Orthop 2016; 40: 1537-1543
• 34 van Zwienen CM, van den Bosch EW, Snijders CJ. et al. Biomechanical comparison of sacroiliac screw techniques for unstable pelvic ring fractures. J Orthop Trauma 2004; 18: 589-595
• 35 Zwingmann J, Konrad G, Kotter E. et al. Computer-navigated iliosacral screw insertion reduces malposition rate and radiation exposure. Clin Orthop Relat Res 2009; 467: 1833-1838
• 36 Osterhoff G, Dodd AE, Unno F. et al. Cement Augmentation in Sacroiliac Screw Fixation Offers Modest Biomechanical Advantages in a Cadaver Model. Clin Orthop Relat Res 2016; 474: 2522-2530
• 37 Vanderschot PM, Broens PM, Vermeire JI. et al. Trans iliac-sacral-iliac bar stabilization to treat bilateral sacro-iliac joint disruptions. Injury 1999; 30: 637-640
• 38 Trikha V, Gaba S, Kumar A. et al. Safe corridor for iliosacral and trans-sacral screw placement in Indian population: A preliminary CT based anatomical study. J Clin Orthop Trauma 2019; 10: 427-431
• 39 Wagner D, Ossendorf C, Gruszka D. et al. Fragility fractures of the sacrum: how to identify and when to treat surgically?. Eur J Trauma Emerg Surg 2015; 41: 349-362
• 40 Rommens PM, Ossendorf C, Pairon P. et al. Clinical pathways for fragility fractures of the pelvic ring: personal experience and review of the literature. J Orthop Sci 2015; 20: 1-11
• 41 Rommens PM, Arand C, Hopf JC. et al. Progress of instability in fragility fractures of the pelvis: an observational study. Injury 2019; 50: 1966-1973
• 42 Mendel T, Ullrich BW, Hofmann GO. et al. Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases. Eur J Trauma Emerg Surg 2021; 47: 11-19
• 43 Lattauschke A, Klauke F, Ullrich BW. et al. [Course of operative treatment of a sacral insufficiency fracture: successful or serious treatment?]. Unfallchirurg 2017; 120: 890-895
• 44 Mehling I, Hessmann MH, Rommens PM. Stabilization of fatigue fractures of the dorsal pelvis with a trans-sacral bar. Operative technique and outcome. Injury 2012; 43: 446-451
• 45 Moed BR, Whiting DR. Locked transsacral screw fixation of bilateral injuries of the posterior pelvic ring: initial clinical series. J Orthop Trauma 2010; 24: 616-621
• 46 Füchtmeier B, Maghsudi M, Neumann C. et al. [The minimally invasive stabilization of the dorsal pelvic ring with the transiliacal internal fixator (TIFI)–surgical technique and first clinical findings]. Unfallchirurg 2004; 107: 1142-1151
• 47 Siekmann H, Becherer L, Neef R. “Iliosacral bridging” – A new alternative minimal invasive fixation of unstable pelvic ring fractures. Arch Surg Clin Res 2018; 2: 29-46
• 48 Schmitz P, Baumann F, Grechenig S. et al. The cement-augmented transiliacal internal fixator (caTIFI): an innovative surgical technique for stabilization of fragility fractures of the pelvis. Injury 2015; 46 (Suppl. 04) S114-S120
• 49 Schmitz P, Baumann F, Acklin YP. et al. Clinical application of a minimally invasive cement-augmentable Schanz screw rod system to treat pelvic ring fractures. Int Orthop 2019; 43: 697-703
• 50 Ebraheim NA, Lin D, Xu R. et al. Computed tomographic evaluation of the internal structure of the lateral sacral mass in the upper sacra. Orthopedics 1999; 22: 1137-1140
• 51 Williams SK, Quinnan SM. Percutaneous Lumbopelvic Fixation for Reduction and Stabilization of Sacral Fractures With Spinopelvic Dissociation Patterns. J Orthop Trauma 2016; 30: e318-e324
• 52 Schmitz P, Lüdeck S, Baumann F. et al. Patient-related quality of life after pelvic ring fractures in elderly. Int Orthop 2019; 43: 261-267
• 53 Acklin YP, Zderic I, Richards RG. et al. Biomechanical investigation of four different fixation techniques in sacrum Denis type II fracture with low bone mineral density. J Orthop Res 2018; 36: 1624-1629
• 54 Schroeder GD, Savage JW, Patel AA. et al. Spinopelvic Fixation in Complex Sacral Fractures. JBJS Reviews 2015;
• 55 Spiegl UJA, Schnake KJ, Osterhoff G. et al. Imaging of Sacral Stress and Insufficiency Fractures. Z Orthop Unfall 2019; 157: 144-153
• 56 Palm HG, Lang P, Hackenbroch C. et al. Dual-energy CT as an innovative method for diagnosing fragility fractures of the pelvic ring: a retrospective comparison with MRI as the gold standard. Arch Orthop Trauma Surg 2020; 140: 473-480
• 57 Chandra V, Wajswol E, Shukla P. et al. Safety and Efficacy of Sacroplasty for Sacral Fractures: A Systematic Review and Meta-Analysis. J Vasc Interv Radiol 2019; 30: 1845-1854
• 58 Ghisla S, Napoli F, Lehoczky G. et al. Posterior pelvic ring fractures: Intraoperative 3D-CT guided navigation for accurate positioning of sacro-iliac screws. Orthop Traumatol Surg Res 2018; 104: 1063-1067
• 59 Behrendt D, Mutze M, Steinke H. et al. Evaluation of 2D and 3D navigation for iliosacral screw fixation. Int J Comput Assist Radiol Surg 2012; 7: 249-255
• 60 Briem D, Windolf J, Rueger JM. [Percutaneous, 2D-fluoroscopic navigated iliosacral screw placement in the supine position: technique, possibilities, and limits]. Unfallchirurg 2007; 110: 393-401
• 61 Takao M, Hamada H, Sakai T. et al. Factors influencing the accuracy of iliosacral screw insertion using 3D fluoroscopic navigation. ArchOrthop Trauma Surg 2019; 139: 189-195
• 62 Thakkar SC, Thakkar RS, Sirisreetreerux N. et al. 2D versus 3D fluoroscopy-based navigation in posterior pelvic fixation: review of the literature on current technology. Int J Comput Assist Radiol Surg 2017; 12: 69-76
• 63 Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 1988; 227: 67-81