Parafusos transilíaco-transacrais: Qual o comprimento necessário dos implantes para uma adequada fixação percutânea do anel pélvico posterior?

Resumo

Objetivo Cirurgiões ortopédicos brasileiros vivenciam a indisponibilidade de parafusos longos que permitam a fixação percutânea do anel pélvico posterior na configuração transilíaco-transacral (TI-TS). O objetivo do presente estudo é mensurar o comprimento dos corredores ósseos de fixação disponíveis para fixação TI-TS em uma amostra populacional para inferir o comprimento necessário do implante.

Métodos Foram avaliados retrospectivamente pacientes que realizaram tomografia computadorizada (TC), identificando inicialmente a existência de um potencial corredor ósseo de fixação (PCOF) em S1, S2 e S3. Cada PCOF foi medido a partir da cortical externa de um ilíaco até a cortical externa do ilíaco contralateral em imagens axiais de TC.

Resultado A análise compreendeu uma amostra de 180 casos. PCOF em S1 foi identificado em 116 (64,4%) casos, PCOF em S2 foi identificado em 178 (98,9%) casos e PCOF em S3 foi identificado em 16 (8,9%) casos. A mediana (intervalo interquartílico - IIQ) da aferição do PCOF de S1 foi de 153 (148–161) mm, variando de 135 a 179 mm. Em S2, a mediana (IIQ) foi de 136 (131–144) mm, com uma variação de 114 a 160 mm. Em S3, a mediana (IIQ) da medição do PCOF foi de 120,5 (115–126) mm, com uma variação de 110 a 131 mm.

Conclusões Demonstramos que os comprimentos máximos dos corredores ósseos de fixação identificados exigiriam parafusos de até 180 mm de comprimento, com uma clara dissociação entre os valores medidos e os parafusos mais longos atualmente comercializados em nosso meio.

Palavras-chave

fixação interna de fraturas - fraturas ósseas - ossos pélvicos - parafusos ósseos

Trabalho desenvolvido no Serviço de Ortopedia e Traumatologia, Hospital Moinhos de Vento, Porto Alegre, RS, Brasil.

Publikationsverlauf

Eingereicht: 21. Juni 2024

Angenommen: 02. Oktober 2024

Artikel online veröffentlicht:
28. April 2025

• Referências

• 1 Matta JM, Saucedo T. Internal fixation of pelvic ring fractures. Clin Orthop Relat Res 1989; (242) 83-97
• 2 Routt ML, Meier MC, Kregor PJ, Mayo KA. Percutaneous iliosacral screws with the patient supine technique. Oper Tech Orthop 1993; 3 (01) 35-45
• 3 Routt Jr ML, Kregor PJ, Simonian PT, Mayo KA. Early results of percutaneous iliosacral screws placed with the patient in the supine position. J Orthop Trauma 1995; 9 (03) 207-214
• 4 Nork SE, Jones CB, Harding SP, Mirza SK, Routt Jr ML. Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma 2001; 15 (04) 238-246
• 5 Calafi LA, Routt Jr ML. Posterior iliac crescent fracture-dislocation: what morphological variations are amenable to iliosacral screw fixation?. Injury 2013; 44 (02) 194-198
• 6 Saiz Jr AM, Kellam PJ, Amin A. et al. Percutaneous sacral screw fixation alone sufficient for mildly displaced U-type sacral fractures with preserved osseous fixation pathways. Eur J Orthop Surg Traumatol 2023;
• 7 Cintean R, Fritzsche C, Zderic I, Gueorguiev-Rüegg B, Gebhard F, Schütze K. Sacroiliac versus transiliac-transsacral screw osteosynthesis in osteoporotic pelvic fractures: a biomechanical comparison. Eur J Trauma Emerg Surg 2023; 49 (06) 2553-2560
• 8 Bishop JA, Routt Jr ML. Osseous fixation pathways in pelvic and acetabular fracture surgery: osteology, radiology, and clinical applications. J Trauma Acute Care Surg 2012; 72 (06) 1502-1509
• 9 Kaiser SP, Gardner MJ, Liu J, Routt Jr ML, Morshed S. Anatomic Determinants of Sacral Dysmorphism and Implications for Safe Iliosacral Screw Placement. J Bone Joint Surg Am 2014; 96 (14) e120
• 10 Tabaie SA, Bledsoe JG, Moed BR. Biomechanical comparison of standard iliosacral screw fixation to transsacral locked screw fixation in a type C zone II pelvic fracture model. J Orthop Trauma 2013; 27 (09) 521-526
• 11 Salazar D, Lannon S, Pasternak O. et al. Investigation of bone quality of the first and second sacral segments amongst trauma patients: concerns about iliosacral screw fixation. J Orthop Traumatol 2015; 16 (04) 301-308
• 12 Gardner MJ, Routt Jr ML. Transiliac-transsacral screws for posterior pelvic stabilization. J Orthop Trauma 2011; 25 (06) 378-384
• 13 Eastman JG, Shelton TJ, Routt Jr MLC, Adams MR. Posterior pelvic ring bone density with implications for percutaneous screw fixation. Eur J Orthop Surg Traumatol 2021; 31 (02) 383-389
• 14 Beaulé PE, Antoniades J, Matta JM. Trans-sacral fixation for failed posterior fixation of the pelvic ring. Arch Orthop Trauma Surg 2006; 126 (01) 49-52
• 15 Chang G, Fram B, Sobol K, Krieg JC. Two Transiliac-Transsacral Screws in a Single Sacral Level: Surgical Technique and Patient Outcomes. Tech Orthop 2021; 36 (01) 50
• 16 Lucas JF, Routt Jr ML, Eastman JG. A Useful Preoperative Planning Technique for Transiliac-Transsacral Screws. J Orthop Trauma 2017; 31 (01) e25-e31
• 17 Eastman JG, Adams MR, Frisoli K, Chip Routt Jr ML. Is S3 a Viable Osseous Fixation Pathway?. J Orthop Trauma 2018; 32 (02) 93-99
• 18 Zhao Y, Zhang S, Sun T. et al. Mechanical comparison between lengthened and short sacroiliac screws in sacral fracture fixation: a finite element analysis. Orthop Traumatol Surg Res 2013; 99 (05) 601-606
• 19 Min KS, Zamorano DP, Wahba GM, Garcia I, Bhatia N, Lee TQ. Comparison of two-transsacral-screw fixation versus triangular osteosynthesis for transforaminal sacral fractures. Orthopedics 2014; 37 (09) e754-e760
• 20 Chen PH, Chen CY, Lin KC, Hsu CJ. Quantification of the Safe Zone of the First to Third Sacral Segments for Transiliac-Transsacral Screw Fixation in Normal and Dysmorphic Sacra. Orthopedics 2024; 47 (01) e13-e18
• 21 Jazini E, Klocke N, Tannous O. et al. Does Lumbopelvic Fixation Add Stability? A Cadaveric Biomechanical Analysis of an Unstable Pelvic Fracture Model. J Orthop Trauma 2017; 31 (01) 37-46
• 22 Gonçalves RM, Freitas A, Aragão VAD. et al. Comparison of sacroiliac screw techniques for unstable sacroiliac joint disruptions: a finite element model analysis. Injury 2023; 54 (Suppl. 06) 110783
• 23 Collinge CA, Crist BD. Combined Percutaneous Iliosacral Screw Fixation With Sacroplasty Using Resorbable Calcium Phosphate Cement for Osteoporotic Pelvic Fractures Requiring Surgery. J Orthop Trauma 2016; 30 (06) e217-e222
• 24 Schultz BJ, Mayer RM, Phelps KD. et al. Assessment of sacral osseous fixation pathways for same-level dual transiliac-transsacral screw insertion. Arch Orthop Trauma Surg 2023; 143 (10) 6049-6056
• 25 Miller AN, Routt Jr ML. Variations in sacral morphology and implications for iliosacral screw fixation. J Am Acad Orthop Surg 2012; 20 (01) 8-16
• 26 Gardner MJ, Morshed S, Nork SE, Ricci WM, Chip Routt Jr ML. Quantification of the upper and second sacral segment safe zones in normal and dysmorphic sacra. J Orthop Trauma 2010; 24 (10) 622-629
• 27 Conflitti JM, Graves ML, Chip Routt Jr ML. Radiographic quantification and analysis of dysmorphic upper sacral osseous anatomy and associated iliosacral screw insertions. J Orthop Trauma 2010; 24 (10) 630-636
• 28 Hwang JS, Reilly MC, Shaath MK. et al. Safe Zone Quantification of the Third Sacral Segment in Normal and Dysmorphic Sacra. J Orthop Trauma 2018; 32 (04) 178-182
• 29 Shaw J, Gary J, Ambrose C, Routt MC. Multidimensional pelvic fluoroscopy: A new and novel technique for assessing safety and accuracy of percutaneous iliosacral screw fixation. J Orthop Trauma 2020; 34 (11) 572-577
• 30 Warner SJ, Haase DR, Chip Routt ML, Eastman JG, Achor TS. Use of 3D Fluoroscopy to Assist in the Reduction and Fixation of Pelvic and Acetabular Fractures: A Safety and Quality Case Series. J Orthop Trauma 2023; 37 (11S): S1-S6