Is there a role for percutaneous pelvic and acetabular reconstruction?

Abstract

The primary goal in the treatment of pelvic fractures is the restoration of haemodynamic stability. The secondary goal is the reconstruction of stability and symmetry of the pelvic ring. Percutaneous reconstruction can only be accepted if these goals are met. The type of definitive surgery is dependent of the degree of instability of the anterior and posterior pelvic ring. Retrograde transpubic screw fixation of pubic rami fractures is a good alternative to external fixation or plate and screw osteosynthesis. The technique of screw placement and image intensifier control is explained. Internal fixation of pure sacroiliac dislocations, fracture-dislocations of the sacroiliac joint and sacral fractures can be fixed with sacroiliac screws, placed percutaneously. Reduction of the fracture or dislocation is performed closed, or open if anatomy cannot be restored in a closed manner. The primary goal in the treatment of acetabular fractures is to restore anatomy. Reduction comes before fixation. The goal of minimising approaches cannot be more important. In most cases open reduction will be necessary to achieve anatomical reconstruction. Only the experienced acetabular surgeon will be able to decide when and how he can restore anatomy through a less invasive approach or with a percutaneous procedure. The anterior column screw can be inserted through a separate incision in addition to a Kocher-Langenbeck approach. It is the same screw as the retrograde transpubic screw but placed in the opposite direction. The posterior column screw is placed percutaneously from the lateral cortex of the ilium in the direction of the posterior column. Techniques of placement of both screws are demonstrated. Open reduction and internal fixation remains the standard of care in stabilisation of pelvic and acetabular fractures. Only the experienced surgeon will be able to judge if percutaneous procedures can be an alternative or a useful additive to conventional techniques.