Percutaneous Ilioilial Fixator Versus Percutaneous Iliosacral Screw in Managing Unstable Sacral Fractures: A Prospective Randomised Controlled Study

Abstract

Introduction: Unstable sacral fractures with pelvic fractures are challenging to both surgeons and patients, particularly in the immediate post-injury phase and later when definitive fixation is undertaken. Percutaneous iliosacral screw fixation is widely regarded as the gold standard treatment for unstable sacral fractures without spinopelvic dissociation. Closed reduction and percutaneous fixation using iliosacral screws for sacral fractures provide early stabilisation without the need for extensive surgical exposure, thereby mitigating major complications associated with open surgical procedures. A new technique for stabilising unstable sacral fractures is the minimally invasive ilioilial fixator, also called a transiliac internal fixator (TIIF), which has gained more attention for its ability to address challenges associated with sacroiliac screw fixation. The objective of this study is to compare the functional, radiological, and surgical outcomes between the percutaneous iliosacral screw and the ilioilial fixator.

Methods: A total of 51 patients with sacral fracture injuries sustained between August 2019 and November 2021 were included in this study, with 25 patients in Group A and 26 patients in Group B. Patient randomization was done using computer-generated randomization facilitated by Random Allocation Software (Mahmood Saghaei, Isfahan, Iran). All patients underwent the chosen intervention within 10 days of the trauma. Patients had follow-up at two weeks, six weeks, and 12 months post-treatment. The results of fixation were evaluated radiologically based on the Matta and Tornetta grading system and clinically using the Majeed pelvic scoring system. Complications were detected in both groups during follow-up visits.

Results: The study found no statistically significant differences between the two patient groups in terms of final clinical assessment (p=0.79), radiological assessment (p=0.78), or the need for another operation (p=1.0). Moreover, there were no statistically significant differences between the groups with respect to complication rates (p=0.63) or the time of union (p=0.14). No differences were noted in terms of intraoperative blood loss (p=0.93) or operative time (p=0.34) but for longer incision length in the ilioilial fixator group (p<0.001) and an increased risk of intraoperative radiation exposure in the iliosacral screw group (p<00.1).

Discussion: Although the iliosacral screw is considered a gold standard for unstable sacral fracture, a TIIF is a good alternative with a very satisfactory outcome.

Conclusion: Although the iliosacral screw still remains the gold standard for the management of sacral fractures, the ilioilial fixator emerges as a good alternative with comparable functional and radiological outcomes.

Keywords: ilioilial fixator; iliosacral screw; pelvic fracture; prospective study; unstable sacral fracture.

Figure 1. Minimally invasive two curvilinear incisions over the PSIS taken during the procedure

PSIS: posterior superior iliac spine Image Credit: First Author

Figure 2. Intraoperative image of the pelvic inlet view showing two polyaxial pedicle screws and connecting rod inserted into the iliac bone toward the greater trochanter

Image Credit: First Author

Figure 3. Postoperative X-ray outlet view of the pelvis showing excellent reduction of the sacral fracture using iliosacral screw fixation above the S1 foramen with fixation of the anterior pelvic ring injury using symphysis plating

Image Credit: First Author

Figure 4. Postoperative X-ray posteroanterior view of the pelvis showing excellent reduction and fixation of the sacral fracture using an iliosacral screw with fixation of the anterior pelvic ring injury using anterior symphysis plating with the good restoration of ring alignment

Image Credit: First Author

Figure 5. Postoperative X-ray inlet view of the pelvis showing excellent reduction of the sacral fracture with ilioilial fixator and good fixation of the anterior pelvic ring with INFIX with the overall good restoration of ring alignment

Image Credit: First Author

Figure 6. One-year follow-up X-ray posteroanterior view of the pelvis showing complete healing at the sacral fracture fixed with iliosacral screw with stabilization of anterior pelvic ring by symphysial plating

Image Credit: First Author