Introduction:
The management of unstable anterior pelvic ring fractures involves two distinct surgical approaches: the anterior subcutaneous internal fixator (INFIX) and plate fixation. A recent study underscores the benefits of INFIX, highlighting its capacity to shorten surgical duration and minimize invasiveness. Conversely, plate fixation stands out for its potential to yield superior functional outcomes. Opting for either method necessitates a thorough consideration of individual patient traits and injury profiles to ensure optimal treatment efficacy.
What Is Pelvic Anterior Ring Fracture?
The pelvis stands as a bowl-shaped structure crucial for supporting the spine and safeguarding the abdominal organs, with a multitude of muscles converging upon it, including those of the abdomen, back, legs, and buttocks. Comprised of three primary bones, the pelvis comprises the ilium, forming the upper aspect of the hip bone; the ischium, shaping its lower and posterior regions; and the pubis, positioned anteriorly. These bones amalgamate in adulthood to fashion the pelvic ring. In addition to this triad, the sacrum, and coccyx, integral components of the vertebral column, further fortify the pelvis's architectural integrity.
Pelvic anterior ring fractures delineate fractures situated in the frontal region of the pelvis, typically stemming from high-energy traumas like motor vehicle collisions, direct pelvic impacts, or falls from considerable heights. When categorized as unstable, these fractures denote a considerable misalignment of pelvic bones, with the potential for displacement or shifting. Despite their rarity, accounting for merely 1.5 to 3.9 percent of all fractures, these injuries carry significant mortality and morbidity burdens, underscoring the critical nature of their management and treatment.
What Is INFIX?
The INFIX surgical method utilizes polyaxial pedicular screws strategically positioned within the anterior pelvis, accompanied by the placement of a connecting rod beneath the skin, offering superior rigidity compared to external fixation alternatives. The procedural protocol begins with the patient positioned supine, facilitating both accessibility and intraoperative imaging via X-rays. After the administration of general anesthesia, the surgical sequence commences with stabilizing the posterior aspect of the ring before addressing its anterior counterpart. An oblique incision, spanning 0.78 to 1.1 inches, is meticulously crafted around the anterior inferior iliac spine (AIIS). Following soft tissue dissection, a precise aperture (hole) is formed between the medial and lateral aspects of the ilium bone. Carefully, a pedicle screw is inserted, ensuring a minimum distance of 0.78 inches between the screw head and the bone surface. This meticulous process is replicated on the contralateral side of the AIIS. Subsequently, a subcutaneous tunnel is meticulously fashioned, bridging the two incision sites. Finally, a resilient curved titanium rod is threaded through, effectively connecting both screws and fortifying pelvic stability.
What Is Plate Fixation?
Plate fixation stands as a conventional method wherein metallic plates and screws are employed to stabilize and realign fractured bones, serving as a cornerstone technique in orthopedic practice. During this surgical intervention, the patient is positioned in the supine posture, and anesthesia induction ensues. Within this context, two distinct approaches emerge the modified stoppa approach, characterized by an incision along the linea alba (a midline structure in the abdominal wall) with subsequent splitting, and the Iiliac fossa approach, which entails an incision within the concave iliac fossa region. Employing a meticulously pre-bent specialized plate, tailored to conform to the nuanced contours of pelvic bones, fractures are then meticulously stabilized, ensuring optimal alignment and structural integrity.
What Are the Advantages of These Two Surgical Approaches?
Advantages of INFIX include:
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INFIX boasts advantages over traditional plate fixation methods when addressing anterior pelvic ring fractures, primarily due to its minimally invasive nature.
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With INFIX procedures, there's a notable reduction in procedural time, reflecting its efficiency and potential for quicker patient recovery.
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INFIX demonstrates suitability for patients with concurrent urological injuries, offering the added benefit of potentially lowering the risk of post-operative wound infections.
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INFIX minimizes tissue damage, thereby facilitating speedier recuperation periods
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INFIX procedures are associated with reduced blood loss compared to traditional plate fixation techniques.
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Studies have suggested that INFIX may be more effective in limiting symphyseal widening compared to plate fixation methods, particularly in cases of symphysis disruption.
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INFIX is considered particularly appropriate for patients with fewer displacement fractures, including those who are obese or have concurrent urethral injuries.
Advantages of plate fixation include:
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Plate fixation stands out for its superior ability to achieve anatomic reduction in pelvic anterior ring fractures, offering patients improved alignment and stability.
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One of the key advantages of plate fixation lies in its provision of direct visualization and access to the fractured regions, enabling precise placement of the reconstructive plate.
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Plate fixation surpasses INFIX in terms of functional outcomes, offering patients enhanced post-operative functionality and mobility.
What Are the Complications of These Two Surgical Approaches?
Challenges linked with the utilization of INFIX include:
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occurrence of lateral femoral cutaneous nerve (LFCN) paralysis, a predicament entailing sensory impairment along the front and side of the thigh. The telltale sign of this paralysis often materializes as a sensation of numbness encompassing the aforementioned regions. Interestingly, for certain individuals, immediate alleviation of symptoms was noted subsequent to the extraction of the INFIX apparatus, whereas others reported a gradual amelioration spanning up to three months post-removal.
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Another complication intertwined with INFIX deployment manifests as superficial infection precipitated by suboptimal soft tissue conditions.
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Heterotopic ossification poses another concern, an anomaly characterized by the ectopic formation of bone tissue in muscles and soft tissues, observed in select cases.
Challenges linked with the utilization of plate fixation include:
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Plate fixation poses the risk of wound infection, adding to its array of challenges.
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Complications such as infections stemming from bladder or urethral disruptions underscore the complexities associated with plate fixation.
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Asymptomatic heterotopic ossification may manifest in a minority of cases.
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Notably, the study highlighted a substantial discrepancy in blood loss, with the plate group encountering nearly 4.5 times more than their INFIX counterparts.
Which Surgical Approach Is Better for Pelvic Anterior Ring Fracture?
In a comparative study focusing on anterior pelvic ring injuries, patients were divided into two groups undergoing distinct treatments: INFIX and plate fixation. The findings of the study indicate that both INFIX and plate fixation are effective modalities for addressing anterior pelvic ring injuries, with all patients in both groups achieving successful fracture healing, albeit with a few encountering complications. Interestingly, while both treatment approaches yielded positive outcomes in terms of fracture healing, there were discernible differences in their respective advantages and drawbacks. INFIX demonstrated notable advantages, including shorter procedure times and reduced blood loss, in contrast to plate fixation. Conversely, plate fixation exhibited a higher frequency of excellent reduction grades, indicative of superior anatomical restoration of the anterior ring, compared to the INFIX group. Moreover, patients treated with plate fixation demonstrated better functional outcomes than those treated with INFIX.
Nevertheless, it is essential to carefully weigh the advantages and limitations of each technique to optimize patient outcomes and minimize complications.
Conclusion:
INFIX emerges as particularly apt for anterior ring injury patients concurrently afflicted with pelvic organ injuries. In contrast, plate fixation finds recommendations for individuals displaying evident displacement in pelvic anterior ring injuries. While the plate fixation cohort yielded superior functional outcome scores, INFIX presents promising prospects with its potential for quicker surgical procedures and shorter recovery timelines. Nevertheless, the selection between INFIX and plate fixation necessitates a meticulous evaluation of individual patient attributes, fracture severity, and surgical nuances to tailor treatment strategies and enhance overall treatment efficacy.
