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SI Transiliosacral Rod
SI Transiliosacral Rod
SI Transiliosacral Rod
36:633–643, 2007
From the Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL.
Presented at the Veterinary Orthopedic Society Conference, Sun Valley, ID, March 3–10, 2007.
Reprints not available. Address correspondence to: Christopher S. Leasure, DVM, The Animal Medical Center, 510 East 62nd Street,
New York, NY 10065-8314. E-mail: Chris.Leasure@amcny.org.
Submitted February 2007; Accepted June 2007
r Copyright 2007 by The American College of Veterinary Surgeons
0161-3499/07
doi:10.1111/j.1532-950X.2007.00315.x
633
634 TRANS-ILIOSACRAL ROD IN FIVE DOGS
Fixation by insertion of screws in lag fashion is gen- iliosacral rod) to stabilize sacroiliac fracture-luxations af-
erally advocated for the surgical stabilization of sacroiliac ter limited open reduction. Our purpose is to describe the
fracture-luxations.1–10 Implant loosening and subsequent clinical and radiographic outcomes of this technique in
loss of reduction is the most common complication after 5 dogs with sacroiliac fracture-luxations.
stabilization by screws inserted in lag fashion.1 In a large
retrospective study, screw loosening occurred in 38% of
MATERIALS AND METHODS
the dogs with sacroiliac fracture-luxations stabilized using
fixation by screws inserted in lag fashion.1 Accurate screw Inclusion Criteria
placement and sufficient screw depth within the sacral
body were important variables lowering the incidence of Medical records (May 2005–September 2006) and radio-
implant failure.1 graphs of 5 dogs with sacroiliac fracture-luxations stabilized
Trans-ilial rods have recently been produced for the with a trans-iliosacral rod were reviewed. Each dog’s signal-
primary or adjunctive stabilization of unilateral and bi- ment, body weight, and pertinent medical history, including
lateral sacroiliac fracture-luxations. The trans-ilial rod the traumatic event causing injury, presence of concomitant
musculoskeletal or soft tissue injuries, the dog’s limb function
was designed to be placed through both ilial wings dorsal
and neurologic status before surgery, the duration of time
to the seventh lumbar vertebrae as a trans-ilial brace. elapsed between injury and surgery, and total days hospital-
Paired nuts are applied to each end of the rod to provide ized were recorded.
locked fixation against the lateral surface of each ilium
therefore decreasing postoperative complications, specifi-
cally implant loosening and subsequent loss of reduction. Preoperative Radiographic Assessment
Fully threaded stainless-steel trans-ilial rods with a single
Preoperative radiographs were reviewed to document
trocar point are available in 3.2 mm (125 mm in length), whether the sacroiliac fracture-luxation was unilateral or bi-
4.0 mm (155 mm in length) and 4.7 mm (175 mm in lateral, identify the presence of concurrent pelvic trauma and
length) diameters (Fig 1). measure the pelvic canal diameter ratio. Pelvic canal diameter
Tomlinson et al10 described use of intraoperative flu- was estimated from measurements made on ventrodorsal
oroscopy to assist with insertion of screws in lag fashion radiographic projections at the level of the sacrum and
after closed reduction of sacroiliac fracture-luxations. We acetabulum. The distance between the caudal aspect of the
have used intraoperative fluoroscopy to facilitate place- sacroiliac joint surface at the level of the sacral wings and the
ment of a trans-ilial rod through both ilia while traversing distance between the medial aspect of each acetabulum at a
the body of the sacrum (hereafter referred to as a trans- point corresponding to the craniodorsal aspect of the ace-
tabulum were measured.10,11 When the preoperative pelvic
displacement was severe and asymmetrical, a line was drawn
from the dorsal spinous processes of the sacrum axially
through the first 2 or 3 coccygeal vertebrae. A line was then
drawn from the craniodorsal aspect of each acetabulum as
described above, perpendicular to the axial line and these
distances were totaled to obtain the distance between the me-
dial aspect of the acetabulae. Pelvic canal diameter was
expressed as a ratio of the pelvic canal width at the medial
aspect of the acetabulae divided by the width of the caudal
sacrum (Fig 2).10,11
Surgical Technique
Under general anesthesia, the dog’s pelvic region was
clipped and prepared for aseptic surgery. The dog was posi-
tioned in sternal recumbency with the hind limbs hanging off
the end of a radiolucent surgical table. A wedge-shaped foam
pad was placed under the dog’s caudal abdomen. A sterile
cover was applied to the fluoroscope arm (C arm) of the flu-
oroscopic unit (Siremobil Compact Fluoroscope; Siemens, Is-
elin, NJ), which was used to obtain intraoperative lateral and
Fig 1. Photograph (from left to right) of 3.2 mm nuts and 3.2, dorsoventral images of the pelvic region. A 2–3 cm dorsal in-
4.0 and 4.7 mm diameter fully threaded stainless-steel trans- cision was made over each displaced ilial wing. The fascia was
ilial rods with a single trocar point. Note the two 4.7 mm nuts incised longitudinally adjacent to each exposed ilial wing.
in locked position on the 4.7 mm diameter rod (insert). Bone holding forceps were placed on the dorsal aspect of each
LEASURE ET AL 635
Fig 3. Lateral and ventrodorsal intraoperative fluoroscopic images of a dog with bilateral sacroiliac fracture-luxations. The bone
holding forceps have been used to reduce the luxation and a Kirschner wire has been placed through the sacral body and each ilia.
hours) was administered for 2–4 weeks to provide postoper- sessment of fracture healing, pelvic canal diameter ratio and to
ative analgesia during convalescence at the discretion of the identify any postoperative complications at each of the follow-
attending clinician. Dogs were discharged to the owner with up evaluations. Lameness was graded at a walk on a scale of
the recommendation to restrict activity (leash walks with lim- 0–4 (0 ¼ no lameness; 1 ¼ subtle weight-bearing lameness;
ited access to stairs and uneven ground) and to perform pas- 2 ¼ obvious weight-bearing lameness; 3 ¼ intermittent non-
sive range of motion exercises for 4–6 weeks. weight-bearing lameness; 4 ¼ consistent non-weight-bearing
lameness).13
The pelvic limbs were palpated to determine if pain could
Long-Term Clinical Assessment be elicited during coxofemoral joint manipulation or direct
palpation over the region of the trans-iliosacral rod and for
Owners were requested to return their dog for long-term any complications associated with implant placement. Rectal
clinical evaluation and radiographs; recommended intervals examination was performed to rule out the presence of pelvic
were 1, 2, and 3 months after surgery. Medical records and canal stenosis. Dogs were sedated with acepromazine maleate
radiographs were reviewed to determine duration of time until (0.02 mg/kg IV) and butorphanol tartrate (0.2 mg/kg IV)
the dog began weight-bearing on the affected limb(s), lame- for radiography. Pelvic radiographs were reviewed and com-
ness grade, maintenance of reduction, implant stability, as- pared with radiographs obtained immediately after surgery to
Fig 4. Ventrodorsal intraoperative fluoroscopic image illus- Fig 5. Ventrodorsal intraoperative fluoroscopic image ob-
trating the cannulated drill bit being used to drill through the tained after both pairs of nuts have been tightened and locked
sacral body over the previously placed Kirschner wire. in position.
LEASURE ET AL 637
Fig 6. Preoperative and immediate postoperative lateral and ventrodorsal pelvic radiographs in a dog with bilateral sacroiliac
fracture-luxations and right coxofemoral luxation repaired with a 3.2 mm diameter trans-iliosacral rod and toggle pin, respectively.
638
Weight- Lameness Score (Days Af- Owner
Concomitant Bearing ter Surgery) Assessment
Musculoskeletal Time from on Affected of Limb
Signalment Sacroiliac and Soft Tissue Injury to Pelvic Limb(s) Complications Function
and Body Fracture- Injuries (Surgical Neurological Primary/Adjunctive Surgery Hospitalization (Days After First Second Final (Days After (Days After
Dog # Weight Luxation(s) Intervention) Abnormalities Sacroiliac Fixation (Days) (Days) Surgery) Recheck Recheck Recheck Surgery) Surgery)
1 29-month-old, Bilateral Right acetabular Absent sciatic and 3.2-mm-diameter 3 14 39 Grade 4 NA Grade 1 Kirschner wire Good (650)
6 kg, female fracture and right femoral reflexes right trans-iliosacral (27) (523) migration (523)
intact Jack coxofemoral luxation hind limb, decreased rod/two 1.6 mm
Russell (femoral head and neck sciatic and femoral Kirschner wires
Terrier ostectomy), bilateral reflexes left hind limb, through ilial
pubic and ischial absent deep pain right wings and L7
fractures, physiologic hind limb, flaccid body
degloving, right anus
inguinal hernia
2 47-month-old, Right Left coxofemoral Mild conscious 4.7-mm-diameter 6 20 1 Grade 2 Grade 0 Grade 0 None Excellent (341)
31 kg, male luxation (toggle pin), proprioception trans-iliosacral (26) (61) (98)
intact left pubic and ischial deficits in the left rod/4.0 mm
Labrador fractures hind limb cancellous lag
Retriever screw, 4.7 mm
transilial brace
3 90-month-old, Bilateral Right coxofemoral Deep pain perception 3.2-mm-diameter 3 8 4 Grade 1 NA Grade 0 Seroma around Excellent (219)
8 kg, male luxation (iliofemoral absent in the right trans-iliosacral (32) (116) end of rod (32)
intact Jack suture), right pubic hind limb rod
Russell and ischial fractures,
Terrier maxillary fracture
(dental bonding),
prepubic tendon
avulsion and urinary
bladder herniation,
pneumothorax
4 12-month-old, Right Left femoral neck None 4.0-mm diameter 6 7 1 NA NA Grade 0 None Excellent (212)
30 kg, female fracture & left trans-iliosacral (130)
TRANS-ILIOSACRAL ROD IN FIVE DOGS
Table 2. Radiographic Parameters Assessed in Five dogs with Sacroiliac Fracture-Luxations Stabilized with Trans-Iliosacral Rods
Reduction
Immediate Final Evaluation
(%)
Signalment and Sacroiliac Preoperative Postoperative PCD Ratio (Days
Dog# Body Weight Fracture-Luxation(s) PCD Ratio Right Left PCD Ratio After Surgery)
1 29-month-old, 6 kg, female Bilateral 1.25 86.1 83.1 1.51 1.20 (523)
intact Jack Russell Terrier
2 47-month-old, 31 kg, male Right 1.35 96.0 NA 1.23 1.13 (98)
intact Labrador Retriever
3 90-month-old, 8 kg, male Bilateral 1.26 87.1 93.8 1.20 1.17 (116)
intact Jack Russell Terrier
4 12-month-old, 30 kg, female Right 1.15 98.1 NA 1.21 1.22 (130)
intact Great Pyrenees
5 84-month-old, 18 kg, male Bilateral 1.40 100.0 99.2 1.12 NA
castrated American Cocker Spaniel
fracture-luxation(s) and adjunctive fixation was used in 2 that had a hind limb amputation and the dog with the
dogs. In dog 2, the sacroiliac fracture-luxation was ini- acetabular fracture that was not surgically addressed.
tially stabilized with 2 screws inserted in lag fashion after Dog 5 died of pulmonary thromboembolism believed
closed reduction with fluoroscopic assistance. The screws to be caused by preexisting heartworm disease 3 days
backed out and reduction was lost at 4 days. During this after surgery. Three dogs (including the 1 that died) were
dog’s revision surgery, 1 screw was replaced with a trans- able to bear weight on the operated limb(s) the day after
iliosacral rod. A single cancellous screw was placed in the surgery. Dog 3 lacked unilateral deep pain perception
sacral body and a 2nd rod was inserted through both ilial preoperatively and began to bear weight on the affected
wings dorsal to the 7th lumbar vertebrae as a transilial limbs at 4 days. Owner compliance with returning for
brace15 to provide additional fixation. scheduled monthly follow-up examinations was variable:
In dog 1, two 1.6 mm Kirschner wires were inserted 3 dogs returned for 1 month follow-up examination and
through both ilial wings and the body of the 7th lumbar radiographs, 1 dog returned for 2-month follow-up ex-
vertebrae to provide rotational stability. Procedures amination, and 4 dogs returned for follow-up examina-
performed to address concurrent orthopedic injuries at tion and radiographs 43 months postoperatively.
the time of the sacroiliac fracture-luxation stabilization Dog 1, with severe bilateral neurologic impairment,
included toggle-pin placement (2 dogs) and iliofemoral was non-weight-bearing in both pelvic limbs when first
suture placement (1 dog) for coxofemoral joint luxations. reevaluated 27 days after stabilization of the dog’s sa-
Dog 4, with a unilateral sacroiliac fracture-luxation and croiliac fracture-luxation and had a mild persistent bilat-
multiple concurrent orthopedic injuries, had the con- eral sciatic and femoral neuropathy. The dog’s non-
tralateral hind limb amputated. The amputation was weight-bearing lameness was ascribed to an untreated
performed at the insistence of the owners despite a rec- acetabular fracture and a femoral head and neck ostec-
ommendation to surgically repair each of the concomi- tomy was performed. According to the owner, this dog
tant orthopedic injuries. began to bear weight on both pelvic limbs 39 days after
surgery. At the final recheck examination (523 days),
neurologic function was normal with a subtle weight-
Postoperative Evaluation bearing lameness in the hind limb that had the acetabular
fracture and subsequent femoral head and neck excision.
Reduction of the sacroiliac joint on the immediate Excluding the dog that died, all sacroiliac fracture-
postoperative radiographs ranged from 83.1–100% luxations healed without appreciable complications.
(mean, 92.9 6.6%). Mean pelvic canal diameter ratio Three dogs had no apparent lameness and 1 dog had a
measured from the immediate postoperative radiographs subtle weight-bearing lameness at final examination.
ranged from 1.12–1.51 (mean, 1.25 0.15). All trans-il- Minor complications were noted in 2 dogs during fol-
iosacral rods were placed in an appropriate location tra- low-up. Dog 3 developed a seroma around each end of
versing the sacral body as determined from the immediate the trans-iliosacral rod at 32 days; however, pressure
postoperative lateral and ventrodorsal radiographs. Res- applied to the ends of the rod did not elicit a pain
toration of dorsal coverage of the femoral head by the response and treatment was not required. Seromas had
acetabulum was achieved in all dogs except in the dog resolved at the final recheck examination (116 days). One
640 TRANS-ILIOSACRAL ROD IN FIVE DOGS
K-wire used in dog 1 to provide adjunctive rotational augmented this effect and also simplified imaging of the
stability migrated out of 1 ilial wing by final radiographic pelvic region in the smaller dogs.
evaluation (523 days), without apparent clinical conse- Positioning the dog in sternal recumbency also allowed
quence. the body of the sacrum to be clearly identified on lateral
Time to final radiographic follow-up evaluation fluoroscopic images facilitating precise implant place-
ranged from 98–523 days (mean, 217 205 days; medi- ment. Previous studies have shown accurate implant
an, 123 days). Mean pelvic canal diameter ratio measured placement within the sacral body to be a critical variable
from radiographs obtained at the final evaluation ranged in preventing screw loosening.1,3,10 In 1 retrospective
from 1.13–1.22 (mean, 1.18 0.04). None of the nuts had study, 50% of inappropriately positioned screws loos-
loosened from their position on the lateral surface of the ened, whereas screws placed accurately within the sacral
ilia. The mean immediate postoperative pelvic canal di- body had only a 12% incidence of loosening.1 Although
ameter ratio was not significantly different from the mean the anatomic landmarks guiding appropriate implant
preoperative pelvic canal diameter ratio (P ¼ .625). There placement are well described,16–19 only 33% of screws
was no significant difference in the mean immediate were correctly placed into the sacral body in 1 retrospec-
postoperative pelvic canal diameter ratio and the mean tive study evaluating open surgical reduction of sacroiliac
pelvic canal diameter ratio measured from the radio- fracture-luxations.1 We found that with the dog correctly
graphs obtained at the final follow-up evaluation positioned on the surgery table and correct centering of
(P ¼ .250). the sacrum within the fluoroscopic field, a K-wire could
be consistently and accurately placed through the body of
the sacrum. Holding the K-wire in place with custom-
Long-Term Outcome designed radiolucent forceps12 allowed us to confirm the
Owners of the 4 surviving dogs were contacted by wire’s position fluoroscopically before implantation.
telephone regarding their dog’s long-term clinical out- When the K-wire was centered and positioned parallel
come. Time from surgery to final follow-up ranged from to the X-ray beam, the wire had the appearance of a
212–650 days (mean, 355 205 days; median, 280 days). radiopaque dot centered over the body of the sacrum.
Limb function was assessed as excellent in 3 dogs and Once positioned correctly, the K-wire was driven through
good in 1 dog. both ilia, traversing the sacrum. Cannulated drill bits
were used to drill over the K-wire which contributed to
the ease and accuracy of the procedure.
DISCUSSION Obtaining sufficient purchase in the sacral body is an-
other important variable which influences the incidence
Our results corroborate that accurate reduction of sa- of screw loosening and subsequent loss of reduction.1 A
croiliac fracture-luxations can consistently be achieved screw or screws placed with a cumulative sacral purchase
using limited open reduction techniques with fluoroscopic 60% of the width of the sacrum have a lower prob-
assistance. We obtained anatomic or near anatomic re- ability of loosening.1 Trans-iliosacral application of a
duction (range, 83–100%; mean, 93%) of the sacroiliac trans-ilial rod as we describe maximizes sacral purchase
fracture-luxation similar to other reports where closed10 by increasing the surface area of contact between the
or open15 reduction techniques were used. Tomlinson cancellous bone and the implant’s threads. In addition,
et al10 reported that closed reductions facilitated by both cortices of the sacral body are engaged. Kaderly3
intraoperative fluoroscopy were 80–100% (mean 92%) described open reduction and placement of a single trans-
accurate as measured on immediate postoperative vent- sacral lag screw for the stabilization of bilateral sacroiliac
rodorsal radiographs. These results are similar to those fracture-luxations in dogs and cats. Although the trans-
achieved with open reduction (range, 74–100%; mean, sacral screw traversed the entire width of the sacrum and
94%) of sacroiliac fracture-luxations.15 engaged both ilia, the fixation only produced unilateral
All of our dogs were positioned in sternal recumbency. compression of the sacroiliac joint subjacent to the head
Tomlinson et al10 positioned dogs in lateral recumbency of the screw.3 Although none of the animals in Kaderly’s
while performing closed fluoroscopic-assisted lag screw report had appreciable loss of reduction or change in the
placement. Positioning dogs in sternal recumbency al- position of the screw at the time of the final radiographic
lowed simultaneous access to both hemipelvis and negat- evaluation performed 3–6 months after surgery, the width
ed the need to reposition the dogs intraoperatively. The of the joint space which was not compressed by the head
weight of the dogs’ hind limbs hanging off the end of the of the screw had increased in 2 cats.3
surgery table pulled the displaced pelvis caudoventrally, Compression of the sacroiliac joint is important to
thus facilitating reduction. Placing a thick radiolucent, provide increased frictional stability to the fixation.3 The
wedge-shaped foam pad under the dog’s caudal abdomen locked nuts on the trans-iliosacral rod provide bilateral
LEASURE ET AL 641
canal stenosis.11 In our dogs, the pelvic canal was not reduction of sacroiliac fracture-luxations. Trans-iliosacral
compromised (diameter ratio 1.10) preoperatively, rods provide stable fixation, allow early weight-bearing
immediate postoperatively, or at the time of the final ra- and appear to be suitable implants for the stabilization of
diographic evaluation. Mean pelvic canal diameter ratio sacroiliac fracture-luxations. Limitations of this study in-
was not statistically different at any time point. In con- clude the small number of dogs, the relatively short-term
trast to previous studies,10,11 the immediate postoperative follow-up and the retrospective nature in which the in-
mean pelvic canal diameter ratio (mean, 1.25 0.15) was formation was collected. A larger clinical case series,
slightly less than the preoperative mean pelvic canal di- preferably prospective, with longer follow-up evaluations
ameter ratio (mean, 1.28 0.10), although this difference would be necessary to corroborate the efficacy of this
was not significant. Dogs had lateral displacement with technique and identify additional complications associ-
widened pelvic canals and most of the pelvic canal di- ated with the trans-iliosacral rod placement.
ameter ratios were decreased after reduction and stabi-
lization. Pelvic canal diameter ratio ranged from 1.13 to
1.22 at the time of final radiographic evaluation and none ACKNOWLEDGMENTS
of the dogs had clinical signs of pelvic canal stenosis.
The authors would like to thank Ms. Debby Sundstrom
This technique of reducing and stabilizing sacroiliac
and Mr. James van Gilder for their assistance with data
fracture-luxations under fluoroscopic guidance is de-
analysis and image preparation, Ms. Linda Rose for her
signed to be minimally invasive and therefore limit post-
assistance with word processing and Mr. Mark Hoffenberg
operative morbidity. A limited approach to the iliac spine
for photographing the implants.
of each displaced ilial wing was made to reduce the
luxation and a limited lateral approach to both ilia was
used to allow insertion of the trans-iliosacral rod. Trim- REFERENCES
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LEASURE ET AL 643
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