[AUTORES: por favor, leiam com atenção as observações

abaixo a respeito do artigo e nos retorne as informações

solicitadas.
1. A revista recomenda que o autor correspondente tenha um
cadastro no ORCID - https://orcid.org/. Caso o autor já
possua este cadastro, nos informe os dados de login (login e
senha) para que possamos puxar esta informação no sistema
de submissão. Não é suficiente informar apenas o número de
registro. Caso não possua, podemos providenciar.
2. O sistema pergunta se os autores têm algum elemento da
pesquisa que gostariam submeter em revistas do grupo
Research Elements. Em caso positivo, indique em qual das
seguintes revistas gostariam de submeter os dados.
DIB - Data in Brief (describing datasets deposited in repositories)

MEX - MethodsX (improvised and novel methods and protocols)

OHX - HardwareX (open-source scientific devices and equipment)

SOFTX - SoftwareX (detailed descriptions of research software)

SIMPA - Software Impacts (brief descriptions of code and software used to compute
scientific results)

INV - Invention Disclosure (descriptions of inventions from the scientific discovery process)

SCTALK - Science Talks (videos of scientific talks, tutorials and early results)

SCR - Stem Cell Research (detailed descriptions of new stem cell lines or sub-lines)

EXCO - Examples and Counterexamples (presentation of mathematical examples and

counterexamples from all research fields)

SOCIMP - Societal Impacts (descriptions of societal impacts of research)

3. A revista também pergunta se os autores desejam

disponibilizar antecipadamente e sem custo uma versão
preprint do artigo, que estará disponível gratuitamente para
leitura não importando a decisão da revista quanto à
publicação.]

Comparison of sacroiliac screw techniques for unstable

sacroiliac joint disruptions: a finite element model
analysis

Highlights
o Two transiliac screws in S1 are biomechanically superior
for stabilizing the sacroiliac joint in vertically unstable
pelvic ring injuries compared to other configurations using
iliosacral screws.
o Lateral displacement, posterior displacement, and von
Mises stress in the posterior screws were reduced with this
construct.
o von Mises stress was reduced in the symphyseal plating
with two transiliac screws in S1.
o The use of two transiliac screws in S1 increases the
fixation strength of vertically unstable AO 61C1.2 type
pelvic injuries.

ABSTRACT [Máximo 350 palavras]

Vertically unstable pelvic injuries associated with sacroiliac
disruption are challenging. Although percutaneous iliosacral
fixation using two screws at S1 vertebral body has been
shown beneficial, the use of two transiliac screws at S1 has
been proposed to increase the fixation strength of the
construct. In the herein study, the finite element method
(FEM) was performed to analyze the biomechanical
behavior of five different constructions using iliosacral
screws only, transiliac screws only, and combining an
iliosacral and a transiliac screw. A vertically unstable AO
61C1.2 type pelvic injury was produced for the evaluation of
the posterior pelvic displacement and implant stress, and the
anterior implant stress using FEM. The symphysis pubis was
fixed with a 3.5-mm reconstruction plate in all cases. The
model was axially loaded with 800N applied in the center of
S1 body, perpendicular to the ground (Y-axis), simulating the
bipodal stance moment. There was a statistically significant
reduction in both posterior displacement and implant stresses
in the groups fixed with at least one transiliac screw
compared to the groups fixed with iliosacral screws. In our
FEM study, the construct using two transiliac screws in S1 is
biomechanically superior for stabilizing the sacroiliac joint
in vertically unstable pelvic ring injuries compared to the
other configurations. Lateral displacement, posterior
displacement, and von Mises stress were reduced with this
construct. A good option can be the use of one iliosacral
screw and one transiliac screw in S1.
Keywords: pelvis; vertical shear; fixation; biomechanical;
finite element models.

[AUTORES: Alguns trechos estão destacados em fonte

rosa. Favor revisá-los e confirmar que a tradução está OK
para os autores.]
INTRODUCTION
Pelvic ring injuries account for 3.0 to 8.2% of all
fractures inyoung patients[1]. They are usually caused by
high-energy trauma, such asautomobile accidents andfalls
fromheight, and are often associated with other skeletal and
non-skeletal injuries [2]. Approximately 46% ofpelvic ring
fractures are mechanically unstable andoftenoccur together
with hemodynamic instability, requiringrapid and specific
actions to reduceand stabilizeexisting injuries [1,3,4].
Stabilization ofthe posterior pelvic component isusually
the most difficult,especiallyin vertical shear injuries
affectingthesacroiliac joint [5,6]. In these cases, the use
oftwopercutaneous iliosacral screws(ISS) has been
describedas themost effective and less invasive method to
stabilizeposterior pelvic instability [5]. It has been
recommended toposition ISS preferablyat the vertebral body
of thefirst sacral vertebra (S1) [7,8]. The presenceof a
surgeontrained in pelvic ringsurgery andthe
existenceofintraoperative fluoroscopic images reducethe
riskof complications [9,10].
However, in some cases, especially whenposterior
component reduction is not anatomical orthere is sacral
dimorphism, placement ofISS becomesa majorchallenge
[11,12]. In these situations, the useofone ISS in S1
andanother onein S2 has been suggested [7-12]. In a study
using finite element analysis, Zhang et al. [13] showed that
one ISS in S1 andanother in S2 providedadditional
biomechanical stabilityinvertically unstable pelvic ring
injuries. However, to the best of ourknowledge,
constructions using twotransiliac screws (TIS) or
combiningoneTIS and one ISS havenot been developedsofar.
The authors hypothesize thatthe use ofat least oneTIS
increasesthe mechanical resistanceof two screwconstructions
used to stabilize thesacroiliac joint. Inthe present study,
fiveiliosacral fixation models in an unstable pelvic injury
(AO 61C1.2) were biomechanically analyzed through finite
element three-dimensional(3D) analysis, so as to describe
structure displacements andstress distributionin bone models
and in osteosynthesis hardware.

MATERIAL AND METHODS

Construction ofthe model
The model was constructed usinghuman pelvic
computed tomography (CT) scans from ahealthy young male
individual (35 years), with no previous injuryat
thesiteandwith abody mass index of 27. Using the
Rhinoceros 3D software (Robert McNeel & Associates,
Seattle, USA), BioCAD models(geometric solids)were
constructed, observingall dimensions ofbone structures
individuallyand reproducingcortical and spongy structures
by means ofmeshesand lines ata higherandlower
concentration, respectively.
Afterbone structures were constructed, anterior
sacroiliac ligament, posterior sacroiliac ligaments (shortand
long), sacrotuberous ligament, andsacrospinous ligament
were reproduced, according to previous studies usingthe
finite element method (FEM) in the pelvis [13-15].
A3.5 mm tick six-hole reconstruction plate was used in
the public symphysis, fixed with four longs 3.5-mm cortical
screws (two ineach side of symphysis), soas to reproducea
stable anterior component. It was decided not to usean
external fixatorin order to reduce potential conflicts with
images of the implants used foriliosacral stabilization. This
model, composedofbone structures, posterior ligamentous
complex,andpubic symphysisfixation, constituted the control
group (CG) model (Figure 1).
Tocreate the experimental groups models,all right
posterior ligaments were removed, and anterior fixation and
left posterior ligamentous structures were maintained.
Therefore, the experimental groups had total
iliosacralligamentous instability in the right hemipelvis, thus
simulatingan AO 61C1.2 type injury.
In the fiveexperimental groups, posterior fixation was
performed asfollows: Group 1 (G1), two ISS, bothending at
the center of S1 vertebral body; Group 2 (G2), two
polymethylmethacrylate (PMMA)-augmented ISS, both
endingat the center of S1 vertebral body; Group 3(G3), two
ISS, one ending at the center of S1 vertebral body and the
other at the center of S2 vertebral body; Group 4 (G4), an
ISS ending at the center of the body of S1 and a TIS in S1,
ending in the contralateral iliac; andGroup 5 (G5), two TIS
in S1, both ending in the contralateral iliac (Figure 2). In all
constructions, virtual models of 7.0-mm cannulated screws
were used, which variedinnumber, position, and length.

Assessment by finite element analysis

The assessed variables were lateral displacement (LD),
posterior screw displacement (PSD), maximum principal
stress (MaxPS), minimum principal stress (MinPS), von
Mises equivalent stress for posterior fixation (VMP), and
von Mises equivalent stress foranterior fixation (VMA).
PSDwasassessed by obtaining the distancefromthe
screw head tothe outer iliac table after the test. To assess
LD,five points were demarcated on two parallel lines, one
crossing the center ofiliosacral joints (points A, A’, and B)
andanother crossing the center of the pubis (points C and
C’). The following parameters were determined:
displacement of the sacrum in relation to the right iliac (S–I),
ofthe right pubis in relationto the sacrum (P–S), ofthe left
iliac in relation to the right iliac (I–I), andof the right pubis
in relation to the left pubis (P–P).
Displacementswereevaluated by the distance between their
respective points in post-test measures. Therefore, S–I
displacementwas defined wasthedistance between pointsA
andB;P–S displacement, betweenpoints B and C; I–I
displacement,between points A and A’;and P–P
displacement, betweenpoints C and C’, atthe Y axis(Figure
3).
Withregard to the mechanical properties of the
materialused for modeling, the cortical bone, thetrabecular
bone, theiliosacral ligaments, and PMMA were considered
as isotropic, uniform, and continuous linear elastic
materials.The parameters ofthe material used for each
componentwere inserted individually, observingtheir
properties (Table 1).
Test conditions and contours weredetermined by
fixingthe pelvisat X, Y and Z axes viathe acetabulaover its
entire innersurface, thusavoidiliacmobility. An 800N load as
applied in the center of S1 body, perpendicular to the ground
(Y-axis), simulatingthe bipodal stance moment, to
exploreonly thesacroiliac joints (Figure 4). Tests were
performed using theSimLab software (Amman, Jordan)
withtetrahedral elements.

Assessment of results
The results obtained were presented in absolute values
and percentage, comparingthe experimental
groupsbetweenthemselves andeach experimental group with
the CG.

RESULTS
The values obtained for LDshowed a reductionin S–I,
P–S, II–, and P–P dislocations for G5, comparedtothe CGand
to theotherexperimental groups. P–P dislocation wasequal
between G4 and G5 (Table 2).
Values for PSD (in mm) were 0.12, 0.10, 0.15, 0.08 and
0.08 for G1, G2, G3, G4 and G5, respectively. There was a
reduction inthis variable in G4 and G5. With
regardtoMaxPSand MinPSon bone structures, both values
werecloserto those of the CGin G5 (Table 3 and Figure 5).
VMP representedthe lowesttensionin posterior fixation
for G5, followed in ascending orderby G1, G4, G2, G3,
respectively. VMA waslower in G4 and G5, compared tothe
CGandto the other experimental groups (Table 3 and Figure
6).
DISCUSSION
In the present study using the finite element method, the
construction with two TIS in S1, both ending in the
contralateral iliac (G5) was biomechanically superior to the
others in sacroiliac fixation in an unstable pelvic AO 61C1.2
type injury. In this group, the findings showed a reduction in
values for the lateral displacement of the sacrum in relation
to the right iliac, of the right pubis in relation to the sacrum,
of the left iliac in relation to the right iliac and of the right
pubis in relation to the left pubis. In addition, the MaxPS and
MinPS in the bone structures had values closer to those of
the CG in G5, and the von Mises equivalent stress for
posterior fixation was lower in this group. Finally, the
displacement of the posterior screw was smaller in G5,
although similar to the value observed in G4 (an ISS ending
at the center of the body of S1 and a TIS in S1, ending in the
contralateral iliac). Our results showed that the stability from
the weakest to the strongest were G3 (two ISS, one ending at
the center of S1 vertebral body and the other at the center of
S2 vertebral body), G2 (two ISS, both ending at the center of
S1 vertebral body, with PMMA augmentation), G1 (two ISS,
both ending at the center of S1 vertebral body), G4 (an ISS
ending at the center of the S1 vertebral body and a TIS in S1,
ending in the contralateral iliac), and G5, strongly suggesting
that the use of two TIS in S1 is biomechanically ideal for
stabilizing the sacroiliac joint in vertically unstable pelvic
ring injuries.
Although not investigated in the current study, PMMA
augmentation and S2 ISS fixation were likely to be
associated with greater lateral and posterior screw
displacement, and greater tension in the posterior screws. We
expected that PMMA augmentation around S1 screw tip
could reduce stress in this construction, which in clinical
setting could directly reduce the risk of implant failure and
loss of reduction; however, this was not observed in our
study. ISS loosening was observed in up to 20% of patients,
with C-type pelvic injuries being a recognized risk factor
[16]. Biomechanical studies have reported enhanced
anchorage at the screw tip of cannulated ISS, with
significantly less displacement after bone cement
augmentation compared to the use of one or two ISS [17-
19]. However, no advantages to cement were observed in
terms of the number of cycles to failure; therefore, PMMA
augmentation of ISS has been suggested as a treatment
option for posterior pelvic ring fixation in osteoporotic bone
only [19,20]. A possible explanation to our finding can be
the poor distribution of bone cement, concentrated around
the screw threads, so forces were transmitted between sacral
ala bone and implants primarily through the bone-screw
interface [21]. Due to the proximity of the implants, both at
S1, and the increased fixation only at the tip of the screws,
high stresses were seen in both the remaining posterior bone
elements (sacral ala) and the implants. This must be viewed
as one of the potential limitations of our study, as the
increased stiffness at the tip of the screws may have
produced small point areas with higher stresses in the rest of
the screw in the finite element analysis.
S2 ISS fixation has been suggested as a safe and
biomechanically effective alternative technique for posterior
pelvic ring disruptions [13,22,23]. In a retrospective cohort
study, Moed and Geer [23] analyzed 49 patients presenting
an unstable pelvic injury involving the posterior ring treated
with S2 ISS. There were 9 bilateral injuries. Intraoperative
nerve monitoring was used in all cases. There were no
intraoperative iatrogenic nerve injuries, and postoperative
loss of reduction requiring revision surgery occurred in 2
patients with osteopenia. These authors concluded that S2
ISS fixation should be used with caution in patients with
suspected pelvic osteopenia. In addition, screws inserted in
S2 vertebral body have less room for placement as S2 sacral
corridor is smaller than the S1 [24]. Some authors showed
that S2 ISS had less cross-sectional area for placement,
which increases the risk of misplacement [24,25].
Interestingly, there is a tendency towards an increase in the
S2 corridor in patients with S1 dysmorphism, although
statistically significant [24]. Therefore, careful attention to
the size and orientation of the S2 vertebral body must be
taken when ISS are placed, which increases difficulties in
the setting of a patient with a vertically unstable pelvic
injury.
The aim of posterior fixation is to provide the patient
with stable fixation for healing and early mobilization [26].
This is preferably done using two ISS in a stable patient,
with adequate preoperative planning to understand the
complex and variable anatomy of the posterior pelvic ring,
thus minimizing potential ISS problems [11,27]. Although in
most cases this is done as an elective procedure, acute
emergent sacroiliac fixation has been shown an option as a
resuscitative maneuver in non-respondent patients with
vertically unstable pelvic ring injuries [6,28]. Despite all
difficulties related to both the patient hemodynamic status
and the technical challenges related to the definitive
sacroiliac fixation, it seems reasonable to always optimize
pelvic mechanics, performing the most stable construct
without increasing the operative time [26-28]. Currently, it is
well-recognized that for vertically unstable pelvic fractures,
double ISS fixation of posterior ring injuries provides a more
stable construction compared to only one ISS [22,29,30].
However, in our study the use of double TIS was superior to
double ISS, which is corroborated by other biomechanical
and clinical studies showing that TIS have superior
extraction strengths compared with ISS inserted into the
sacral body [31,32]. These findings are even more important
in osteoporotic patients, in whom the TIS threads purchase a
stronger bone on the contralateral iliac cortex, thus
increasing the resistance to vertical shear deformation forces
[33]. Moreover, the distance from the sacroiliac joint to the
center of the sacral body is significantly less than the
distance from the sacroiliac joint to the contralateral iliac
cortex [33].
Nevertheless, despite the superior biomechanical
stability demonstrated with the TIS, one must be aware of
the potential drawbacks and risks of this technique. First,
there seems to be some concern regarding the fixation
strength of ISS when there is greater instability of the
posterior pelvic ring, such as in vertically unstable injuries.
In this situation, the triangular osteosynthesis fixation has
been advocated, combining unilateral lumbopelvic
osteosynthesis for vertical stabilization and ISS fixation for
horizontal stabilization [34,35]. However, in a
biomechanical study comparing the stability of two TIS
versus triangular osteosynthesis, Min et al. [36]observed a
comparable biomechanical stability profile between these
constructions in both translation and rotation. Secondly, TIS
fixation violates the contralateral, uninjured sacroiliac joint,
what can theoretically be associated with chronic pain in
patients receiving this stabilization method. This was
investigated by Mardam-Bey et al. [37] in a retrospective
clinical study involving 36 patients treated with TIS and 26
patients treated with unilateral ISS. These authors concluded
that TIS did not adversely affect patient outcomes or
subjective pain scores in unilateral pelvic ring injuries,
compared to unilateral ISS. Heydemann et al. [38] showed
similar results in 53 patients presenting either unilateral
sacroiliac disruptions or sacral fractures followed-up for at
least 12 months after TIS fixation. They found that TIS
across the contralateral, uninjured sacroiliac joint resulted in
no differences in pain and function when compared with
standard ISS fixation. Finally, it has been identified an
increased risk of extraosseous screw placement with the S1
TIS fixation compared to the ISS fixation [31]. In contrast to
the relatively safe pathway for ISS placement in S1, the use
of TIS is more limited by the critical diameter of the
transsacral corridors [39-41]. It has been shown that both the
configuration of the sacral alae and the vertical position of
the sacroiliac joints varied significantly [42]. In this context,
the adoption of regular preoperative evaluation using CT-
based 3D statistical models to understand sacral anatomy
and the existence of surgically transsacral S1 and S2
pathways has been suggested [42,43].
Our study has several strengths. First, to the best of our
knowledge, this is the first study to evaluate the
biomechanical behavior of transiliac versus iliosacral screws
using FEM. Although some studies used the same toll to
analyze ISS fixation, comparisons were done between
different ISS fixations or were established between distinct
ISS constructs with other fixation methods [13,21,22,32,44].
Secondly, we were able to show that the TIS fixation is
superior to the ISS fixation. In the current study, both groups
using TIS fixation in S1 showed superior biomechanical
behavior for stabilizing the sacroiliac joint in vertically
unstable pelvic ring injuries. The same findings have been
observed in clinical studies [31,33,45]. Moreover, even when
there is no room for placing twoTIS in S1, a second ISS
must be placed either in S1 or S2 to prevent rotation and
increase fixation strength [46], which was also demonstrated
in our study (Group 4). Thirdly, the pubic symphysis was
stabilized with a plate instead of fixed with an external
fixator or leaved with no fixation. Some authors have tested
distinct posterior pelvic fixation constructs in vertical shear
models of complete sacroiliac disruption;however no
anterior injury fixation was done, which do not resemble the
clinical setting [7,47]. While stabilizing the posterior pelvic
ring is of primary importance in achieving stability of
vertically unstable pelvic ring injuries, anterior pelvic plating
has been shown to significantly augment stability of the
construct, restoring the normal response of the hemipelvis to
axial loading and potentially preventing sacroiliac joint
displacement and residual step-off [12,48].Finally, we used
the FEM for the biomechanical analysis, which is a proven a
useful technology to reduce biases when comparing different
constructs used for fracture fixation in orthopedic trauma.
We have been shown that both two-dimensional and 3D
FEM avoid variations in bone quality and anatomy, fracture
patterns, and fixation location [49-52].
Despite the strengths, we acknowledge that our study
has some limitations. First, as previously mentioned in this
study, the very-well localized distribution of the bone
cement around the screw threads could have biased our
findings, demonstrating an inferior biomechanical behavior
of two PMMA-augmented S1 ISS compared to two S1 ISS
with no augmentation. even though biomechanical studies
have been reporting enhanced anchorage at the screw tip of
cannulated ISS [17-19], in the clinical setting many times the
S1 corridor is extremely narrow, especially in women
[24,53,54]. Therefore, in many patients the close contact
between the PMMA-augmented S1 ISS is inevitable,
generating higher stresses both in the sacral ala and the
implants [21]. Secondly, there was no comparison between
the ISS and TIS fixation with other methods used to manage
the patient with a vertically unstable unilateral sacroiliac
dislocation, such as the transiliac tension-band plate,
lumbopelvic fixation with or without an additional ISS, and
the transsacral bar [29]. However, biomechanical
investigations showed no superiority of these fixation
methods over the ISS fixation [22,26,29]. In addition,
another biomechanical investigation demonstrated
comparable stability between the lumbopelvic fixation and
the TIS [36]. Finally, the anterior pelvic ligaments were not
reproduced in our model. However, the symphysis pubis was
fixed with a superior six-hole 3.5-mm plate in all groups,
including the control. This made possible the evaluation and
comparison between the experimental groups and between
these and the CG. Our findings showed that the use of at
least one TIS reduced the von Mises equivalent stress on the
anterior plate (G5<G4) compared to the groups fixed with
ISS (G3<G1<G2). Moreover, Sagi et al. [12] showed that
anterior symphyseal plating for the vertically unstable pelvic
injuries significantly increases the stability of the fixation
construct, restoring the normal response of the hemipelvis to
axial loading. In the clinical setting, this can theoretically
reduce the risk of plate failure or screw loosening by
reducing the tension forces in the symphysis pubis, also
reducing the deformation forces acting on the screws used
for the sacroiliac fixation.

Conclusion
In our FEM study, the construct using two TIS in S1 is
biomechanically superior for stabilizing the sacroiliac joint
in vertically unstable pelvic ring injuries compared to the
other configurations. Lateral displacement, posterior
displacement, and von Mises stress were reduced with this
construct. A good option can be the use of one ISS and one
TIS in S1.
References
1.El-Desouky II, Mohamed MM, Kandil AE. Percutaneous
iliosacral screw fixation in vertically unstable pelvic injuries,
a refined conventional method. Acta Orthop
Belg2016;82:52-9
2.McCormack R, Strauss EJ, Alwattar BJ, Tejwani
NC.Diagnosis and management of pelvic fractures. Bull
NYU Hosp Jt Dis 2010;68:281-91.
3.Enninghorst N, Toth L, King KL McDougall D, Mackenzie
S, Balogh ZJ. Acute definitive internal fixation of pelvic ring
fractures in polytrauma patients: a feasible option. J
Trauma2010;68:935-41.
4.Mardanpour K, Rahbar M. The outcome of surgically
treated traumatic unstable pelvic fractures by open reduction
and internal fixation. J Injury Violence Res 5;2013:77-83.
5.Coccolini F, Stahel PF, Montori G, Biffl W, Horer TM,
Catena F, et al. Pelvic trauma: WSES classification and
guidelines. World J Emerg Surg2017;12.
6.Gardner MJ, Chip Routt Jr.ML. The antishock iliosacral
screw. J Orthop Trauma2010;24:e86-9.
7.Yinger K, Scalise J, Olsen SA, Bay BK, Finkemeier CG.
Biomechanical comparison of posterior pelvic ring fixation.
J Orthop Trauma2003;17:481-7.
8.Da Silva Jr. WC, C. De Souza MP, Bortoli FS, Frajuca C,
Souza RC. Obtaining the predicted number of cycles of
femoral prosthesis manufactured with ASTM F138 and
ASTM F75 alloys, applying the method of finite element. J
Phys: Conf Ser2021;1730.
9.Benders KEM, Leenen LPH. Management of
hemodynamically unstable pelvic ring fractures. Front
Surg2020;7:601321.
10.Cruz HA,De Angelis GP. Corredor de segurança sacro-
ilíaco: análise para inserção segura de parafusos íliossacrais.
Rev Bras Ortop2013;48:348-56.
11.Chip Routt Jr. ML, Simonian PT, Inaba RTJ. Iliosacral
screw complications. Oper Tech Orthop1997;7:206-20.
12.Sagi HC, Ordway NR, DiPasquale T. Biomechanical
analysis of fixation for vertically unstable sacroiliac
dislocations with iliosacral screws and symphyseal plating.
JOrthop Trauma2004;18:138-43.
13.Zhang L, Peng Y, Du C, Tang P. Biomechanical study of
four kinds of percutaneous screw fixation in two types of
unilateral sacroiliac joint dislocation: a finite element
analysis. Injury2014;45:2055-9.
14.Henyš P, Ramezani M, Schewitz D, Höch A, Möbius D,
Ondruschka B, et al. Sacrospinous and sacrotuberous
ligaments influence in pelvis kinematics. J
Anat2022;241:928-37.
15.Venayre B, Koyama Y, Kurosawa D, Hammer N,
Lingslebe U, Murakami E, et al. Quantitative evaluation of
the sacroiliac joint fixation in stress reduction on both
sacroiliac joint cartilage and ligaments: a finite element
analysis. Clin Biomech (Bristol, Avon)2021;85:105350.
16.Kim JW, Oh CW, Oh JK, Kyung HS, Park KH, Yoon SD,
et al. The incidence of and factors affecting iliosacral screw
loosening in pelvic ring injury. Arch Orthop Trauma
Surg2016;136:921-7.
17.Grechenig S, Gänsslen A, Gueorguiev B, Berner A,
Müller M, Nerlich M. PMMA-augmented SI screw: a
biomechanical analysis of stiffness and pull-out force in a
matched paired human cadaveric model. Injury2015;46
(Suppl 4):S125-8.
18.Grüneweller N, Raschke MJ, Zderic I, Widmer D, W
Dirk, Gueorguiev B, et al. Biomechanical comparison of
augmented versus non-augmented sacroiliac screws in a
novel hemi-pelvis test model. J Orthop Res2017;35:1485-93.
19.Lodde MF, Katthagen JC, Schopper CO, Zderic I,
Richards RG, Gueorguiev B, et al. Does cement
augmentation of the sacroiliac screw lead to superior
biomechanical results for fixation of the posterior pelvic
ring? A biomechanical study. Medicina
(Kaunas)2021:57;1368.
20.Osterhoff G, Dodd AE, Unno F, Wong A, Amiri S,
Lefaivre KA, et al. Cement augmentation in sacroiliac screw
fixation offers modest biomechanical advantages in a
cadaver model. Clin Orthop Relat Res2016;474:2522-30.
21.Lewis GS, Mischler D, Wee H, Reid JS, Varga P. Finite
element analysis of fracture fixation. Curr Osteoporos
Rep2021;19:403-16.
22.Lu Y, He Y, Li W, Yang Z, Peng R, Yu L. Comparison of
biomechanical performance of five different treatment
approaches for fixing posterior pelvic ring injury. J Healthc
Eng2020;2020:5379593.
23.Moed BR, Geer BL. S2 iliosacral screw fixation for
disruptions of the posterior pelvic ring: a report of 49 cases.
J Orthop Trauma2006;20:378-83.
24.Carlson DA, Scheid DK, Maar DC, Baele JR, Kaehr DM.
Safe placement of S1 and S2 iliosacral screws: the
"vestibule" concept. J Orthop Trauma2000;14:264-9.
25.Mendel T, Noser H, Wohlrab D, Stock K, Radetzki F.
The lateral sacral triangle--a decision support for secure
transverse sacroiliac screw insertion. Injury2011;42:1164-70.
26.Ilharreborde B, Breitel D, Lenoir T, Mosnier T, Skalli W,
Guigui P, et al. Pelvic ring fractures internal fixation:
iliosacral screws versus sacroiliac hinge fixation. Orthop
Traumatol Surg Res2009;95:563-7.
27.Routt Jr. ML, Simonian PT, Agnew SG, Mann FA.
Radiographic recognition of the sacral alar slope for optimal
placement of iliosacral screws: a cadaveric and clinical
study. J Orthop Trauma1996;10:171-7.
28.Barei DP, Bellabarba C,Mills WJ, Routt Jr.ML.
Percutaneous management of unstable pelvic ring
disruptions. Injury2001;32 Suppl 1:SA33-44.
29.Blum L, Hake ME, Charles R, Conlan T, Rojas D, Martin
MT, et al. Vertical shear pelvic injury: evaluation,
management, and fixation strategies. Int
Orthop2018;42:2663-74.
30. Deng HL, Li DY, Cong YX, Zhang BF, Lei JL, Wang H,
et al. Clinical analysis of single and double sacroiliac screws
in the treatment of Tile C1 pelvic fracture. Biomed Res Int
2022;2022:6426977.
31.Gardner MJ, Routt Jr. ML. Transiliac-transsacral screws
for posterior pelvic stabilization. J Orthop
Trauma2011;25:378-84.
32.Zhao Y, Zhang S,Sun T, Wang D, Lian W, Tan J, et al.
Mechanical comparison between lengthened and short
sacroiliac screws in sacral fracture fixation: a finite element
analysis. Orthop Traumatol Surg Res2013;99:601-6.
33.Ziran N, Collinge CA, Smith W, Matta JM. Trans-sacral
screw fixation of posterior pelvic ring injuries: review and
expert opinion. Patient Saf Surg 2022;16:24.
34.Josten C, Schildhauer TA, Muhr G. Therapie instabiler
Sacrumfrakturen bei Beckenringbrüchen. Erstergebnisse
einer frühbelastbaren Osteosynthese. Chirurg1994;65:970-5.
35.Schildhauer TA, Josten C, Muhr G. Triangular
osteosynthesis of vertically unstable sacrum fractures: a new
concept allowing early weight-bearing. J Orthop
Trauma1998;12:307-14.
36.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. Orthopedics2014;37:e754-60.
37.Mardam-Bey SW, Beebe MJ, Black JC, Chang EY,
Kubiak EN, Bishop JA, et al. The effect of transiliac-
transsacral screw fixation for pelvic ring injuries on the
uninjured sacroiliac joint. J Orthop Trauma2016;30:463-8.
38.Heydemann J, Hartline B, Gibson ME, Ambrose CG,
Munz JW, Galpin M, et al. Do transsacral-transiliac screws
across uninjured sacroiliac joints affect pain and functional
outcomes in trauma patients? Clin Orthop Relat
Res2016;474:1417-21.
39.Day CS, Prayson MJ, Shuler TE, Towers J, Gruen GS.
Transsacral versus modified pelvic landmarks for
percutaneous iliosacral screw placement--a computed
tomographic analysis and cadaveric study. Am J Orthop
(Belle Mead NJ) 2000;29(9 Suppl):16-21.
40.Mendel T, Appelt K, Kuhn P, Suhm N. Der sakroiliakale
Knochenkorridor. Ein virtuelles Volumenmodell zur sicheren
Implantation transartikulärer Schrauben.
Unfallchirurg2008;111:19-26.
41.Zheng ZH, Xu F, Luo ZQ, Ren Y, Fu T, Xu HQ, et al. A
useful intraoperative technique for transiliac-transsacral
screws: a point-to-point coaxial guide apparatus. J Orthop
Surg Res2021;16:89.
42.Wagner D, Kamer L, Rommens PM, Sawaguchi T,
Richards RG, Noser H. 3D statistical modeling techniques to
investigate the anatomy of the sacrum, its bone mass
distribution, and the trans-sacral corridors. J Orthop
Res2014;32:1543-8.
43.Wagner D, Kamer L, Sawaguchi T, Richards RG, Noser
H, Hofmann A, et al. Morphometry of the sacrum and its
implication on trans-sacral corridors using a computed
tomography data-based three-dimensional statistical model.
Spine J.2017;17:1141-7.
44.Lee CH, Hsu CC, Huang PY. Biomechanical study of
different fixation techniques for the treatment of sacroiliac
joint injuries using finite element analyses and
biomechanical tests.Comput Biol Med2017;87:250-7.
45.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 Trauma2013;27:521-6.
46.van Zwienen CMA, van den Bosch EW, Snijders CJ,
Kleinrensink GJ, van Vugt AB. Biomechanical comparison
of sacroiliac screw techniques for unstable pelvic ring
injuries. J Orthop Trauma2004;18:589-95.
47.Comstock CP, van der Meulen MC, Goodman SB.
Biomechanical comparison of posterior internal fixation
techniques for unstable pelvic fractures. J Orthop
Trauma1996;10:517-22.
48.Willhuber GC, Zderic I, Gras F, Wahl D, Sancineto C,
Barla J, et al. Analysis of sacro-iliac joint screw fixation:
does quality of reduction and screw orientation influence
joint stability? A biomechanical study. Int
Orthop2016;40:1537-43.
49.Freitas A, Barin FR, Battaglion LR, da Costa HI, Santos
ED, Rosado HA, et al. Proposal for a new fixation method
for Pauwels Type III femoral neck fracture-metaphyseal
stem: a finite-element analysis. lndian J Orthop2021;55:378-
84.
50.Freitas A, Bontempo RL, Azevedo FAR, Battaglion LR,
Giordano MN, Barin FR, et al. New fixation method for
Pauwels type III femoral neck fracture: a finite element
analysis of sliding hip screw, L-shaped, and L-shaped with
medial plate. Eur J Orthop Surg Traumatol2021;31:1069-75.
51.Giordano V, Godoy-Santos AL, Belangero WD, Pires
RES, Labronici PJ, Koch HA. Mind the gap between the
fracture line and the length of the working area: a 2-D finite
element. Rev Bras Ortop2018;5:88-93.
52.Giordano V, Freitas A, Pires RE, Battaglion LR, Lobo
MO, Belangero WD. Evaluation of a locking
autocompression screw model in Pauwels type-3 femoral
neck fracture: in vitro analysis. Bioengineering2022;9:464.
53.Gras F, Gottschling H, Schröder M, Marintschev I,
Hofmann GO, Burgkart R. Transsacral osseous corridor
anatomy is more amenable to screw insertion in males: a
biomorphometric analysis of 280 pelves. Clin Orthop Rel
Res2016;474:2304-11.
54.Trikha V, Gaba S, Kumar A, Mittal S, Kumar A. Safe
corridor for iliosacral and trans-sacral screw placement in
Indian population: a preliminary CT based anatomical study.
J Clin Orthop Trauma.2019;10:427-31.

TABLES

Table 1. Parameters of the material used in the experiment:

elasticity modulus and Poisson coefficient.
Material Elasticity modulus (MPa) Poisson coefficient (v)
Cortical bone 12,000 0.3
Trabecular bone 1,500 0.3
Stainless steel 200,000 0.29
PMMA 3,000 0.4
Ligament 397 0.3

Source: Lu Y et al., 2020 [22].

Table 2. Valuesfor LDinthe CGand in experimental groups.
LD Groups
CG (%) G1 (%) G2 (%) G3 (%) G4 (%) G5 (%)
S–I (mm) 0.6 0.13 0.14 0.17 0.11 0.1
(100%) (21.7%) (23.3%) (28.3%) (18.3%) (16.7%)
P–S (mm) 0.15 0.12 0.11 0.13 0.09 0.07
(100%) (80%) (73.3%) (86.7%) (60%) (46.7%)
I–I (mm) 0.05 0.04 0.03 0.06 0.03 0.02
(100% (80%) (60%) (120%) (60%) (40%)
P–P (mm) 0.08 0.05 0.04 0.06 0.03 0.03
(100%) (62.5%) (50%) (75%) (37.5%) (37.5%)
Source: Authors, 2023.
Legends: CG = control group; I–I = displacement of the left
ileum in relation to the right ileum; LD = lateral
displacement; P–P = displacement of the right pubis in
relation to the left pubis; P–S= displacement of the sacrum
in relation to the right pelvis; S–I = displacement of the
sacrum in relation to the right ileum.

Table 3. Values for MaxPS and MinPS in the CG and in

experimental groups.
Tension forces
Groups
(bone)
CG G1 G2 G3 G4 G5
MaxPS (Mpa) 31.8 37.3 102.1 126.5 37.3 33.2
MinPS(Mpa) -38.9 -108.2 -122.0 -113.6 -42.3 -39.0
Source: Authors, 2023.
Legends: Max PS = maximum principal stress; MinPS =
minimum principal stress.

Table 4. Values for VMPand VMA inthe CGandin

experimental groups.
Tension forces
Groups
(osteosynthesis)

CG G1 G2 G3 G4 G5

VMP (Mpa) X 84.6 92.3 98.1 85.7 71.2

VMA (Mpa) 1.22 0.54 0.46 1.05 0.41 0.34

Source: Authors, 2023.

Legends: CG = control group; VMA = von Mises equivalent
stress for anterior fixation; VMP = von Mises equivalent
stress for posterior fixations.

FIGURE LEGENDS

[AUTOR: As figuras estão

com resolução baixa e perdem
qualidade ao ajustarmos para
300dpi (resolução geralmente
ideal para as revistas) e ao
tentarmos editar os textos. O
ideal
seria os autores gerarem as
imagens novamente com
resolução mais alta e já com
os textos
traduzidos para o inglês.]
[AUTOR: As figuras estão com resolução baixa e perdem
qualidade ao ajustarmos para 300dpi (resolução geralmente
ideal para as revistas) e ao tentarmos editar os textos. O ideal
seria os autores gerarem as imagens novamente com
resolução mais alta e já com os textos traduzidos para o
inglês.]
Figure 1. Image of BioCAD model for the control group.
Cortical and trabecular structures, posterior ligamentous
complex (in pink) and osteosynthesiswithreconstruction
platein the pubic symphysis (in blue).
Figure 2. Images representing the models used in the control
group and in the experimental groups.

Control group G3

G1 G4

G2 G5

Figure 3. Assessment of lateral displacement. Two parallel

lines were defined, one crossing the center ofiliosacral joints
(points A, A’ and B) andthe other crossing the center ofthe
pubis (points C and C’).
Figure 4. Test condition and contours, illustrated in the
control group model. Thepink arrow indicatesthe
regionwhere load was applied (center of S1 body,
perpendicular to the ground). Greenarrows indicate the
regions of pelvis fixation (viathe acetabula, over its entire
inner surface).
Loading

Region of fixation

Figure 5. Maximum principal stress (A) and minimum

principal stressfor the CGand the experimental
groups.Negative values exclusively denotethe direction of
observation axis.
A
Maximum principal stress (B)
 CG G1 G2

G3 G4 G5

B MPa
Minimum principal stress (C)
0.000
-13.561
-27.121
-40.682
54.243
-67.803
-81.364
-94.925
-108.485
122.046

CG G1 G2

G3 G4 G5

Figure 6. Von Mises equivalent stress for anterior fixations

(A) and for posterior fixation (B) in the CGand in
experimental group.

A
Von Misesequivalent stress for posterior fixations (D)

CG G1 G2
 G3 G4 G5
Von Misesequivalent stress for anterior fixation (E)

CG G1 G2

G3 G4 G5