The ideal site of cement application in cement augmented sacroiliac screw fixation: the biomechanical perspective

Abstract

Purpose To compare construct stability of cement augmented sacroiliac screws using two different cementation sites in a biomechanical fragility fracture model of the pelvis. Methods A fracture model with an incomplete fracture of the sacral ala and complete fracture of the anterior pelvic ring mimicking a FFP IIB fragility fracture of the pelvis was established in five fresh frozen human cadaveric pelvises. Sacral fracture stabilization was achieved with bilateral 7.3 mm fully threaded sacroiliac screws. Cement augmentation was performed at the tip of the screw (body of S1; Group A) on one side, and at the midshaft of the screw (sacral ala; Group B) on the contralateral side. Biomechanical testing was conducted separately on both sides comprising cyclic loading of axial forces transferred through the tested hemipelvis from L5 to the ipsilateral acetabulum. Combined angular displacement in flexion and internal rotation (“gap angle”), angular displacement of the ilium in relation to the screw (“screw tilt ilium”), and screw tip cutout were evaluated. Results Relative interfragmentary movements were associated with significantly higher values in group A versus group B for “gap angle” (2.4° vs. 1.4°; p < 0.001), and for “screw tilt ilium” (3.3° vs. 1.4°; p < 0.001), respectively. No significant difference was indicated for screw tip cutout between the two groups (0.6 mm [Group A] vs. 0.8 mm [Group B]; p = 0.376). Conclusion The present study demonstrated less fragment and screw displacements in a FFP IIB fracture model under physiologic cyclic loading by cement augmentation of sacroiliac screws at the level of the lateral mass compared to the center of vertebral body of S1.

Effective treatment of highest instability in a subacute fragility fracture of the pelvis (FFP IV) using a cement augmented transsacral screw only

“…Thirdly, the implementation of combined sacroplasty in transsacral screw fixation provides additional resistance against vertical shear and may reduce the moment resulting from a long screw. We believe, that bilateral PMMA augmentation at the weakest point (lateral masses) instead of the sacral body in transsacral screw fixation enhances the construct's resistance against vertical and rotational forces [11] . Additionally, in elderly and anguished patients with reduced bone healing capacity, augmentation at the vertical fracture lines contributes to early pain reduction and bypasses the need for fracture healing.…”