title: Does Lumbopelvic Fixation Add Stability? A Cadaveric Biomechanical Analysis of an Unstable Pelvic Fracture Model.
abstract: OBJECTIVE
  We sought to determine the role of lumbopelvic fixation (LPF) in the treatment of zone II sacral fractures with varying levels of sacral comminution combined with anterior pelvic ring (PR) instability. We also sought to determine the proximal extent of LPF necessary for adequate stabilization and the role of LPF in complex sacral fractures when only 1 transiliac-transsacral (TI-TS) screw is feasible.
  
  
  METHODS
  Fifteen L4 to pelvis fresh-frozen cadaveric specimens were tested intact in flexion-extension (FE) and axial rotation (AR) in a bilateral stance gliding hip model. Two comminution severities were simulated through the sacral foramen using an oscillating saw, with either a single vertical fracture (small gap, 1 mm) or 2 vertical fractures 10 mm apart with the intermediary bone removed (large gap). We assessed sacral fracture zone (SZ), PR, and total lumbopelvic (TL) stability during FE and AR. The following variables were tested: (1) presence of transverse cross-connector, (2) presence of anterior plate, (3) extent of LPF (L4 vs. L5), (4) fracture gap size (small vs. large), (5) number of TI-TS screws (1 vs. 2).
  
  
  RESULTS
  The transverse cross-connector and anterior plate significantly increased PR stability during AR (P = 0.02 and P = 0.01, respectively). Increased sacral comminution significantly affected SZ stability during FE (P = 0.01). Two versus 1 TI-TS screw in a large-gap model significantly affected TL stability (P = 0.04) and trended toward increased SZ stabilization during FE (P = 0.08). Addition of LPF (L4 and L5) significantly improved SZ and TL stability during AR and FE (P < 0.05). LPF in combination with TI-TS screws resulted in the least amount of motion across all 3 zones (SZ, PR, and TL) compared with all other constructs in both small-gap and large-gap models.
  
  
  CONCLUSIONS
  The role of LPF in the treatment of complex sacral fractures is supported, especially in the setting of sacral comminution. LPF with proximal fixation at L4 in a hybrid approach might be needed in highly comminuted cases and when only 1 TI-TS screw is feasible to obtain maximum biomechanical support across the fracture zone.
authors.affiliation: *R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD; and †Globus Medical, Inc, Audubon, PA.
authors.forename: Ehsan
authors.initials: E
authors.lastname: Jazini
authors.forename: Noelle
authors.initials: N
authors.lastname: Klocke
authors.forename: Oliver
authors.initials: O
authors.lastname: Tannous
authors.forename: Herman S
authors.initials: HS
authors.lastname: Johal
authors.forename: John
authors.initials: J
authors.lastname: Hao
authors.forename: Kanaan
authors.initials: K
authors.lastname: Salloum
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Gelb
authors.forename: Jason W
authors.initials: JW
authors.lastname: Nascone
authors.forename: Eric
authors.initials: E
authors.lastname: Belin
authors.forename: C Max
authors.initials: CM
authors.lastname: Hoshino
authors.forename: Mir
authors.initials: M
authors.lastname: Hussain
authors.forename: Robert V
authors.initials: RV
authors.lastname: OʼToole
authors.forename: Brandon
authors.initials: B
authors.lastname: Bucklen
authors.forename: Steven C
authors.initials: SC
authors.lastname: Ludwig
mesh_terms: D001863:Bone Screws; D002102:Cadaver; D005260:Female; D005593:Fracture Fixation, Internal / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D008159:Lumbar Vertebrae / Q000601:surgery*; D008297:Male; D009038:Motion; D016059:Range of Motion, Articular; D012447:Sacrum / Q000293:injuries* / Q000503:physiopathology* / Q000601:surgery; D016103:Spinal Fractures / Q000175:diagnosis / Q000503:physiopathology* / Q000601:surgery*; D016896:Treatment Outcome