Plate Osteosynthesis, Subcutaneous Internal Fixation and Anterior Pelvic Bridge Fixation

Surgical treatment of anterior pelvic fragility fractures is indicated to improve stability of the pelvic ring after fixation of the posterior pelvis. In order to achieve durable fixation in weakened bone, implants should realize optimal anchoring as well as improved load distribution and transfer. Plates provide the strongest mechanical fixation for the pelvic bone. Major disadvantage is the requirement for extended and lengthy surgical dissection around vital neurovascular and visceral structures that in turn may lead to significant perioperative morbidity. A standard surgical approach to the symphysis and rami is carried out through a transverse suprapubic Pfannenstiel incision. In case fixation of lateral rami fractures is needed, the modified Stoppa approach can be performed. The subcutaneous pedicle screw-rod crossover fixator and the pelvic bridge can also be useful for fixation of anterior pelvic ring fractures. Disadvantages include lower mechanical strength of fixation, compared to conventional plating, and possible need for removal of the construct. Indications include unstable unilateral or bilateral pubic rami fractures, isolated or in combination with posterior lesions where load-bearing stability is required for ambulatory rehabilitation. The anterior subcutaneous cross-over internal pelvic fixator consist of two large diameter long pedicle screws inserted into the supraacetabular regions and interconnected by a curved rod. Data is favorable, demonstrating adequate healing at the average of 3 months after the surgery. The implants were routinely removed after 4–6 months. The most notorious complication was lateral femoral cutaneous nerve palsy. Heterotopic ossification around the screw heads was noted. The anterior pelvic bridge represents a subcutaneously placed internal fixator to interconnect the ipsilateral iliac crest to an ipsilateral or contralateral pubic tubercle and spans a fracture of the anterior pelvic ring. The pelvic bridge provides quick pain relief and the opportunity of rapid postoperative mobilization. Complications related to the pelvic bridge include superficial wound infection, pubic fracture; asymptomatic nonunion and temporary lateral femoral cutaneous nerve palsy. The anterior subcutaneous three-point pelvic fixator is a minimally invasive stabilization frame for the anterior pelvic ring using the internal fixator system of the implants for spinal fusion. A pedicle screw is positioned into the iliac wing just below the anterior superior iliac spine on both sides. One or two additional screws are positioned into the pubic bone close to the symphysis. The three to four screws are connected by a curved rod which runs parallel to the inguinal ligament on both sides. This rod is positioned epifascial to prevent direct pressure on neural or vascular structures of the inguinal region. The main disadvantage is the restricted comfort for the patient because the rod is palpable in the subcutaneous layer. Experience of anterior internal fixators with the treatment of fragility fractures of the pelvis is sparse yet promising. Plating and subcutaneous internal constructs provide appropriate stability of the anterior pelvic ring, with improved patient satisfaction, nursing care and diminished perioperative morbidity.