A comprehensive biomechanical analysis of sacral alar iliac fixation: an in vitro human cadaveric model

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  • 1 MedStar Musculoskeletal Education and Research Institute, Department of Orthopaedic Surgery, MedStar Union Memorial Hospital;
  • | 2 Department of Orthopedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and
  • | 3 Department of Orthopedic Surgery, Saitama Medical University, Saitama, Japan
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OBJECTIVE

The objective of the current study was to quantify and compare the multidirectional flexibility properties of sacral alar iliac fixation with conventional methods of sacral and sacroiliac fixation by using nondestructive and destructive investigative methods.

METHODS

Twenty-one cadaveric lumbopelvic spines were randomized into 3 groups based on reconstruction conditions: 1) S1–2 sacral screws; 2) sacral alar iliac screws; and 3) S1–iliac screws tested under unilateral and bilateral fixation. Nondestructive multidirectional flexibility testing was performed using a 6-degree-of-freedom spine simulator with moments of ± 12.5 Nm. Flexion-extension fatigue loading was then performed for 10,000 cycles, and the multidirectional flexibility analysis was repeated. Final destructive testing included an anterior flexural load to construct failure. Quantification of the lumbosacral and sacroiliac joint range of motion was normalized to the intact spine (100%), and flexural failure loads were reported in Newton-meters.

RESULTS

Normalized value comparisons between the intact spine and the 3 reconstruction groups demonstrated significant reductions in segmental flexion-extension, lateral bending, and axial rotation motion at L4–5 and L5–S1 (p < 0.05). The S1–2 sacral reconstruction group demonstrated significantly greater flexion-extension motion at the sacroiliac junction than the intact and comparative reconstruction groups (p < 0.05), whereas the sacral alar iliac group demonstrated significantly less motion at the sacroiliac joint in axial rotation (p < 0.05). Absolute value comparisons demonstrated similar findings. Under destructive anterior flexural loading, the S1–2 sacral group failed at 105 ± 23 Nm, and the sacral alar iliac and S1–iliac groups failed at 119 ± 39 Nm and 120 ± 28 Nm, respectively (p > 0.05).

CONCLUSIONS

Along with difficult anatomy and weak bone, the large lumbosacral loads with cantilever pullout forces in this region are primary reasons for construct failure. All reconstructions significantly reduced flexibility at the L5–S1 junctions, as expected. Conventional S1–2 sacral fixation significantly increased sacroiliac motion under all loading modalities and demonstrated significantly higher flexion-extension motion than all other groups, and sacral alar iliac fixation reduced motion in axial rotation at the sacroiliac joint. Based on comprehensive multidirectional flexibility testing, the sacral alar iliac fixation technique reduced segmental motion under some loading modalities compared to S1–iliac screws and offers potential advantages of lower instrumentation profile and ease of assembly compared to conventional sacroiliac instrumentation techniques.

ABBREVIATIONS

ROM = range of motion.

Image from Barath et al. (pp 332–336).

 

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  • 1

    Abdu WA, Wilber RG, Emery SE: Pedicular transvertebral screw fixation of the lumbosacral spine in spondylolisthesis. A new technique for stabilization. Spine (Phila Pa 1976) 19:710715, 1994

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Abumi K, Panjabi MM, Duranceau J: Biomechanical evaluation of spinal fixation devices. Part III. Stability provided by six spinal fixation devices and interbody bone graft. Spine (Phila Pa 1976) 14:12491255, 1989

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Allen BL Jr, Ferguson RL: The Galveston technique of pelvic fixation with L-rod instrumentation of the spine. Spine (Phila Pa 1976) 9:388394, 1984

  • 4

    Boachie-Adjei O, Dendrinos GK, Ogilvie JW, Bradford DS: Management of adult spinal deformity with combined anterior-posterior arthrodesis and Luque-Galveston instrumentation. J Spinal Disord 4:131141, 1991

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Boos N, Marchesi D, Zuber K, Aebi M: Treatment of severe spondylolisthesis by reduction and pedicular fixation. A 4-6-year follow-up study. Spine (Phila Pa 1976) 18:16551661, 1993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Brown MD: Lumbar spine fusion, in Finneson BE (ed): Low Back Pain, ed 2. Philadelphia: JB Lippincott, 1980, p 382

  • 7

    Buchowski JM, Kebaish KM, Sinkov V, Cohen DB, Sieber AN, Kostuik JP: Functional and radiographic outcome of sacroiliac arthrodesis for the disorders of the sacroiliac joint. Spine J 5:520529, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Chang TL, Sponseller PD, Kebaish KM, Fishman EK: Low profile pelvic fixation: anatomic parameters for sacral alar-iliac fixation versus traditional iliac fixation. Spine (Phila Pa 1976) 34:436440, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Cunningham BW, Lewis SJ, Long J, Dmitriev AE, Linville DA, Bridwell KH: Biomechanical evaluation of lumbosacral reconstruction techniques for spondylolisthesis: an in vitro porcine model. Spine (Phila Pa 1976) 27:23212327, 2002

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10

    Elder BD, Ishida W, Lo SL, Holmes C, Goodwin CR, Kosztowski TA, et al.: Use of S2-alar-iliac screws associated with less complications than iliac screws in adult lumbosacropelvic fixation. Spine (Phila Pa 1976) 42:E142E149, 2017

    • Search Google Scholar
    • Export Citation
  • 11

    Finger T, Bayerl S, Bertog M, Czabanka M, Woitzik J, Vajkoczy P: Impact of sacropelvic fixation on the development of postoperative sacroiliac joint pain following multilevel stabilization for degenerative spine disease. Clin Neurol Neurosurg 150:1822, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Guyer DW, Yuan HA, Werner FW, Frederickson BE, Murphy D: Biomechanical comparison of seven internal fixation devices for the lumbosacral junction. Spine (Phila Pa 1976) 12:569573, 1987

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Jackson RP, McManus AC: The iliac buttress. A computed tomographic study of sacral anatomy. Spine (Phila Pa 1976) 18:13181328, 1993

  • 14

    Jain A, Kebaish KM, Sponseller PD: Sacral-alar-iliac fixation in pediatric deformity: radiographic outcomes and complications. Spine Deform 4:225229, 2016

  • 15

    Jain A, Sullivan BT, Kuwabara A, Kebaish KM, Sponseller PD: Sacral-alar-iliac fixation in children with neuromuscular scoliosis: minimum 5-year follow-up. World Neurosurg 108:474478, 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Kostuik JP, Valdevit A, Chang HG, Kanzaki K: Biomechanical testing of the lumbosacral spine. Spine (Phila Pa 1976) 23:17211728, 1998

  • 17

    Kuklo TR, Bridwell KH, Lewis SJ, Baldus C, Blanke K, Iffrig TM, et al.: Minimum 2-year analysis of sacropelvic fixation and L5-S1 fusion using S1 and iliac screws. Spine (Phila Pa 1976) 26:19761983, 2001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Lee CK, Langrana NA: Lumbosacral spinal fusion. A biomechanical study. Spine (Phila Pa 1976) 9:574581, 1984

  • 19

    Mattei TA, Fassett DR: Low-profile pelvic fixation with sacral alar-iliac screws. Acta Neurochir (Wien) 155:293297, 2013

  • 20

    McCord DH, Cunningham BW, Shono Y, Myers JJ, McAfee PC: Biomechanical analysis of lumbosacral fixation. Spine (Phila Pa 1976) 17 (8 Suppl):S235S243, 1992

    • Search Google Scholar
    • Export Citation
  • 21

    Molinari RW, Bridwell KH, Lenke LG, Ungacta FF, Riew KD: Complications in the surgical treatment of pediatric high-grade, isthmic dysplastic spondylolisthesis. A comparison of three surgical approaches. Spine (Phila Pa 1976) 24:17011711, 1999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Nottmeier EW, Pirris SM, Balseiro S, Fenton D: Three-dimensional image-guided placement of S2 alar screws to adjunct or salvage lumbosacral fixation. Spine J 10:595601, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    O’Brien JR, Matteini L, Yu WD, Kebaish KM: Feasibility of minimally invasive sacropelvic fixation: percutaneous S2 alar iliac fixation. Spine (Phila Pa 1976) 35:460464, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    O’Brien JR, Yu W, Kaufman BE, Bucklen B, Salloum K, Khalil S, et al.: Biomechanical evaluation of S2 alar-iliac screws: effect of length and quad-cortical purchase as compared with iliac fixation. Spine (Phila Pa 1976) 38:E1250E1255, 2013

    • Search Google Scholar
    • Export Citation
  • 25

    O’Brien JR, Yu WD, Bhatnagar R, Sponseller P, Kebaish KM: An anatomic study of the S2 iliac technique for lumbopelvic screw placement. Spine (Phila Pa 1976) 34:E439E442, 2009

    • Search Google Scholar
    • Export Citation
  • 26

    Panjabi MM: Biomechanical evaluation of spinal fixation devices: I. A conceptual framework. Spine (Phila Pa 1976) 13:11291134, 1988

  • 27

    Pashman RS, Hu SS, Schendel MJ, Bradford DS: Sacral screw loads in lumbosacral fixation for spinal deformity. Spine (Phila Pa 1976) 18:24652470, 1993

  • 28

    Saer EH III, Winter RB, Lonstein JE: Long scoliosis fusion to the sacrum in adults with nonparalytic scoliosis. An improved method. Spine (Phila Pa 1976) 15:650653, 1990

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Shirado O, Zdeblick TA, McAfee PC, Warden KE: Biomechanical evaluation of methods of posterior stabilization of the spine and posterior lumbar interbody arthrodesis for lumbosacral isthmic spondylolisthesis. A calf-spine model. J Bone Joint Surg Am 73:518526, 1991

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Smith SA, Abitbol JJ, Carlson GD, Anderson DR, Taggart KW, Garfin SR: The effects of depth of penetration, screw orientation, and bone density on sacral screw fixation. Spine (Phila Pa 1976) 18:10061010, 1993

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Sponseller PD, Zimmerman RM, Ko PS, Pull Ter Gunne AF, Mohamed AS, Chang TL, et al.: Low profile pelvic fixation with the sacral alar iliac technique in the pediatric population improves results at two-year minimum follow-up. Spine (Phila Pa 1976) 35:18871892, 2010

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Tsuchiya K, Bridwell KH, Kuklo TR, Lenke LG, Baldus C: Minimum 5-year analysis of L5-S1 fusion using sacropelvic fixation (bilateral S1 and iliac screws) for spinal deformity. Spine (Phila Pa 1976) 31:303308, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    van Royen BJ, van Dijk M, van Oostveen DP, van Ooij B, Stadhouder A: The flying buttress construct for posterior spinopelvic fixation: a technical note. Scoliosis 6:6, 2011

    • Crossref
    • Search Google Scholar
    • Export Citation

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