Percutaneous Placement of Iliosacral Screws for Unstable Pelvic Ring Injuries: Comparison between One and Two C-arm Fluoroscopic Techniques Kuo-Ti Peng, MD, Kuo-Chin Huang, MD, Min-Chi Chen, PhD, Yen-Yao Li, MD, and Robert Wen-Wei Hsu, MD Background: This study compares the efficacy and safety of percutaneous placement of iliosacral screws between one and two C-arm fluoroscope groups. Methods: This case series contains con- secutive 18 unstable pelvic injuries, which were treated with percutaneous placement of iliosacral screws. A single orthopaedic surgeon (K.-T.P.) operated on all these patients. The patients were divided into two groups on the basis of the method of radiographic control. In group 1 (10 patients), iliosacral screws were introduced under the assistance of one C-arm fluoroscope. In group 2 (eight patients), per- cutaneous placements of iliosacral screws were performed under the control of two sets of fluoroscope. Results: There were neither clinical complications nor malpositioned screws in both groups. The median time from initial preparation to completion of the first screw insertion was 45.0 and 16.0 minutes for groups 1 and 2, respectively; the radi- ation exposure was 5.7 and 4.5 minutes, respectively. The differences between groups were statistically significant (p < 0.001). Conclusions: The use of two sets of fluoroscope provides a speedier method with less radiation exposure for percuta- neous placement of iliosacral screws than the use of one set. Key Words: Pelvic fracture, Pelvic ring injury, Sacroiliac joint disruption, Percutaneous placement of iliosacral screws, Two-fluoroscopic technique. J Trauma. 2006;60:602– 608. U nstable pelvic ring injuries are always challenging and intricate problems for orthopaedic surgeons and trau- matologists because of the associated significant mor- bidity and mortality. Pelvic ring stability is a vital target of management to diminish bleeding, smooth the progress of rehabilitation, and prevent long-term complications related to mechanical instability. 1–3 To obtain stabilization of a severely disrupted pelvis, it is necessary to achieve secure fixation of the posterior elements. Various techniques have therefore been employed in the fixation of the posterior pelvis, each with disadvantages specific to the technique. Percutaneous placement of iliosacral screws is an attractive procedure with the well-known advantage of providing an excellent biome- chanical stability through a minimally invasive approach. 4–6 However, the procedure is still technically demanding and always needs a long learning curve because of the limitations of radiographic visualization of the relevant landmarks and the difficulties of three-dimensional interpretation. To posi- tion the iliosacral screws speedily, easily, and safely, we had developed a protocol for introducing the screws under the assistance of two sets of fluoroscope. This investigation was designed to prove the hypothesis that the two C-arm tech- nique is in various ways superior to the one C-arm technique for percutaneous placement of iliosacral screws. PATIENTS AND METHODS Between July 2002 and December 2003, 18 patients with unstable pelvic ring injuries were treated at the authors’ institu- tion with percutaneous placement of iliosacral screws. The first 10 patients were treated with one C-arm technique and the latter eight patients were treated with two C-arm technique. A single orthopaedic surgeon (K.-T.P.) operated on all these patients. The patients were divided into two groups. Group 1 was composed of 10 patients (median age, 28.5 years; range, 19 – 65 years) who were treated under the assistance of one C-arm fluoroscope. Group 2 was composed of eight patients (median age, 31.0 years; range, 17–53 years) who were treated under the radio- graphic control of two sets of fluoroscope. The surgical indications were unstable pelvic ring inju- ries, for which percutaneous placement of iliosacral screws was chosen for posterior fixation. All patients were hemody- namically stable at the time of the indicatory procedure. Some hemodynamically unstable patients were treated by initially stabilizing the pelvic lesions with anterior pelvic external fixation devices and/or arterial embolization after angiography. The posterior lesions were assessed again when the patients’ hemodynamics stabilized; if unsatisfactory, they were further addressed by posterior fixation with percutane- ous iliosacral screws. Such patients were also included in this case series. Submitted for publication May 13, 2004. Accepted for publication December 1, 2005. Copyright © 2006 by Lippincott Williams & Wilkins, Inc. From the Department of Orthopaedic Surgery (K.-T.P., K.-C.H., Y.-Y.L., R.W.-W.H.), Chang Gung Memorial Hospital at Chia-Yi, Tai- wan; and the The Biostatistics Center and Department of Public Health (M.-C.C.), Chang Gung University, Taiwan. Address for reprints: Dr. Kuo-Chin Huang, M.D., Hyperbaric Medicine Center, Department of Orthopaedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, No. 6, West Section, Chia-Pu Road, Pu-Tz City, Chia-Yi Hsien 613, Taiwan; email: kc2672@adm.cgmh.org.tw. DOI: 10.1097/01.ta.0000200860.01931.9a The Journal of TRAUMA  Injury, Infection, and Critical Care 602 March 2006