Percutaneous screw fixation of the pelvic ring and acetabulum: an anatomical, technical, and fluoroscopic review

Background: Traumatic injuries to the pelvic ring and acetabulum present significant management challenges due to their anatomical complexity. While historically treated with conservative measures or open reduction, the emergence of percutaneous techniques has provided a minimally invasive alternative for both high-energy trauma in younger patients and fragility fractures in the geriatric population.

Objective: This review aims to detail the anatomical, fluoroscopic, and technical requirements for percutaneous pelvic surgery, focusing on established osseous corridors and the prevention of iatrogenic complications.

Key Points: Successful percutaneous fixation relies on a precise understanding of sacro-acetabular and sacro-ischiatic trabecular systems. Key corridors include iliosacral, trans-sacral, anterior and posterior columns, and supra-acetabular pathways. Fluoroscopic guidance via Inlet, Outlet, and oblique views is mandatory to navigate these corridors while avoiding neurovascular structures, including the lumbosacral trunk, superior gluteal pedicle, and sciatic nerve. Technical refinements, such as the use of drill-tip guide wires for enhanced tactile feedback and specific reduction maneuvers like the "Metaizeau trick," facilitate accurate screw placement. Large-diameter cannulated screws (6.5 mm to 8.0 mm) are utilized to achieve stable internal fixation. Preoperative planning with three-dimensional imaging is essential to identify anatomical variations, such as sacral dysmorphism, which significantly alter safe screw trajectories.

Conclusion: Percutaneous techniques offer stable fixation with reduced soft tissue disruption and shorter hospital stays. Mastery of pelvic anatomy and radiographic landmarks is essential for surgeons to ensure safety and efficacy in treating these complex injuries.