In-screw cement augmentation for iliosacral screw fixation in posterior ring pathologies with insufficient bone stock

  • M. A. König
  • S. Hediger
  • J. W. Schmitt
  • T. Jentzsch
  • K. Sprengel
  • C. M. L. Werner
Original Article



Minimal invasive screw fixation is common for treating posterior pelvic ring pathologies, but lack of bone quality may cause anchorage problems. The aim of this study was to report in detail a new technique combining iliosacral screw fixation with in-screw cement augmentation (ISFICA).

Description of technique

The patient was put under general anesthesia and placed in the supine position. A K-wire was inserted under inlet–outlet view to guide the fully threaded screw. The screw placement followed in adequate position. Cement was applied through a bone filler device, inserted at the screwdriver. The immediate control of cement distribution, accurate screw placement and potential leakage were obtained via intraoperative CT scan.

Patients and methods

Twenty consecutive patients treated with ISFICA were included in this study. The mean age was 74.4 years (range 48–98). Screw placement, possible cement leakage and screw positioning were evaluated via intraoperative CT scan. Postoperative neurologic deficits, pain reduction and immediate postoperative mobilization were clinically evaluated.


Twenty-six screws were implanted. All patients were postoperatively, instantly mobilized with reduced pain. No neurologic deficits were apparent postoperatively. No cement leakage occurred. One breach of the iliac cortical bone was noted due to severe osteoporosis.

One screw migration was seen after 1 year and two patients showed iliosacral joint arthropathy, which led to screw removal.


ISFICA is a very promising technique in terms of safety, precision and initial postoperative outcome. Long-term outcomes such as lasting mechanical stability or pain reduction and screw loosening despite cement augmentation should be investigated in further studies with larger patient numbers.


Pelvic fracture Cement augmentation Iliosacral screw 


Compliance with ethical standards

This study was performed with ethical requirements, with ethical approval obtained at the “Kantonale Ethikkommission Zürch”: KEK 2014-0557.

Conflict of interest

M. A. König, S. Hediger, J. W. Schmitt, T. Jentzsch, K. Sprengel and CML Werner declare that they have no conflict of interest.


  1. 1.
    Osterhoff G, Ossendorf C, Wanner GA, Simmen H-P, Werner CML. Percutaneous iliosacral screw fixation in S1 and S2 for posterior pelvic ring injuries: technique and perioperative complications. Arch Orthop Trauma Surg. 2011;131:809–13. Accessed 22 Nov 2014.
  2. 2.
    Osterhoff G, Ossendorf C, Wanner GA, Simmen H-P, Werner CML. Posterior screw fixation in rotationally unstable pelvic ring injuries. Injury. 2011;42:992–6. Accessed 22 Nov 2014.
  3. 3.
    Vanderschot P, Kuppers M, Sermon A, Lateur L. Trans-iliac-sacral-iliac-bar procedure to treat insufficiency fractures of the sacrum. Indian J Orthop. 2009; 43:245–52. Accessed 22 Nov 2014.
  4. 4.
    Hilgert RE, Finn J, Egbers H-J. Technique for percutaneous iliosacral screw insertion with conventional C-arm radiography. Unfallchirurg. 2005;108:954, 956–60. Accessed 22 Nov 2014.
  5. 5.
    Young JW, Burgess AR, Brumback RJ, Poka A. Pelvic fractures: value of plain radiography in early assessment and management. Radiology. 1986;160:445–51. Accessed 22 Nov 2014.
  6. 6.
    Garant M. Sacroplasty: A new treatment for sacral insufficiency fracture. J Vasc Interv Radiol. 2002;13:1265–7.
  7. 7.
    Bayley E, Srinivas S, Boszczyk BM. Clinical outcomes of sacroplasty in sacral insufficiency fractures: a review of the literature. Eur Spine J. 2009;18:1266–71. Accessed 22 Nov 2014.
  8. 8.
    Frey ME, Depalma MJ, Cifu DX, Bhagia SM, Carne W, Daitch JS. Percutaneous sacroplasty for osteoporotic sacral insufficiency fractures: a prospective, multicenter, observational pilot study. Spine J. 2008;8:367–73. Accessed 22 Nov 2014.
  9. 9.
    Hess GM. Sacroplasty for the treatment of sacral insufficiency fractures. Unfallchirurg. 2006;109:681–6. Accessed 22 Nov 2014.
  10. 10.
    Kortman K, Ortiz O, Miller T, Brook A, Tutton S, Mathis J, et al. Multicenter study to assess the efficacy and safety of sacroplasty in patients with osteoporotic sacral insufficiency fractures or pathologic sacral lesions. J Neurointerv Surg. 2013;5:461–6. Accessed 22 Nov 2014.
  11. 11.
    Mehling I, Hessmann MH, Rommens PM. Stabilization of fatigue fractures of the dorsal pelvis with a trans-sacral bar. Operative technique and outcome. Injury. 2012;43:446–51. Accessed 7 Nov 2014.
  12. 12.
    Fensky F, Schäffler a, Siebenlist S, König B, Stöckle U. Percutaneous iliosacral screw fixation for pelvis insufficiency fracture after implantation of a pedestal cup: case report. Unfallchirurg. 2011;114:1115–9. Accessed 22 Nov 2014.
  13. 13.
    Tsiridis E, Upadhyay N, Gamie Z, Giannoudis PV. Percutaneous screw fixation for sacral insufficiency fractures: a review of three cases. J Bone Joint Surg Br. 2007;89:1650–3. Accessed 22 Nov 2014.
  14. 14.
    Mears SC, Sutter EG, Wall SJ, Trauma F, Rose DM, Belkoff SM. Biomechanical comparison of three methods of sacral fracture fixation in osteoporotic bone. Spine (Phila. Pa. 1976). 2010;35:392–5. Accessed 22 Nov 2014.
  15. 15.
    Gardner MJ, Routt MLC. Transiliac–transsacral screws for posterior pelvic stabilization. J Orthop Trauma. 2011;25:378–84.CrossRefPubMedGoogle Scholar
  16. 16.
    Papanastassiou ID, Setzer M, Eleraky M, Baaj AA, Nam T, Binitie O, et al. Minimally invasive sacroiliac fixation in oncologic patients with sacral insufficiency fractures using a fluoroscopy-based navigation system. J Spinal Disord Tech. 2011;24:76–82.
  17. 17.
    Wähnert D, Hofmann-Fliri L, Schwieger K, Brianza S, Raschke MJ, Windolf M. Cement augmentation of lag screws: an investigation on biomechanical advantages. Arch Orthop Trauma Surg. 2013;133:373–9. Accessed 22 Nov 2014.
  18. 18.
    Cook SD, Salkeld SL, Stanley T, Faciane A, Miller SD. Biomechanical study of pedicle screw fixation in severely osteoporotic bone. Spine J. 2004;4:402–8. Accessed 6 Nov 2014.
  19. 19.
    Sarzier JS, Evans AJ, Cahill DW. Increased pedicle screw pullout strength with vertebroplasty augmentation in osteoporotic spines. J Neurosurg. 2002;96:309–12. Accessed 22 Nov 2014.
  20. 20.
    Zheng Z, Zhang K, Zhang J, Yu B, Liu H, Zhuang X. The effect of screw length and bone cement augmentation on the fixation strength of iliac screws. J Spinal Disord Tech. 2009;22:545–50.CrossRefPubMedGoogle Scholar
  21. 21.
    Fuchs T, Rottbeck U, Hofbauer V, Raschke M, Stange R. Pelvic ring fractures in the elderly. Underestimated osteoporotic fracture. Unfallchirurg. 2011;114:663–70. Accessed 22 Nov 2014.
  22. 22.
    Müller F, Füchtmeier B. Percutaneous cement-augmented screw fixation of bilateral osteoporotic sacral fracture. Unfallchirurg. 2013;116:950–4. Accessed 22 Nov 2014.
  23. 23.
    Tjardes T, Paffrath T, Baethis H, Shafizadeh S, Steinhausen E, Steinbuechel T, et al. Computer assisted percutaneous placement of augmented iliosacral screws: a reasonable alternative to sacroplasty. Spine (Phila. Pa. 1976). 2008;33:1497–500.
  24. 24.
    Trumm CG, Rubenbauer B, Piltz S, Reiser MF, Hoffmann R-T. Screw placement and osteoplasty under computed tomographic-fluoroscopic guidance in a case of advanced metastatic destruction of the iliosacral joint. Cardiovasc Intervent Radiol. 2011;34 Suppl 2:S288–93. Accessed 22 Nov 2014.
  25. 25.
    Wähnert D, Raschke MJ, Fuchs T. Cement augmentation of the navigated iliosacral screw in the treatment of insufficiency fractures of the sacrum: a new method using modified implants. Int Orthop. 2013;37:1147–50. Accessed 22 Nov 2014.
  26. 26.
    Briem D, Windolf J, Rueger JM. Percutaneous, 2D-fluoroscopic navigated iliosacral screw placement in the supine position: technique, possibilities, and limits. Unfallchirurg. 2007;110:393–401. Accessed 22 Nov 2014.
  27. 27.
    Smith HE, Yuan PS, Sasso R, Papadopolous S, Vaccaro AR. An evaluation of image-guided technologies in the placement of percutaneous iliosacral screws. Spine (Phila. Pa. 1976). 2006;31:234–8.
  28. 28.
    Zwingmann J, Konrad G, Mehlhorn a T, Südkamp NP, Oberst M. Percutaneous iliosacral screw insertion: malpositioning and revision rate of screws with regards to application technique (navigated vs. conventional). J Trauma. 2010;69:1501–6. Accessed 22 Nov 2014.
  29. 29.
    Zwingmann J, Hauschild O, Bode G, Südkamp NP, Schmal H. Malposition and revision rates of different imaging modalities for percutaneous iliosacral screw fixation following pelvic fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg. 2013;133:1257–65. Accessed 22 Nov 2014.

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • M. A. König
    • 1
  • S. Hediger
    • 1
  • J. W. Schmitt
    • 1
  • T. Jentzsch
    • 1
  • K. Sprengel
    • 1
  • C. M. L. Werner
    • 1
  1. 1.Department of TraumatologyUniversity Hospital ZurichZurichSwitzerland

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