Evaluation of iliac screw, S2 alar-iliac screw and laterally placed triangular titanium implants for sacropelvic fixation in combination with posterior lumbar instrumentation: a finite element study

Abstract

Purpose

This study aimed to implement laterally placed triangular titanium implants as a technique of sacropelvic fixation in long posterior lumbar instrumentation and to characterize the effects of iliac screws, S2 alar-iliac screws and of triangular implants on rod and S1 pedicle screw stresses.

Methods

Four female models of the lumbopelvic spine were created. For each of them, five finite element models replicating the following configurations were generated: intact, posterior fixation with pedicle screws to S1 (PED), with PED and iliac screws (IL), with PED and S2 alar-iliac (S2AI) screws, and with PED and bilateral triangular titanium implants (SI). Simulations were conducted in compression, flexion–extension, lateral bending and axial rotation. Rod stresses in the L5-S1 segment as well as in the S1 pedicle screws were compared.

Results

One anatomical model was not simulated due to dysmorphia of the sacroiliac joints. PED resulted in the highest implant stresses. Values up to 337 MPa in lateral bending were noted, which were more than double than the other configurations. When compared with IL, S2AI and SI resulted in lower stresses in both screws and rods (on average 33% and 41% for S2AI and 17% and 50% for SI).

Conclusions

Implant stresses after S2AI and SI fixations were lower than those attributable to IL. Therefore, pedicle screws and rods may have a lower risk of mechanical failure when coupled with sacropelvic fixation via S2AI or triangular titanium implants, although the risk of clinical loosening remains an area of further investigation.

Graphical abstract

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References

  1. 1.

    Lombardi JM, Shillingford JN, Lenke LG, Lehman RA (2018) Sacropelvic fixation. When, why, how? Neurosurg Clin North Am 29:389–397. https://doi.org/10.1016/j.nec.2018.02.001

    Article  Google Scholar 

  2. 2.

    Shen FH, Mason JR, Shimer AL, Arlet VM (2013) Pelvic fixation for adult scoliosis. Eur Spine J. https://doi.org/10.1007/s00586-012-2525-3

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Weistroffer JK, Perra JH, Lonstein JE et al (2008) Complications in long fusions to the sacrum for adult scoliosis: minimum five-year analysis of fifty patients. Spine (Phila Pa 1976) 33:1478–1483. https://doi.org/10.1097/brs.0b013e3181753c53

    Article  Google Scholar 

  4. 4.

    Emami A, Deviren V, Berven S et al (2002) Outcome and complications of long fusions to the sacrum in adult spine deformity: Luque-Galveston, combined iliac and sacral screws, and sacral fixation. Spine (Phila Pa 1976) 27:776–786. https://doi.org/10.1097/00007632-200204010-00017

    Article  Google Scholar 

  5. 5.

    Edwards CC, Bridwell KH, Patel A et al (2004) Long adult deformity fusions to L5 and the sacrum: a matched cohort analysis. Spine (Phila Pa 1976) 29:1996–2005. https://doi.org/10.1097/01.brs.0000138272.54896.33

    Article  Google Scholar 

  6. 6.

    Fleischer GD, Kim YJ, Ferrara LA et al (2012) Biomechanical analysis of sacral screw strain and range of motion in long posterior spinal fixation constructs: effects of lumbosacral fixation strategies in reducing sacral screw strains. Spine (Phila Pa 1976) 37:7–13. https://doi.org/10.1097/brs.0b013e31822ce9a7

    Article  Google Scholar 

  7. 7.

    Kleck CJ, Illing D, Lindley EM et al (2017) Strain in posterior instrumentation resulted by different combinations of posterior and anterior devices for long spine fusion constructs. Spine Deform 5:27–36. https://doi.org/10.1016/j.jspd.2016.09.045

    Article  PubMed  Google Scholar 

  8. 8.

    Sutterlin CE III, Field A, Ferrara LA et al (2016) Range of motion, sacral screw and rod strain in long posterior spinal constructs: a biomechanical comparison between S2 alar iliac screws with traditional fixation strategies. J Spine Surg 2:266–276. https://doi.org/10.21037/jss.2016.11.01

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Kostuik JP (2005) Spinopelvic fixation. Neurol India 53:483–488

    Article  PubMed  Google Scholar 

  10. 10.

    Kim YJ, Bridwell KH, Lenke LG et al (2006) Pseudarthrosis in long adult spinal deformity instrumentation and fusion to the sacrum: prevalence and risk factor analysis of 144 cases. Spine (Phila Pa 1976) 31:2329–2336. https://doi.org/10.1097/01.brs.0000238968.82799.d9

    Article  Google Scholar 

  11. 11.

    Chang T-L, Sponseller PD, Kebaish KM, Fishman EK (2009) Low profile pelvic fixation: anatomic parameters for sacral alar-iliac fixation versus traditional iliac fixation. Spine (Phila Pa 1976) 34:436–440. https://doi.org/10.1097/brs.0b013e318194128c

    Article  Google Scholar 

  12. 12.

    Daniels AH, DePasse JM, Eltorai AEM, Palumbo MA (2016) Perpendicular iliac screw placement for reinforcement of spinopelvic stabilization. Orthopedics 39:e1209–e1212. https://doi.org/10.3928/01477447-20160729-02

    Article  PubMed  Google Scholar 

  13. 13.

    Hoernschemeyer DG, Pashuck TD, Pfeiffer FM (2017) Analysis of the s2 alar-iliac screw as compared with the traditional iliac screw: does it increase stability with sacroiliac fixation of the spine? Spine J 17:875–879. https://doi.org/10.1016/j.spinee.2017.02.001

    Article  PubMed  Google Scholar 

  14. 14.

    Shillingford JN, Laratta JL, Tan LA et al (2018) The free-hand technique for S2-alar-iliac screw placement: a safe and effective method for sacropelvic fixation in adult spinal deformity. J Bone Joint Surg Am 100:334–342. https://doi.org/10.2106/JBJS.17.00052

    Article  PubMed  Google Scholar 

  15. 15.

    Laratta JL, Shillingford JN, Meredith JS, Lenke LG, Lehman RA, Gum JL (2018) Robotic versus freehand S2 alar iliac fixation: in-depth technical considerations. J Spine Surg 4(3):638–644. https://doi.org/10.21037/jss.2018.06.13

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Heiney J, Capobianco R, Cher D (2015) A systematic review of minimally invasive sacroiliac joint fusion utilizing a lateral transarticular technique. Int J Spine Surg 9:40

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Sachs D, Capobianco R (2013) Minimally invasive sacroiliac joint fusion: one-year outcomes in 40 patients. Adv Orthop 2013:536128. https://doi.org/10.1155/2013/536128

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Bornemann R, Roessler PP, Strauss AC et al (2017) Two-year clinical results of patients with sacroiliac joint syndrome treated by arthrodesis using a triangular implant system. Technol Health Care 25:319–325. https://doi.org/10.3233/THC-161272

    Article  PubMed  Google Scholar 

  19. 19.

    Schroeder JE, Cunningham ME, Ross T, Boachie-Adjei O (2014) Early results of sacro-iliac joint fixation following long fusion to the sacrum in adult spine deformity. HSS J 10:30–35. https://doi.org/10.1007/s11420-013-9374-4

    Article  PubMed  Google Scholar 

  20. 20.

    Lindsey D, Kiapour A, Yerby S, Goel V (2015) Sacroiliac joint fusion minimally affects adjacent lumbar segment motion: a finite element study. Int J Spine Surg 9:1–8. https://doi.org/10.14444/2064

    Article  Google Scholar 

  21. 21.

    Lindsey DP, Kiapour A, Yerby SA, Goel VK (2018) Sacroiliac joint stability: finite element analysis of implant number, orientation, and superior implant length. World J Orthop 9:14–23. https://doi.org/10.20959/wjpr2016-6447

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Le Huec JC, Aunoble S, Philippe L, Nicolas P (2011) Pelvic parameters: origin and significance. Eur Spine J 20(Suppl 5):564–571. https://doi.org/10.1007/s00586-011-1940-1

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Rho JY, Hobatho MC, Ashman RB (1995) Relations of mechanical properties to density and CT numbers in human bone. Med Eng Phys 17:347–355. https://doi.org/10.1016/1350-4533(95)97314-F

    Article  CAS  PubMed  Google Scholar 

  24. 24.

    Zheng NN, Yong-hing K (1997) Biomechanical modeling of the human sacroiliac joint. Med Biol Eng Comput 35:77. https://doi.org/10.1007/bf02534134

    Article  CAS  PubMed  Google Scholar 

  25. 25.

    Shi D, Wang F, Wang D et al (2014) 3-D finite element analysis of the influence of synovial condition in sacroiliac joint on the load transmission in human pelvic system. Med Eng Phys 36:745–753. https://doi.org/10.1016/j.medengphy.2014.01.002

    Article  PubMed  Google Scholar 

  26. 26.

    Phillips ATM, Pankaj P, Howie CR et al (2007) Finite element modelling of the pelvis: inclusion of muscular and ligamentous boundary conditions. Med Eng Phys 29:739–748. https://doi.org/10.1016/j.medengphy.2006.08.010

    Article  CAS  PubMed  Google Scholar 

  27. 27.

    Yang H, Jekir MG, Davis MW, Keaveny TM (2016) Effective modulus of the human intervertebral disc and its effect on vertebral bone stress. J Biomech 49(7):1134–1140. https://doi.org/10.1016/j.jbiomech.2016.02.045

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Soriano-Baron H, Lindsey DP, Rodriguez-Martinez N et al (2015) The effect of implant placement on sacroiliac joint range of motion. Spine 40:E525–E530. https://doi.org/10.1097/brs.0000000000000839

    Article  PubMed  Google Scholar 

  29. 29.

    Wieding J, Souffrant R, Fritsche A, Mittelmeier W, Bader R (2012) Finite element analysis of osteosynthesis screw fixation in the bone stock: an appropriate method for automatic screw modelling. PLoS ONE 7(3):33776. https://doi.org/10.1371/journal.pone.0033776

    Article  CAS  Google Scholar 

  30. 30.

    Lindsey DP, Perez-Orribo L, Rodriguez-Martinez N et al (2014) Evaluation of a minimally invasive procedure for sacroiliac joint fusion:an in vitro biomechanical analysis of initial and cycled properties. Med Devices Evid Res 7:131–137. https://doi.org/10.2147/MDER.S63499

    Article  Google Scholar 

  31. 31.

    Vleeming A, Schuenke MD, Masi AT et al (2012) The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat 221:537–567. https://doi.org/10.1111/j.1469-7580.2012.01564.x

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Lindsey DP, Parrish R, Gundanna M et al (2018) Biomechanics of unilateral and bilateral sacroiliac joint stabilization: laboratory investigation. J Neurosurg Spine 28:326–332. https://doi.org/10.3171/2017.7.SPINE17499

    Article  PubMed  Google Scholar 

  33. 33.

    Hlubek RJ, Godzik J, Newcomb AGUS, Lehrman JN, de Andrada B, Bohl MA, Farber SH, Kelly BP, Turner JD (2018) Iliac screws may not be necessary in long-segment constructs with L5-S1 anterior lumbar interbody fusion: cadaveric study of stability and instrumentation strain. Spine J. https://doi.org/10.1016/j.spinee.2018.11.004

    Article  PubMed  Google Scholar 

  34. 34.

    La Barbera L, Galbusera F, Wilke HJ, Villa T (2017) Preclinical evaluation of posterior spine stabilization devices: can we compare in vitro and in vivo loads on the instrumentation? Eur Spine J 26:200–209. https://doi.org/10.1007/s00586-016-4766-z

    Article  PubMed  Google Scholar 

  35. 35.

    La Barbera L, Costa F, Villa T (2016) ISO 12189 standard for the preclinical evaluation of posterior spinal stabilization devices—II: a parametric comparative study. Proc Inst Mech Eng Part H J Eng Med 230:134–144. https://doi.org/10.1177/0954411915621588

    Article  Google Scholar 

  36. 36.

    La Barbera L, Villa T (2016) ISO 12189 standard for the preclinical evaluation of posterior spinal stabilization devices: I—assembly procedure and validation. Proc Inst Mech Eng Part H J Eng Med 230:122–133. https://doi.org/10.1177/0954411915621587

    Article  Google Scholar 

  37. 37.

    Pihlajamaki H, Myllynen P, Bostman O (1997) Complications of transpedicular lumbosacral fixation for non-traumatic disorders. J Bone Joint Surg Br 79:183–189

    Article  CAS  PubMed  Google Scholar 

  38. 38.

    Chen CS, Chen WJ, Cheng CK et al (2005) Failure analysis of broken pedicle screws on spinal instrumentation. Med Eng Phys 27:487–496. https://doi.org/10.1016/j.medengphy.2004.12.007

    Article  PubMed  Google Scholar 

  39. 39.

    Farrokhi MR, Razmkon A, Maghami Z, Nikoo Z (2010) Inclusion of the fracture level in short segment fixation of thoracolumbar fractures. Eur Spine J 19:1651–1656. https://doi.org/10.1007/s00586-010-1449-z

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Camisa W, Condez BI, Leasure JM et al (2014) Development of a biomechanical model for sacroiliac range of motion. In: 2014 AAOS Annual Meeting, pp 42–43

  41. 41.

    Ambati D, Wright E, Lehman R et al (2015) Bilateral pedicle screw fixation provides superior biomechanical stability in transforaminal lumbar interbody fusion: a finite element study. Spine J 15(8):1812–1822

    Article  PubMed  Google Scholar 

  42. 42.

    Liu C, Kamara A, Yan Y (2018) Investigation into the biomechanics of lumbar spine micro-dynamic pedicle screw. BMC Musculoskelet Disord 19(231):1–11

    Google Scholar 

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Acknowledgements

We thank Dr. Enrico Gallazzi for critical reading of the manuscript.

Funding

Funding by SI-BONE Inc. (Santa Clara, CA, USA) is gratefully acknowledged.

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Correspondence to Fabio Galbusera.

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Casaroli, G., Galbusera, F., Chande, R. et al. Evaluation of iliac screw, S2 alar-iliac screw and laterally placed triangular titanium implants for sacropelvic fixation in combination with posterior lumbar instrumentation: a finite element study. Eur Spine J 28, 1724–1732 (2019). https://doi.org/10.1007/s00586-019-06006-0

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Keywords

  • Sacroiliac joint
  • Sacropelvic fixation
  • Finite element analysis
  • Alar-iliac screws
  • Iliac screws
  • Triangular implants