Routt prospectively tracked complications in 177 consecutive patients treated with 244 percutaneous iliosacral screws for posterior pelvic ring disruptions at a level-one trauma center. The study asks: what goes wrong with this technique, and how can it be prevented? All patients were supine with fluoroscopic guidance; fractures were classified by the Tile system (B1–C3) and followed with postoperative CT.
Before this paper, posterior pelvic ring fixation relied on open exposures through traumatized soft tissues, and deep wound infection rates of 7.5% or more were accepted as the cost of stability. Routt's series showed that a percutaneous supine technique could achieve 0% posterior infection and 1.1% nonunion — but only if imaging was done correctly.
The critical decision rule from this paper: always use three fluoroscopic views (inlet, outlet, lateral sacral) before committing screw trajectory. The lateral sacral view reveals sacral alar slope and upper sacral morphology that biplanar imaging cannot show. Every misplacement in this series happened without it.
When you have a Tile type C injury, a single iliosacral screw is not enough. Patients with head injuries, spasticity, or anticipated noncompliance need supplementary posterior fixation. The anterior construct alone cannot protect a single posterior screw under pathologic loading.
Postoperative CT is mandatory after iliosacral screw placement. Plain radiographs will miss subtle malreductions and extraosseous screw positioning that CT identifies. And an extraosseous screw tip near iliac vessels is a reoperation, not a clinic finding.
Routt prospectively tracked complications in 177 consecutive patients treated with 244 percutaneous iliosacral screws for posterior pelvic ring disruptions at a level-one trauma center. The study asks: what goes wrong with this technique, and how can it be prevented? All patients were supine with fluoroscopic guidance; fractures were classified by the Tile system (B1–C3) and followed with postoperative CT.
Before this paper, posterior pelvic ring fixation relied on open exposures through traumatized soft tissues, and deep wound infection rates of 7.5% or more were accepted as the cost of stability. Routt's series showed that a percutaneous supine technique could achieve 0% posterior infection and 1.1% nonunion — but only if imaging was done correctly.
The critical decision rule from this paper: always use three fluoroscopic views (inlet, outlet, lateral sacral) before committing screw trajectory. The lateral sacral view reveals sacral alar slope and upper sacral morphology that biplanar imaging cannot show. Every misplacement in this series happened without it.
When you have a Tile type C injury, a single iliosacral screw is not enough. Patients with head injuries, spasticity, or anticipated noncompliance need supplementary posterior fixation. The anterior construct alone cannot protect a single posterior screw under pathologic loading.
Postoperative CT is mandatory after iliosacral screw placement. Plain radiographs will miss subtle malreductions and extraosseous screw positioning that CT identifies. And an extraosseous screw tip near iliac vessels is a reoperation, not a clinic finding.