Computational simulation of sacral-alar-iliac (S2AI) screw fixation of pelvis and implications for fluoroscopic procedure: A cadaver study

Purpose: To determine an easy and convenient method of sacral-alar-iliac (S2AI) screw fixation and introduce the surgical landmarks for fluoroscopic procedure by analyzing 3-D models of pelvis and virtual implantation in a 3-D model. Materials and Methods: Eighty-two cadavers underwent computed tomography scans and the images imported into Mimics((R)) software to make the 3-D pelvis model. The pedicle screw (o 8.5 mm/length 115 mm) was processed into a 3-D model using a 3-D-sensor (Comet5((R))) at the actual size and virtually placed as the S2AI screw. The ideal screw position was defined as the maximal intraosseous length without cortical perforation along the entire path. The ideal entry point and screw trajectory were verified and assessed to introduce the surgical landmark for fluoroscopic procedure. Results: There was no cortical violation around nerve root canal and greater sciatic notch through the entry point between first and second dorsal sacral foramen. There was no impossible model of S2AI screws. The average screw length was 99.8 mm (range, 59.8-115 mm; standard deviation, 16.1) and just one model had shorter than 65 mm S2AI screw. The factors limiting the intra-iliac screw length were sex (p = 0.000) and the iliac groove around the sacroiliac joint (p = 0.000). A free 360 degrees rotation with magnification revealed that the screw trajectory was consistently directed toward the anteroinferior iliac spine (AIIS) in any plane. Conclusion: The ideal entry point of S2AI screw showed a wide range of tolerance between the first and second dorsal sacral foramen; and thus, there was no need for deep dissection to identify the first dorsal sacral foramen. Considering the tendency to shift the pilot hole laterally and the ideal screw trajectory was consistently directed toward AIIS, the entry point is better to be located with a medial shift.