Injury, Int. J.

Care Injured 47 (2016) 2077–2080

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

“Anterior subcutaneous pelvic internal fixator (INFIX), Is it safe?” A

cadaveric study
T. Apivatthakakula,b,* , N. Rujiwattanaponga
a
Department of Orthopaedics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
b
Excellence Center in Osteology Research and Training Center (ORTC), Chiang Mai University, Thailand

A R T I C L E I N F O A B S T R A C T

Introduction: Anterior pelvic internal fixator (INFIX) is used to treat unstable pelvic ring injuries. Nerve
Keywords: injury complications with this procedure have been reported.
Anterior pelvic internal fixation
Objectives: This anatomic study attempted to identify structures at risk after application of INFIX.
INFIX
Femoral nerve
Materials and methods: INFIX was applied in fifteen fresh, frozen, anatomical specimens using polyaxial
Lateral femoral cutaneous nerve pedicular screws and subcutaneous rods. Surgical dissection was done to identify the structures at risk
Injury including the femoral nerve (FN), femoral artery (FA), femoral vein (FV) and the lateral femoral cutaneous
nerve (LFCN) related to which are potentially affected by the implant.
Results: All structures at risk were closer to the rod than to the pedicular screw. Measurements were made
between the rod and the structures at risk. The LFCN was an average of 13.49  1.65 mm (95% CI
12.871–14.103) from the lateral end of the rod. The FN was an average of 12.43  3.42 mm (95% CI
11.151–13.709), the FA was an average of 12.80  3.67 (95% CI 11.430–14.173) and the FV was an average of
13.48  3.73 (95% CI 12.082–14.871) below the rod. No direct compression of the rod to the structure at
risk was observed.
Conclusions: The femoral nerve is the structure most at risk of compression by the INFIX rod. Careful
surgical technique is required in every step of this surgery. We suggest using polyaxial screws and
recommend that during screw insertion the surgeon should leave some space between the screw and
rectus fascia. The the rod should be trimmed as short as possible to reduce LFCN irritation.
ã 2016 Elsevier Ltd. All rights reserved.

Introduction another technique for subcutaneous internal fixation using a

High energy unstable pelvic ring injuries frequently involve
disruption of anterior and posterior bony and/or ligamentous
structures. Anterior pelvic external fixation is a common method
for supplementing posterior fixation [1]. There are, however,
complications associated with external fixators including pin tract
infection, osteomyelitis, loss of reduction and nerve damage [2].
To avoid these complications, several surgeons have developed
novel techniques for internally stabilizing the anterior pelvic ring
[3–6]. Kuttner et al. described the surgical technique and midterm
results of anterior subcutaneous fixation using the polyaxial
pedicular screws just medial to the anterior inferior iliac spine
(AIIS) which is connected to a contoured spinal rod [3]. Vaidya et al.
described a modified technique for treatment of unstable pelvic
ring injury which they called INFIX [4]. Cole et al. presented
* Corresponding author at: Department of Orthopaedics, Faculty of Medicine,
Chiang Mai University, Chiang Mai, 50200 Thailand.
E-mail address: tapivath@gmail.com (T. Apivatthakakul).
precontoured low profile 3.5 mm locking reconstruction plate fixed
from the anterior superior iliac spine (ASIS) to the pubic symphysis
on both sides [6,7]. Each of these techniques has been reported to
have had good clinical outcomes including good tolerance, low
morbidity, low wound complication rates and the provision of
stability equivalent to other techniques.
Complications resulting from use of an anterior pelvic internal
fixator (APIF) have included irritation of the lateral femoral
cutaneous nerve (LFCN). Kuttner et al. [3] found the problem in 32%
of cases and both Cole et al. [6] and Vaidya et al. [4] reported a 4%
incidence rate. In addition, Hesse et al. [8] treated 8 instances of
iatrogenic femoral nerve palsy (two bilateral) which had
developed in 6 INFIX patients suggesting a potentially devastating
risk to the femoral nerves. In each case, they removed the INFIX,
but despite this early implant removal, problems of quadriceps
weakness, disturbance of skin sensation, and/or gait problems
were still present at early follow-up.
Although the APIF technique was described in 2009, the
anatomic relationships of the screws and rods to vital structures of
the pelvis have not yet been completely demonstrated. Moazzan

http://dx.doi.org/10.1016/j.injury.2016.08.006
0020-1383/ã 2016 Elsevier Ltd. All rights reserved.
2078 T. Apivatthakakul, N. Rujiwattanapong / Injury, Int. J. Care Injured 47 (2016) 2077–2080

et al. [8] studied anatomic structures at risk in anatomical

specimens after application of APIF from two incisions over both
iliac crest and an incision centered over the pubic symphysis. They
reported that this technique was safe from risk of compression of
the LFCN, the femoral nerve (FN), the femoral artery (FA) and the
femoral vein (FV). However, the technique used by Moazzan was
different from INFIX which fixed the rod between both AIIS.
Merriman et al. [9] measured the CT scans of 13 patients after INFIX
to determine the shortest distance between the fixation compo-
nents and important structures including femoral neurovascular
bundle, the urinary bladder, the cranial margin of the hip, the
relation of the screws and bone corridor and their position relative
to the skin. This study’s use of CT scans precluded measurement of
the FN and LFCN as they were too small to be accurately seen on CT
scans. The knowledge gap in this area could be filled by additional
anatomical studies of INFIX in anatomical specimens.
The current anatomic study was conducted to determine which
structures are at risk after application of INFIX by measuring the
closest distance between the implants and the structures at risk
using fresh anatomical specimens.

Materials and methods

Ethical Review Board approval was obtained before the start of

this study. Fifteen fresh-frozen non-preserved whole body
anatomical specimens with an intact pelvis and no previous
surgery in the abdominal area were obtained including 8 males and
7 females. INFIX was applied to the intact specimens following the
techniques described by Vaidya et al. [4]. All important application
steps were followed including the following: the polyaxial
pedicular screws sat 15–50 mm proud of the AIIS. The screw
was advanced until the head was lying just above the fascia of the
rectus femoris. The contoured connecting rod was then tunneled
subcutaneously as dictated by the crease forming the “bikini line”
[10], and excess rod length was trimmed in situ with a rod cutter
(Fig. 1).
Dissections of the specimens were then performed by opening
the tunnel over the rod and extending the incision laterally to
identify the structures at risk. The relationship and proximity to
the LFCN, FN, FA, and FV were identified, and their proximity to the
rods and screws was recorded (Fig. 2). The closest distance to each
structure was measured twice with digital calipers and the values
were averaged.
Results
The LFCN, FN, FA, and FV were identified in all specimens; in all
male specimens the spermatic cord was identified as well. All those
structures were intact and had not been damaged during the
placement of the INFIX. From the dissection, we observed that all
the structures at risk were closer to the rod than to the pedicular
screw. Measurements made between the rod and each of the
structures at risk found that the LFCN was an average of about
13.5 mm from the lateral end of the rod. The FN was an average of
about 12.5 mm, the FA was an average of about 12.8 mm and the FV
was an average of about 13.5 mm from the rod above. (Table 1).
Discussion
Recent evolution of INFIX for the treatment of unstable pelvic
ring injuries has reduced the complications of anterior external
fixation [3,4,11]. The new methods also allow for definitive and
stable anterior fixation of vertical shear and unstable pelvic
fractures and can be combined with posterior fixation if indicated.
A secondary operative procedure, however, is still required for
removal of the device [4]. Kuttner et al. [3] reported that the main
Fig. 1. Application of INFIX.
a) The rod was contoured at the bikini line.
b) The rod was inserted subcutaneously and fixed to the poly axial pedicular screw.
advantages of the modifications is a simple, less complicated
surgical techniques which help prevent damage to soft tissue,
result in a lower risk of neurovascular lesions (although 32% of
patients had transient LFCN lesions) and the avoidance of pin
infections [8]. Vaidya, who introduced and popularized the INFIX
technique, later reported two cases of minor complications of
unilateral anterior thigh paresthesia from the retraction of the
LFCN [4]. A multicenter study of complications from INFIX
application reported that the most common complications were
heterotrophic ossification (35%) and irritation of the LFCN (30%)
That study reported no cases of femoral nerve injury [12].
The relationship of the INFIX to the key vascular, urologic, bony
and surface structures was evaluated by measuring the shortest
distance between the fixator components and important anatomi-
cal structures, including FA FV, using CT scans. The FA and FV were
located 22 mm below the rod [9]. Using the CT scans, however, was
not possible to measure the distance between LFCN and FN and the
fixator components. Our study found that the FN at
12.43  3.42 mm was the closest structure to the rod. The FN lies
over the iliopsoas muscle lateral to the FA and FV which is at
greater risk of being compressed by the rod.
Iatrogenic FN injury from INFIX was first described by Hesse
et al. who reported 6 patients who experienced 8 femoral nerve
palsies (2 bilateral) after INFIX [8]. The FN provides sensation to the
anterior and medial thigh and the medial leg through the anterior
femoral cutaneous, the medial femoral cutaneous, and the long
saphenous nerves, respectively. It supplies the quadriceps,
sartorius and pectineus muscles. Motor and sensory deficit in
those muscles include weakness of hip flexion and knee extension,
 T. Apivatthakakul, N. Rujiwattanapong / Injury, Int. J. Care Injured 47 (2016) 2077–2080
Fig. 2. Identified structures at risk after INFIX.
a) Structures at risk include the spermatic cord (S), femoral nerve (N), femoral artery
(A) and femoral vein (V).
b) The lateral femoral cutaneous nerve was identified lateral to the rod.
Table 1
Closest distance between structures at risk and the rod.
Structure Mean  Sd (mm) 95% CI (mm)
LFCN 13.49  1.65 (12.871–14.103)
FN 12.43  3.42 (11.151–13.709)
FA 12.80  3.67 (11.430–14.173)
FV 13.48  3.73 (12.082–14.871)
reduction or absence of the patellar reflex, and anesthesia of the
anterior and medial thigh and medial aspect of the leg [13]. In the
study by Hesse et al., all the patients reported knee or anterior
thigh pain, quadriceps weakness, limping and numbness of the
anterior or medial thigh. Early removal of implants, as was
accomplished in the study, is a basic principle for the relief of nerve
compression and is followed by supportive treatment for pain
control, knee support and early physiotherapy. The limited space
for the iliopsoas and the FN with INFIX is a likely cause of the nerve
palsies observed by Hesse. Careful physical examination of the FN
function both before and after surgery is important. Iatrogenic
femoral neuropathy has to be detect and implant revision should
be accomplished promptly.
The depth of insertion of the pedicular screw is a critical step. In
small or thin patients the screw has to be inserted deeper to avoid
skin complications which may result in a high risk of compression
2079
of the FN. Monoaxial INFIX pedicular screws were shown to
provide a stiffer construction than polyaxial INFIX or 2 pin supra
acetabular external fixators in distraction testing [14]. However,
application of monoaxial pedicular screws is more difficult in
terms of proper rod contouring and rod-screw attachment; it also
requires more traction on the skin and nearby LFCN. In our study,
the average distance between the FN and the rod was
12.43  3.42 mm (95% CI 11.151–13.709) which is quite a short
distance. The degree of compression of the nerve was directly
related to the depth of pedicular screw insertion. We suggest that
polyaxial screws should be used in order to control the depth of the
screw and rod application and that the screw and rod should be
located some distance above the fascia of the rectus femoris, but
not touching the fascia to keep more space available for the
iliopsoas and the FN. The fixation stiffness may be lower since the
pedicular screws are far away from the bone, but the accompa-
nying compression of the FN resulted in increased morbidity.
LFCN irritation is one of the most common complications
following INFIX [3,4,12]. Kuttner et al. [3] reported temporary
lesions of LFCN in 27% of 19 patients. Vaidya et al. [12] in a
multicenter study reported 30% of patients had irritation of the
LFCN. The LFCN provides sensory innervation to the lateral aspect
of the thigh. It leaves the pelvis by passing under the inguinal
ligament close to the anterior superior iliac spine (ASIS).
Anatomical variation of LFCN has been described. It is usually
located within 2 cm inferomedial to the ASIS with more than 90%
having either one or two branches [15,16]. The average distance
between the LFCN and the FA was 6 cm in males and 5 cm in
females [15]. There are nine anatomical variations reported in the
literature which are based on the position of the bony landmark
ASIS or the iliac crest, the femoral artery or the inguinal ligament.
However, there has been no report of a relationship between the
LFCN and the AIIS which is the insertion point for the INFIX or the
supraacetabular external fixator. Vaidya et al. proposed that it is
possible to injure the LFCN during implantation or removal of the
fixator. Surgeons are familiar with the supraacetabular placement
of the Schanz pin, and are aware that nerve injury may be caused
by the improper placement of the rod. Our study demonstrated
that the distance between the end of the rod and the LFCN is an
average of 13.49  1.65 mm (95% CI 12.871–14.103). That finding
means that during manipulation and insertion of the rod, there is a
chance that the end of the pedicular screw or rod may irritate or
compress the nerve. The length of the end of the rod lateral to the
pedicular screw has a direct relationship to the LFCN. If the rod is
too long, the end will be unnecessarily close to the nerve. We
suggest using polyaxial screws for easier assembly of the rod to the
pedicular screw in order to reduce the difficulty of rod insertion.
We also recommend trimming the rod as short as possible to allow
more space for the LFCN.
A limitation of our study is that all the specimens had intact,
stable and normal anatomic pelvises. In displaced unstable
fractures, the normal anatomy is distorted. The small number of
cases in this study limited the opportunity to identify nerve
injuries. Another potential limitation is that the size of the average
Asian and Caucasian pelvis may be different. Finally, the vessels in
the anatomical specimens were collapsed, while in a live patient
the vessels would be expanded and thus closer to the rod.
Conclusions
The FN is the structure most at risk for compression by the INFIX
rod. Careful surgical technique is required in every step of the
surgery to avoid that problem. We suggest using polyaxial screws
and leaving some space between the screw and rectus fascia during
screw insertion. The end of the rod should be trimmed as short as
possible to reduce the incidence of the LFCN irritation.
2080 T. Apivatthakakul, N. Rujiwattanapong / Injury, Int. J. Care Injured 47 (2016) 2077–2080
Conflict of interest statement
The authors have no conflicts to report.
Acknowledgement
The authors receive financial support from the Endowment
Fund, Faculty of Medicine, Chiang Mai University and Excellence
Center in Osteology Research and Training Center (ORTC), Chiang
Mai University, Thailand for preparation of this manuscript. We
thanks Dr Lamar Robert, Chiang Mai, Thailand and Dr Ryan Martin,
Calgary, Canada for his kind review of our paper.
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