Name: Percutaneous Pars Fracture Fixation
Uploaded: 2026-10-02T08:11:00Z
Channel: Arthrex
Description: Saqib Hasan, MD (San Francisco, CA), demonstrates a percutaneous approach to pars fracture fixation using the fully threaded spine compression screw with optional endoscopic debridement of the fracture.

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<p>Saqib Hasan, MD (San Francisco, CA), demonstrates a percutaneous approach to pars fracture fixation using the fully threaded spine compression screw with optional endoscopic debridement of the fracture.</p>

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VID1-008419-en-US | A | Percutaneous Pars Fracture Fixation

Saqib Hasan, MD

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Percutaneous Pars Fracture Fixation

Speaker  Hello everyone. My name is Doctor Saqib Hassan. I'm from Golden State Orthopedics and Spine. And today we're going to be discussing how to perform a percutaneous pars fracture fixation with or without debridement of the pars fracture depending on the chronicity of the pars fracture. So the first thing we want to start off by doing is make sure if we're going to be using fluoroscopy and not navigation, is to make sure we have excellent fluoroscopic imaging of the pars on both the AP and lateral plane. Again, without navigation, this procedure can be very challenging. If you are not sure where the starting point is for your incision. Another important part of positioning the patient for this procedure is to ensure that the patient has the proper amount of kyphosis of the lumbar spine, because we all know that patients who have higher incidence of pars fracture have been known to have a higher pelvic incidence and have more lumbar lordosis, which can make this procedure more challenging if you're trying to fire a screw with significant lordosis. So again, what we did in this particular specimen is that we've added a lot of bumps to increase the kyphosis. And if you were to do this on a patient, I would recommend using a Wilson frame instead of a Jackson frame to avoid the lordosis. So let's start by actually marking. That's going to be the position of our screw. Okay. All right. We're going to mark that. Okay. So as you can see on my AP radiograph, what I did is I marked a starting point from the bottom of the lamina going across the pars bisecting the pedicle. Speaker  I'm going to actually make it right in the middle of the pedicle. Maybe angle a little bit medial. So you can see that in this particular X-ray I'm bisecting the pedicle. I'm not too lateral to the pedicle. So my screw is going to have nice fixation in the pars. And I have a good starting point on the lamina with the inferior articular process. So we're going to take that incision. We're going to bring it all the way down. Okay. And then I'm going to do a similar one for the opposite side. And then we're going to do that right there. Again. That's pretty good. We're on the inferior articular process lamina junction. And I'm bisecting the pedicle. I'm going to mark that one. I do the lateral line because I know that my trajectory is going to be kind of like this. So I'm going to use this angle and then I'm going to actually meet in the middle right there. I'm going to try this one first. So I'm going to go mark the angle hit spinous process there. Okay. I have the right trajectory on the AP. I have to make sure my lateral is good to make sure I land on the pars. Okay, so that's pretty good. That's right in line with our pars. So now I'm going to have a good approximation of where I'm going to be. Speaker  I can still make some micro adjustments. So it's important to understand that it's okay if you're not perfect on the first go. All right. So we're going to swap that out. We kind of know where we're going to end up being. We know that we're a little bit lateral. So I'm going to watch that again. I'm going to angle there. I like my position on the lateral. I'm going to go more steeper. All right. I like to typically now that I have my position I'm going to mount this a little bit. Okay. Let's get that in there a little bit more. Okay, I like that. So what I'm going to do is I'm going to drop my hand. You see my, my trajectory, obviously it looks good. It's just micro adjustments. We're going to we're going to pull this back a little bit. So you can see that I have a good pars trajectory. You can see that I'm bisecting the pedicle and the key is on the AP. You want to stay lateral to the medial particular line. Because obviously if you're medial to the medial particular line you can have injury to the traversing nerve root. I think I'm going to have good fixation there. Now what we're going to do next is we're going to take our wire out and measure. Now this part can be tricky. Obviously, if you're on navigation, you can do an intraoperative measurement of the navigation. Next we're going to do is we're going to insert our dilator. Speaker  Sometimes you can experience a little resistance. Now we want to measure the length of our wire. And you can see I have this drill guide, which is very helpful. The point of this, of this drill guide is to be able to catch the lamina. Okay, you can see that this drill guide has two tines. And the point of these tines are to be able to have some grip of the lamina. So the tendency can be when you're doing this drilling is to skive this way or that way, but the tines actually help you quite a bit in making sure you you have the appropriate trajectory and you don't lose that trajectory when you're drilling the path of the guide wire. So we're going to do that again. We're going to take our tines. We're going to put this in here like this. Again, you have to kind of rotate to get through because of soft tissues. Now I'm in my position. I'm going to always drill on the lateral okay. Because I don't want to skive. The tendency is to skive superficial or deep. And we're measuring on our guide. Our measurement is showing that we are approximately 35. So I'm going to on the side of 36 because I think we have our wire just a little bit shorter. And a nice little trick to do is to make sure that the tines of this soft tissue drill guide are on the lamina. You can do a gentle tap. Speaker  And then again, we can just double check our length. We can see I like that position. I think 36 is going to be perfect. Okay. And now we can commence with our drilling. Now one little trick that you have to remember is that obviously we know that everything we're doing is based off this guide wire. You can see the guide wire is not sitting in the middle of the hole. So I like to kind of just make sure we adjust this so it sits right in the middle. You see now it's perfect. And if you pay attention to the last AP, the drill guide was a little bit off, but this is how you can make sure you're staying in the center. Because if it's in the center, you know that you're drilling right in line collinear with this wire versus off axis if it's like this. So a small tidbit, but it helps a lot to make sure you maintain your position. Okay, I like my position there and you can always do some minor corrections if you need to. Although I don't recommend too much correction because then the guide wire might catch. So I like my position there. I'm going to start right now we're at 36, but I think we're closer to 40. So I'm going to take a 40 on this one. Yep. I like that a 40. I'm going to take that at 40. Typically when you are measuring the width of the pars screw, I like to use a preoperative CT to see about how wide that pars is. Speaker  The average is about anywhere from 4 to 5mm. In some patients you might have six, but I think generally 4 to 5 is the average. So we're going to be taking a four by 40 millimeter screw. Okay. Now here's our screw. Nice. I'm having a nice bite. I already feel the bite here in the compression that's happening. I'm kind of at the end point. I feel a lot of resistance. You don't want to go too far. Okay. And then now that we're done. Pull that out. So you can see now that we're done putting our placing our screw, we can pull our guide wire. That looks very nice. I like that I didn't have it too deep or I can still retrieve if needed. It's right down the middle of the path and that looks beautiful. You can see we bisected the pedicle. I like my position. It's right where the pars fracture would be. One other thing we want to touch upon before we conclude is what you would do if you had a chronic pars fracture, the steps would be a little bit different. We walk through the instrumentation part, but what I would typically start with is I would actually start by localizing on the pars with my endoscope. So again we showed the direction of our pars screw. So what we would do is prior to actually beginning the instrumentation portion, I would localize to the pars fracture right here. Speaker  And it's important that you debride the edges of a of the chronic pars fracture. Because typically you're going to find a lot of scar tissue within the fracture site, which can impede bony healing. Typically when you have fracture gapping and it's a chronic pars fracture, it behooves the surgeon to perform a debridement. And typically if you want to perform this the most minimally invasive way, I would obviously do this. Endoscopically we have patients who are high level athletes who are trying to return to sports. It makes the most sense if you're going to do minimally invasive pars fixation, also do a minimally invasive endoscopic pars debridement right here. So we already put the screw in. So what we're gonna do is we're going to debride that area. And hopefully we're going to be able to see the position of our screw in a nice position. So what I'm first going to do is draw a line that is just parallel to the pars fracture. So I know that my pars fracture is somewhere around here. And because we're just going to go direct onto the pars fracture there's not much more that needs to be done except just mark how lateral you're going to be. That's typically where you'd find the pars fracture. I'm going to make a mark right there. And then I'm going to take my incision. Okay. Get this needle in here. And I'm going to take this here. And I'm going to just do a little soft tissue dissection again. Speaker  And let's just make sure we like our position on the pars. That's it right there. Okay. We're going to hold that position. Okay. And we're going to go right there. Yep. You can see on the X-ray I'm right where the pars fracture should be. Okay. So if the AP in the lateral all line up, then all means they'll have us go a little bit deeper. I'll see that PA screw. Okay. And you can actually see this is medial okay. As I walk down here it's lateral and you can I'm falling off the edge here. So my part is right here. This is the pars. Obviously there is no pars fracture in this in this specimen. And we're going to create one. But the idea is that when I land here you would see a lot of soft tissue. You would feel bone here bone here and you'd feel soft tissue in between because typically there's some fracture gapping there. So you can see our part fracture would be here. We can start to see some of the screw that I don't want to drill out the screw, but you can see the screws coming this way. In that trajectory, you can actually follow the screw. It's actually coming this way towards the top of the pars. And this is our trajectory. You can see all the threads of the screw there. Essentially when you're doing this, the workflow is for chronic pars fracture. Once we have debrided the pars fracture, we would then have the scope holder kind of look at the fracture site. Speaker  And then what we would do then is all the steps we performed before, whether doing it with fluoroscopy or navigation, you would then fire the guide wire first, and then you can drill over that. And you can actually directly visualize your drilling as well as your guide wire placement. So it adds that extra level of security knowing that you're in the right spot. You know, we're very close to neural elements here. You want to be very, very exact and precise when you're doing this procedure. So I always will start with my debridment and make sure I know where my pars is prior to putting the screw in, I do put some biologic bone graft into this defect. It helps that there's bone graft into the defect prior to adding the compression screw, and it will help to compress some biologics within that pars fracture zone. Another important element is to make sure that when you're debriding, to make sure you have bleeding bone at the site of the pars fracture, that also encourages bony healing. As far as post-operative protocol for the patient, we typically will place the patient in a LSO brace and limit lumbar extension. For the first six weeks. We will start gentle physical therapy at six weeks with avoiding hyperextension or extension exercises. And typically the return to play can be anywhere from six months to a year for most active athletes.

Percutaneous Pars Fracture Fixation

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