Robotic-assisted percutaneous iliac fixation: Outcomes, history, and review.

BACKGROUND

Long-construct fusions extending into the pelvis require durable sacropelvic fixation to withstand biomechanical forces. Traditional iliac screws provide strong fixation but are limited by wound complications, offset-connector requirements, and hardware prominence. S2-alar-iliac screws improve soft-tissue outcomes but may violate the sacroiliac joint, contribute to postoperative sacroiliac joint pain, and demonstrate variable fusion rates. With advances in robotics, medialized iliac trajectories may re-establish the advantages of iliac fixation while reducing complication profiles. This study evaluates the safety, accuracy, and perioperative outcomes of robotically placed iliac screws using a medialized, percutaneous technique.

METHODS

A retrospective review was performed of all patients who underwent robotically navigated iliac fixation between January 1, 2019, and January 1, 2025. Demographic, perioperative, and postoperative variables were collected, including sex, body mass index (BMI), ASA class, blood loss, surgery duration, complications, opioid use, visual analog scale pain scores, and primary versus revision status.

RESULTS

Twenty-eight patients met inclusion criteria (9 primary, 19 revision). Mean age was 67.21 years, mean BMI 26.77, and mean ASA of 2.07. Mean blood loss was 81.61 mL. Mean visual analog scale scores improved by 2.11 points at 2 weeks. No surgical-site infections occurred. Two patients required revision for symptomatic hardware prominence, both with BMI<20. Two patients had 90-day complications unrelated to iliac fixation. Screw accuracy was 100%, with no cortical breaches or offset-connector requirements.

CONCLUSIONS

Robotically placed medialized iliac screws appear to mitigate shortcomings of traditional iliac and S2-alar-iliac fixation. This technique avoids sacroiliac joint violation, minimizes wound complications, and provides precise fixation, representing a safe and effective technique. These findings support further investigation through prospective, comparative studies with longer follow-up to validate the long-term durability and generalizability of this approach.