Sacral Fractures Research Articles

Impact of Pelvic Fracture Sites on Fibrinogen Depletion in Patients with Blunt Trauma: A Single-Center Cohort Study.

Background: We aimed to examine the association of pelvic fracture sites with the minimum fibrinogen level within 24 h after hospital arrival. Methods: We conducted a single-center cohort study using health records review. We included patients with pelvic fractures transported by ambulance to a tertiary-care hospital from January 2012 to December 2018 and excluded those transported from other hospitals or aged younger than 16 years. The pelvic fracture was diagnosed and confirmed by trauma surgeons and/or radiologists. We classified the fracture sites of the pelvis as ilium, pubis, ischium, acetabulum, sacrum, sacroiliac joint diastasis, and pubic symphysis diastasis, and each side was counted separately except for pubic symphysis diastasis. We performed linear regression analysis to evaluate the association between pelvic fracture sites and the minimum fibrinogen level within 24 h of arrival. Results: We analyzed 120 pelvic fracture patients. Their mean age was 47.3 years, and 69 (57.5%) patients were men. The median Injury Severity Score was 24, and in-hospital mortality was 10.8%. The mean minimum fibrinogen level within 24 h of arrival was 171.4 mg/dL. Among pelvic fracture sites, only sacrum fracture was statistically significantly associated with the minimum fibrinogen level within 24 h of arrival (estimate, −34.5; 95% CI, −58.6 to −10.4; p = 0.005). Conclusions: Fracture of the sacrum in patients with pelvic fracture was associated with lower minimum fibrinogen levels within 24 h of hospital arrival and the requirement of blood transfusion.

The impact of misplaced percutaneous iliac dynamic reference frame pins used during navigated spine surgery: incidence and outcomes.

Image guidance requires placement of a dynamic reference frame (DRF), often either onto local spinous process or by freehand intraosseous DRF placement into the ilium via the posterior superior iliac spine (PSIS). There is a paucity of studies in the literature that describe the complications of intraosseous DRF placement. The aim of this study was to describe the radiographic location, prevalence and nature of complications, and long-term clinical outcomes of attempted DRF placement into the PSIS. All lumbosacral spine surgical procedures performed between August 2019 and February 2021 at a single institution were queried, and operations in which a DRF was targeted to the PSIS were included. Patient demographic characteristics, indications for surgery, surgical outcomes, and complications were extracted. Intraoperative CT scans were reviewed by 2 independent researchers to determine the accuracy of DRF placement into the PSIS and to assess for DRF malposition. Of 497 lumbar spine operations performed between August 2019 and February 2021 by 4 surgeons, 85 utilized intraoperative navigation with a PSIS pin. Thirteen operations were excluded due to an inability to visualize the entirety of the pin on intraoperative CT. Of 72 DRFs evaluated, 77.8% had been correctly placed in the PSIS. Of the 22.2% of DRFs not placed into the PSIS, 11 entered the sacrum, 6 crossed the sacroiliac joint, and 2 were deep enough to enter the pelvis. Pain at the pin site was present in 4 patients, of whom 3 had resolution of pain at the last follow-up evaluation. There were no significant complications due to DRF placement: no sacral fractures, significant navigation errors, retroperitoneal hematomas, or neurological deficits. Over a mean ± SD follow-up period of 9 ± 5.2 months, there were no incidences of pin site infection. Interrater reliability between the reviewers was 95.8%. This was the first study to examine radiological and clinical outcomes after DRF placement in the PSIS. In this study, a majority of pins were correctly placed within the PSIS, although 22.2% of pins were malpositioned. There were no serious complications, and a majority of those patients with persistent pin site pain had resolution at last follow-up.

Update on Interventional Radiology of the Spine.

Interventional radiologists now perform spinal interventions routinely for diagnostic and therapeutic purposes. New technologies for the management of spine pathologies have emerged with promising results in terms of safety and efficacy. Interventional radiology techniques in the spine include percutaneous biopsy and therapies for intervertebral disk herniation or spinal stenosis, facet and sacroiliac joint pathologies, vertebral and sacral fractures, and metastases. These techniques can also be easily combined one with the other or to further therapeutic approaches including systemic therapies, surgical approaches, and radiotherapy. This review provides a comprehensive overview of current percutaneous imaging-guided interventional radiology techniques in the spine. It will help readers become familiar with the most common indications, learn about different technical considerations during performance, and review the available evidence. Controversies concerning new products and technical approaches are also addressed.

Dual-energy CT in sacral fragility fractures: defining a cut-off Hounsfield unit value for the presence of traumatic bone marrow edema in patients with osteoporosis

BackgroundDemographic change entails an increasing incidence of fragility fractures. Dual-energy CT (DECT) with virtual non-calcium (VNCa) reconstructions has been introduced as a promising diagnostic method for evaluating bone microarchitecture and marrow simultaneously. This study aims to define the most accurate cut-off value in Hounsfield units (HU) for discriminating the presence and absence of bone marrow edema (BME) in sacral fragility fractures.MethodsForty-six patients (40 women, 6 men; 79.7 ± 9.2 years) with suspected fragility fractures of the sacrum underwent both DECT (90 kVp / 150 kVp with tin prefiltration) and MRI. Nine regions-of-interest were placed in each sacrum on DECT-VNCa images. The resulting 414 HU measurements were stratified into “edema” (n = 80) and “no edema” groups (n = 334) based on reference BME detection in T2-weighted MRI sequences. Area under the receiver operating characteristic curve was calculated to determine the desired cut-off value and an associated conspicuity range for edema detection.ResultsThe mean density within the “edema” group of measurements (+ 3.1 ± 8.3 HU) was substantially higher compared to the “no edema” group (-51.7 ± 21.8 HU; p < 0.010). Analysis in DECT-VNCa images suggested a cut-off value of -12.9 HU that enabled sensitivity and specificity of 100% for BME detection compared to MRI. A range of HU values between -14.0 and + 20.0 is considered indicative of BME in the sacrum.ConclusionsQuantitative analysis of DECT-VNCa with a cut-off of -12.9 HU allows for excellent diagnostic accuracy in the assessment of sacral fragility fractures with associated BME. A diagnostic “one-stop-shop” approach without additional MRI is feasible.

Multimodal Neuroelectrophysiological Monitoring Combined with Robot-Assisted Placement of a Transiliac-Transsacral Screw for the Treatment of Transforaminal Sacral Fractures.

Objective This study aimed to evaluate the safety and efficacy of the fixation of transforaminal sacral fractures using TiRobot-assisted transiliac-transsacral (TITS) screws under multimodal neuroelectrophysiological monitoring (MNM). Methods From January 2019 to May 2021, 22 patients (17 male and 5 female patients) with transforaminal sacral fractures who were treated with closed reduction and placement of TiRobot-assisted TITS screws under MNM were retrospectively evaluated. The average age of the patients was 43.32 ± 11.40 years (range: 19–63). The patients received MNM, including somatosensory-evoked potentials (SEPs), motor-evoked potentials (MEPs), and electromyographic monitoring (EMG), prior to surgery, during closed reduction and the placement of the guidewire and TITS screw, and at the end of surgery. The operation was adjusted according to the MNM results. Results Overall, 22 TITS screws were inserted in 22 patients, including 5 TITS screws in the S1 body and 17 TITS screws in the S2 body. The average time needed for screw placement was 27.95 ± 6.84 mins, and the average frequency of X-ray fluoroscopy exposures was 31.00 ± 5.56 for each patient. Anterior ring fixation was performed in 4 patients using an external fixator, in 5 patients using cannulated screws, and in 13 patients using reconstruction plates. The mean follow-up time was 14.46 ± 2.46 months (12–20 months). Tornetta and Matta radiographic outcomes were excellent in 10 patients, good in 9 patients, fair in 2 patients, and poor in 1 patient. The proportion of excellent and good ratings was 86.36%. At the final follow-up, the average Majeed score was 82.18 ± 14.52, with clinical outcomes that were excellent in 9 patients, good in 9 patients, fair in 1 patient, and poor in 3 patients. The proportion of excellent and good ratings was 82.82%. Preoperatively, the amplitude of the SEP on the injured side was lower than that on the contralateral side before reduction in 9 patients (>50%). In this study, no screw was mistakenly inserted into the sacral canal, and no surgical site infection occurred. Conclusion MNM combined with TiRobot assistance can safely implant TITS screws and can effectively identify the neurological function of patients under anesthesia and reduce iatrogenic nerve injury.

Percutaneous Sacroplasty with or without Radiofrequency Ablation for Treatment of Painful Sacral Metastases.

Percutaneous sacroplasty is a variation of percutaneous vertebroplasty that has gained attention as a therapeutic option for patients with painful sacral insufficiency fractures due to osteoporosis or metastases. Additionally, percutaneous sacroplasty can also be used to treat painful sacral metastases without a pathologic fracture. The purpose of this retrospective study was to compare the efficacy and safety of fluoroscopy-guided percutaneous sacroplasty alone versus percutaneous sacroplasty plus radiofrequency ablation for the treatment of painful sacral metastases. For this retrospective study, 126 patients (with a total of 162 painful sacral metastases) were enrolled from October 2012 to February 2021 and assigned to receive either percutaneous sacroplasty plus radiofrequency ablation (n = 51, group A) or percutaneous sacroplasty alone (n = 75, group B). Four different approaches were used for percutaneous sacroplasty: transiliac, interpedicular, anterior-oblique, and posterior. The Visual Analog Scale, Oswestry Disability Index, and Karnofsky Performance Scale were used to evaluate outcomes. The Visual Analog Scale, Oswestry Disability Index, and Karnofsky Performance Scale scores showed significant improvement in both groups after treatment (P < .05). The overall pain relief rate was significantly better in group A than in group B (90% versus 76%, P = .032). There were no significant differences in the incidence of polymethylmethacrylate leakage between the 2 groups or among the 4 different approaches (P > .05). Both percutaneous sacroplasty alone and the combination of percutaneous sacroplasty and radiofrequency ablation are safe and effective for treatment of painful sacral metastases. The combination of percutaneous sacroplasty and radiofrequency ablation appears to be more effective than percutaneous sacroplasty alone.

Do all Isler's type sacral fractures necessarily require surgical fixation?

A unilateral vertical sacral fracture that exits medial or through the L5-S1 facet joint is considered to affect the lumbo-sacral integrity, and it is denoted as an indication for surgical fixation. However, no studies have analysed the outcomes after non-operative treatment of such injuries. A retrospective review of all sacral fractures treated over a five-year period was performed to identify patients with Isler's fractures. Demographic and surgical data, all pre-operative and follow-up images (AP radiographs, CT images), functional outcomes based on VAS, SF-12 and return to work were documented for all patients. The incidence of Isler's fractures was 18% (34/181). The mean age was 42.12 ± 16.3years. As per Isler's subtypes, fractures passed through L5-S1 joint in 13 (Type 2a) and medial to it in 15 (Type 2b), fractures of L5 or S1 facets in 3 (Type 1), Type 3 injuries were not detected. All patients had concomitant pelvic ring injuries. Sixteen fractures (neurologically intact, < 1cm displacement, anterior ring stable, no facetal dislocation) were treated non-operatively while 18 patients underwent surgery. At a mean of 15.2months, the fractures had united in all patients radiographically. The mean VAS score for low back pain (1.4 ± 1.01 vs 1.5 ± 0.79), ability to squat and sit cross-legged (56.3% vs 55.6%) and return to work (68.8% vs 66.7%), and Majeed score (77.2 ± 3.9 vs 79.6 ± 4.1) were similar in non-surgical and surgical groups, respectively, at the final follow-up. Our study indicates that 47% of Isler's fractures were mechanically stable and could be effectively treated non-operatively with good radiological and functional outcomes.

Detection of Sacral Fractures on Radiographs Using Artificial Intelligence.

Background:Sacral fractures are often difficult to diagnose on radiographs. Computed tomography (CT) and magnetic resonance imaging (MRI) can improve the detection rate but cannot always be performed. The accuracy of artificial intelligence (AI) in detecting orthopaedic fractures is now comparable with that of orthopaedic specialists. However, the ability of AI to detect sacral fractures has not been investigated, to our knowledge. We hypothesized that the ability to detect sacral fractures on radiographs could be improved by using AI, and aimed to develop an AI model to detect sacral fractures accurately on radiographs with better accuracy than that of orthopaedic surgeons.Methods:Subjects were patients with suspected pelvic fractures for whom radiographs and CT scans had been obtained. The radiographs were labeled according to sacral fracture status based on CT results. The data set was divided into a training set (2,038 images) and a test set (200 images). Eight convolutional neural network (CNN) models were trained using the training set. Post-trained models were used to evaluate their discrimination ability. The detection ability of 4 experienced orthopaedic surgeons was also measured using the same test set. The results of fracture assessment by the orthopaedic surgeons were compared with those of the 3 CNNs with the greatest area under the receiver operating characteristic curve.Results:Among the 8 trained models, the highest areas under the curve were for InceptionV3 (0.989), Xception (0.987), and Inception ResNetV2 (0.984). The detection rate was significantly higher for these 3 CNNs than for the orthopaedic surgeons.Conclusions:By enhancing the processing of probabilistic tasks and the communication of their results, AI may be better able to detect sacral fractures than orthopaedic surgeons.Level of Evidence:Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Sacral Insufficiency Fractures.

Primary osteoporosis is the most common cause of sacral insufficiency fractures (SIFs). Therefore, a multidisciplinary team approach is necessary for treatment of the fracture and the underlying biologic pathology, as well as prevention of future fragility fractures. The presentation of SIFs typically includes lower back or buttock pain after a ground-level fall or without an identified trauma. Symptoms often have an insidious onset and are nonspecific; consequently, a delay in diagnosis and treatment is common. Clinicians need to have a high index of suspicion, particularly in high-risk patients. Postmenopausal women who are >55 years of age are the most common demographic affected by SIFs. Other risk factors include osteoporosis, history of a prior fragility fracture, local irradiation, long-term corticosteroid use, rheumatoid arthritis, metabolic bone disorders, vitamin D deficiency, pregnancy, history of prior multilevel spinal fusion, and malignancy. Typical imaging on computed tomography (CT) shows sclerosis of cancellous bone in the sacral ala, with or without a discrete fracture line or displacement. Magnetic resonance imaging is more sensitive than CT and shows hypointense signal on T1-weighted sequences and hyperintensity on T2-weighted or short tau inversion recovery sequences. The treatment of SIFs is dependent on the severity of symptoms, fracture displacement, and instability of the pelvis. Accepted treatments include nonoperative rehabilitation, sacroplasty, iliosacral screw fixation, transsacral bar or screw fixation, transiliac internal fixation, and lumbopelvic fixation.

Sacral insufficiency fracture after treatment for cervical cancer

A 61-year-old female patient was referred to the gynaecologic oncology clinic of the Regional Cancer Centre, Thiruvananthapuram, Kerala, India, in December, 2019, with complaints of postmenopausal bleeding and vaginal discharge with a cervical mass. She was diagnosed to have squamous cell carcinoma of the uterine cervix (stage IIIC1). She received radical radiotherapy using a four-field 2D conventional technique with concurrent weekly intravenous cisplatin 40 mg/m2 followed by high-dose-rate intracavitary brachytherapy, which was completed in January, 2020. She had a complete response to treatment and was on regular follow-up.

Focusing on individual morphological fracture characteristics of pelvic ring fractures in elderly patients can support clinical decision making

IntroductionPelvic ring fractures in the elderly are often caused by minor trauma. Treatment of these patients is currently based on fracture classification, clinical course, and ability to mobilize. Our aim was to identify morphological fracture characteristics with potential prognostic relevance and evaluate their association with clinical decision making and outcome, as well as their interobserver reliability.MethodsFive fracture characteristics were investigated as potential variables: 1. Extent of the dorsal pelvic ring fracture (absent, unilateral, bilateral); 2. Extent of the ventral pelvic ring fracture (absent, unilateral, bilateral); 3. Presence of a horizontal sacral fracture; 4. Ventral dislocation; 5. Ventral comminution.These characteristics were assessed retrospectively in a series of 548 patients. The association of their presence with the decision to perform surgery, failure of conservative treatment and the length of hospital stay (LOS) was determined. Further, the inter-observer reliability for the specific characteristics was calculated and the relation with survival assessed.ResultsFour of the five evaluated characteristics showed an association with clinical decision making and patient management. In particular the extent of the dorsal fractures (absent vs. unilateral vs. bilateral) (OR = 7.0; p < 00.1) and the presence of ventral comminution/dislocation (OR = 2.4; p = 0.004) were independent factors for the decision to perform surgery. Both the extent of the dorsal fracture (OR = 1.8; p < 0.001) and the presence of ventral dislocation (OR = 1.7; p = 0.003) were independently associated with a prolonged overall LOS.The inter-observer agreement for the fracture characteristics ranged from moderate to substantial.A relevant association with increased mortality was shown for horizontal sacral and comminuted ventral fractures with hazard ratios (HR) of 1.7 (95% CI: 1.1, 2.5; p = 0.008) and HR = 1.5 (95% CI: 1.0, 2.2; p = 0.048).ConclusionIn the elderly, the extent of the dorsal fractures and the presence of ventral comminution/dislocation were associated to the decision to undergo surgery, failure of conservative treatment and length of stay. Survival was related to horizontal sacral fractures and ventrally comminuted fractures. These characteristics thus represent a simplified but highly informative approach for the evaluation of pelvic ring fractures in the elderly. This approach can support clinical decision making, promote patient-centred treatment algorithms and thus improve the outcome of individualized care.

Percutaneous posterior transiliac plate versus iliosacral screw fixation for posterior fixation of Tile C-type pelvic fractures: a retrospective comparative study

BackgroundThis study aimed to compare the clinical outcomes and complications between two minimally invasive surgical techniques: percutaneous transiliac plate fixation and iliosacral (IS) screw fixation for the treatment of Tile C-type pelvic bone fractures.MethodsWe retrospectively reviewed the data of 77 consecutive patients with Tile C pelvic ring injuries who underwent either percutaneous transiliac plate fixation or IS screw fixation in a single academic center between November 2007 and January 2018. We recorded patients’ demographics, surgery-related data, and postoperative surgical outcomes and compared the incidence of complications and revision surgery rates between the two groups.ResultsOverall, 14 patients were included in the plate group, while 63 were included in the IS screw fixation group. No significant differences were observed in the patients’ demographics between the two groups except for a longer interval from injury to surgery (13.5 days vs. 5.4 days, P = 0.001). Both groups acquired fracture union in all cases. There was one case of infection requiring surgical debridement in the plating group. Notably, nerve injury (n = 3) and implant loosening (n = 5) occurred in the IS screw group, but the difference was not significant.ConclusionsBoth percutaneous posterior transiliac plating and IS screw fixation in patients with Tile C-type pelvic bone fractures showed good results. We recommend IS screw fixation as the primary treatment and propose posterior plating as treatment for sacral dysmorphism and bilateral sacral alar fractures in patients with spinopelvic dissociation.Level of evidenceIII

Functional, morphological and molecular characteristics in a novel rat model of spinal sacral nerve injury-surgical approach, pathological process and clinical relevance

Spinal sacral nerve injury represents one of the most serious conditions associated with many diseases such as sacral fracture, tethered cord syndrome and sacral canal tumor. Spinal sacral nerve injury could cause bladder denervation and detrusor underactivity. There is limited clinical experience resolving spinal sacral nerve injury associated detrusor underactivity patients, and thus the treatment options are also scarce. In this study, we established a spinal sacral nerve injury animal model for deeper understanding and further researching of this disease. Forty 8 w (week) old Sprague Dawley rats were included and equally divided into sham (n = 20) and crush group (n = 20). Bilateral spinal sacral nerves of rats were crushed in crush group, and sham group received same procedure without nerve crush. Comprehensive evaluations at three time points (1 w, 4 w and 6 w) were performed to comprehend the nature process of this disease. According to urodynamic test, ultrasonography and retrograde urography, we could demonstrate severe bladder dysfunction after spinal sacral nerve injury along the observation period compared with sham group. These functional changes were further reflected by histological examination (hematoxylin-eosin and Masson’s trichrome staining) of microstructure of nerves and bladders. Immunostaining of nerve/bladder revealed schwann cell death, axon degeneration and collagen remodeling of bladder. Polymerase Chain Reaction results revealed vigorous nerve inflammation and bladder fibrosis 1 week after injury and inflammation/fibrosis returned to normal at 4 w. The CatWalk gait analysis was performed and there was no obvious difference between two groups. In conclusion, we established a reliable and reproducible model for spinal sacral nerve injury, this model provided an approach to evaluate the treatment strategies and to understand the pathological process of spinal sacral nerve injuries. It allowed us to understand how nerve degeneration and bladder fibrosis changed following spinal sacral nerve injury and how recovery could be facilitated by therapeutic options for further research.

Sacral fractures in geriatric patients

Sacral fractures in geriatric patients are increasing and form a distinct entity. Clinical findings can be unspecific, which is why they are easily overlooked. It is mandatory to analyze the whole pelvic ring for evaluation of pelvic stability and for making treatment decisions. The primary diagnostics are made using plain X‑radiography; however, for assessment of the posterior pelvic ring an examination using sectional imaging is regularly necessary. The fragility fractures of the pelvis (FFP) classification is suitable as a guideline for the surgical treatment to be used. Stable fractures without relevant displacement after initial mobilization should be treated conservatively. Instability, failure of mobilization and persistent pain are, however, common reasons for surgical treatment. Fracture displacement determines if minimally invasive procedures for posterior and anterior pelvic ring stabilization are possible. Otherwise, complex open procedures such as spinopelvic fixation may be necessary.

Low-energy fractures of the pelvis in the elderly and mortality

Abstract Objective While the prognostic impact of hip fractures in the elderly is widely accepted, the risk and excess mortality associated with pelvic fragility fractures is still underestimated and receives considerably less attention. Morbidity and mortality might thereby be related to fracture morphology and/or patient characteristics. The aim of this project is to investigate the prognostic value of specific fracture characteristics with respect to overall survival and to compare it with an established classification system. Methods Retrospective analysis of patients ≥60 years, treated conservatively for a CT-scan verified, low-energy pelvic ring fracture diagnosed between August 2006 and December 2018. Survival data was available from patients’ charts and cantonal or national registries. The prognostic value of fracture characteristic describing the anterior and posterior involvement of the pelvic ring was investigated. This analysis was repeated after patients were stratified into a high-risk vs a low-risk group according to patient characteristic (age, gender, comorbidities, mobility, living situation). This allowed to assess the impact of the different fracture morphologies on mortality in fit vs. frail senior patients separately Results Overall, 428 patients (83.4% female) with a mean age of 83.7 years were included. Two thirds of patients were still living in their home and mobile without walking aid at baseline. In-hospital mortality was 0.7%, overall, one-year mortality 16.9%. An independent and significant association of age, gender and comorbidities to overall survival was found. Further, the occurrence of a horizontal sacral fracture as well as a ventral comminution or dislocation was associated with an increased mortality. The effect of a horizontal sacral fracture was more accentuated in low-risk patients while the ventral fracture components showed a larger effect on survival in high-risk patients. No association of the FFP classification with survival was observed. Conclusion Specific fracture characteristics such as horizontal sacral fracture, comminuted and dislocated ventral fractures may indicate a higher mortality risk of patients with a pelvic fragility fracture. Hence, they should be taken into account in future treatment algorithms and decisions on patient management.

Complex pelvic injury in a morbidly obese patient – A case report

Unstable pelvic ring injuries continue to be challenging to manage. Obese patients have a higher risk of complications and such management entails additional difficulties for emergency services and the medical-surgical team. A 41-year-old male with a body mass index of 44 fell from a water slide and suffered an anteroposterior pelvic compression impact injury. He presented with a Tile C1.3 pelvic fracture, Denis III sacral fracture, and Roy-Camille Type 4 spinopelvic dissociation. We performed a posterior triangular fixation and anterior double plating, and the patient gained full recovery and was able to return to work. This case report focuses on some key tools and techniques to consider when managing complex pelvic fractures in obese patients, requiring specialized equipment or adjustments to conventional treatments to obtain a good outcome. We used accessory portals through the fat pad to adequately place the plate screws. In addition, we used polypropylene mesh for post-operative incisional hernia prophylaxis, longer instruments for iliosacral screw placement, and a multidisciplinary approach with rehabilitation and nutrition control.

Management of a rare case of isolated U-shaped displaced sacral fracture in a young female high school student

Sacral fractures in young healthy patients are usually linked to high-energy trauma. They are often associated with multiple other injuries. Isolated sacral fractures are rare and can be easily missed in the absence of other surrounding pelvic or spinal injuries. In this article, we present a rare case of isolated U-shaped displaced sacral fracture despite the high-energy mechanism of injury being missed on initial presentation. This is a 17-year-old healthy female who presented to the emergency department after falling from five-meter height. She complained of lower back pain and inability to ambulate. Physical examination revealed significant sacral tenderness, bilateral lower limb weakness and hypoesthesia, anesthesia of the saddle area, weak anal tone and absent anal reflex. Initial radiographs showed no apparent fractures. Further imaging by pelvic computed tomography, however, revealed an isolated U-shaped displaced sacral fracture. The patient was treated by decompression and lumbopelvic fixation by triangular osteosynthesis and iliosacral screw. This fixation method restored stability of the spinopelvic junction and allowed for early mobilization. At her 18-month follow-up visit, she showed minimal disability score (10%) on the Oswestry Disability Index. In conclusion, sacral fractures are considered exceedingly rare to occur in isolation and in young healthy patients.

Multi-slice spiral computed tomography in diagnosing unstable pelvic fractures in elderly and effect of less invasive stabilization.

BACKGROUNDOlder people are more likely to experience pelvic fractures than younger people. Multi-slice spiral computed tomography (CT) uses three-dimensional (3D) reconstruction technology to generate 3D images that can clearly demonstrate the 3D space of fractures and detect fractures at a higher rate.AIMTo investigate the clinical value of multi-slice spiral CT 3D reconstruction in the diagnosis of unstable pelvic fractures in the elderly as well as the effect of less invasive stabilization.METHODSA total of 86 patients with unstable pelvic fractures treated between March 2016 and March 2019 underwent femoral supracondylar bone traction before surgery. Pelvic radiography and multi-row spiral CT were performed successively once the patient’s vital signs and hemodynamic indices were stable. Secondary processing of the original data was performed to obtain 3D reconstruction images and determine the vertical displacement of the pelvis. After basic or complete reduction, minimally invasive internal fixation using hollow lag screws was performed. The detection rates of fracture location and classification by X-ray and CT reconstruction were compared. Patients were divided into two groups according to the presence or absence of preoperative 3D reconstruction to compare postoperative reduction, wound healing time, fracture healing time, hospitalization time, visual analog scale (VAS) score, poor internal fixation, and functional recovery. RESULTSThe diagnostic coincidence rates of X-rays for pubic symphysis, ilium wing, sacroiliac periarticular, and sacral fractures were lower than those of CT reconstruction. The coincidence rate of CT reconstruction in the clinical classification of pelvic fractures was 100%, whereas 11 cases were misdiagnosed by X-ray; the total coincidence rate was 87.21%. The total excellent and good rates of postoperative reduction were significantly higher in the study group than in the control group (P < 0.05). The wound healing, fracture healing, and hospitalization times were significantly shorter in the study group than in the control group (P < 0.05). The VAS scores decreased in both groups postoperatively and were lower in the study group than in the control group (P < 0.05). The total incidence of poor postoperative internal fixation was significantly lower in the study group than in the control group (P < 0.05). The overall rate of postoperative functional recovery was significantly higher in the study group than in the control group (P < 0.05).CONCLUSIONMulti-slice spiral CT has high guiding significance for the diagnosis, classification, and treatment of unstable pelvic fractures in the elderly. Preoperative 3D reconstruction can effectively shorten the operation time and promote fracture healing, while minimally invasive internal fixation can effectively reduce pain and promote functional recovery of fracture sites, making it worthy of clinical application.

Clinical and MRI features of sacral insufficiency fractures after radiotherapy in patients with cervical cancer

BackgroundTo determine the incidence, clinical and MRI features of sacral insufficiency fracture (SIF) after radiotherapy (RT) in patients with cervical cancer.MethodsOur study included 167 patients with cervical cancer after radiotherapy that underwent pelvic MRI for follow-up. MRIs included pre-enhanced T1-weighted, coronal fat-Suppressed T2-weighted (FS-T2W) and enhanced T1-weighted imaging. The clinical and MRI dates were reviewed. The gold standard of SIF was based on radiologic findings, clinical data and follow-up at least 12 months.Results28 patients (10.8%) with 47 sites were diagnosed with SIFs, including 9 patients with unilateral SIF and 19 patients with bilateral SIFs. The median age was 60 years (range 41–72 years), and 89.3% (25/28) of patients were postmenopausal. 64.3% (18/28) of patients were symptomatic, and 53.6% of patients (15/28) had concomitant pelvic fractures. The median interval time from RT to SIFs was 10 months (range 3–34 months). For the lesion-wise analysis based on all MR images, all lesions were detected by visualizing bone marrow edema patterns, and fracture lines were detected in 64.6% (31/47) of SIFs. No soft-tissue tumors were founded. For each MRI sequence analysis, coronal FS-T2WI detected the most bone marrow edema pattern and fracture line than T1WI or enhanced T1WI.ConclusionSIF is a common complication in cervical cancer after radiotherapy, which has some certain clinical and MRI features. Coronal FS-T2WI may be more useful to detect and characterize these fractures than other imaging sequences.

The "Eiffel Tower" technique: novel long-axis sacroplasty under electromagnetic navigation assistance; feasibility and descriptive study.

To describe a novel long-axis multimodal navigation assisted technique - the so-called Eiffel Tower technique - aimed at integrating recent technological improvements for the routine treatment of sacral insufficiency fractures. The long-axis approach described in the present study aimed at consolidating the sacral bone according to biomechanical considerations. The purpose was (i) to cement vertically the sacral alae all along and within the lateral fracture lines, resembling the pillars of a tower, and (ii) to reinforce cranially with a horizontal S1 landing zone (or dense central bone) resembling the first level of the tower. An electromagnetic navigation system was used in combination with CT and fluoroscopic guidance to overtop extreme angulation challenges. All patients treated between January 2019 and October 2021 in a single tertiary center were retrospectively reviewed. A description of the technique is provided. Twelve female patients (median age: 80 years [range: 32 to 94]) were treated for sacral insufficiency fractures with the "Eiffel Tower" technique. The median treatment delay was 8 weeks (range: 3 to 20) and the initial median pain assessed by the visual analogue scale was 7 (range: 6 to 8). Pain was successfully relieved (visual analogue score < 3) for 9 patients (75%) and persisted for 2 patients (17%). One patient was lost during the follow-up. No complication was noted. The "Eiffel Tower" multimodal cementoplasty integrates recent technological developments, in particular electromagnetic navigation, with the purpose of reconstructing the biomechanical chain of the sacral bone. • Sacral insufficiency fractures are common and can be efficiently treated with percutaneous sacroplasty. • The long axis sacroplasty approach can be challenging given both the shape of the sacral bone and the angulation to reach the target lesion. • The "Eiffel Tower" technique is a novel approach using electromagnetic navigation to expand the concept of the long axis route, adding a horizontal S1 landing zone.