Sacral Fractures Research Articles

Development of a sacral fracture model to demonstrate effects on sagittal alignment.

To develop a modeling framework to predict the secondary consequences on spinal alignment following correction and to demonstrate the impact of pedicle subtraction osteotomy (PSO) location on sagittal alignment. Six patients were included, and pelvic incidence (PI) was measured. Full-length standing radiographs were uploaded into PowerPoint and manipulated to model S1-S2 joint line sacral fractures at 15°, 20°, 25°, and 30°. PSO corrections with hinge points at the anterior superior corner and vertical midpoint of the L3-5 vertebral bodies were modeled. Anterior translation (AT) and vertical shortening (VS) were calculated for the six PSO locations in the four fracture angle (FA) models. PI had a strong effect in the mixed AT and VS models (P < 0.001). Both AT and VS were significantly different from zero at all FA (p < 0.001), and pairwise comparisons revealed all FA were different from each other with respect to both AT and VS after adjusting for PSO location (p < 0.001), increasing as FA increased. Varying PSO location resulted in significant differences in AT when comparing all locations (p < 0.001). AT was greatest for all FA in all patients when the PSO correction was performed at the L3-AS (p < 0.001). There were significant differences in VS when comparing the L5-Mid PSO location to the L3-AS, L3-Mid, L4-AS, and L4-Mid PSO locations (p < 0.034). PSO correction superior to a sacral fracture resulted in AT and VS of the spine. It is crucial that these changes in spinal measures be predicted and accounted for to optimize patient sagittal alignment and outcomes.

Incidence of and Risk Factors for Screw Loosening after Iliosacral Screw Fixation for Posterior Pelvic Ring Injury.

Screw loosening is a common complication of iliosacral screw fixation, with subsequent loss of stability and fracture re-displacement. This study aimed to investigate the incidence of and risk factors for screw loosening after iliosacral screw fixation for posterior pelvic ring injury. A total of 135 patients with posterior pelvic ring injuries who were treated with iliosacral screw fixation in our department between July 2015 and April 2021 were selected for this retrospective analysis. The possible risk factors for screw loosening were investigated using univariate and multivariate logistic regression analyses of patient demographics and trauma-related and iatrogenic variables, including age, sex, body mass index, Osteoporosis Self-Assessment Tool for Asians (OSTA) index, mechanism of injury, Young-Burgess classification, site of injury, type of injury, type of screw, mode of fixation, numbers of guidewire adjustments, accuracy of screw position, and quality of fracture reduction. The incidence of screw loosening was 15.6% (n = 21). The mean duration for screw loosening was 3.2 ± 1.5 months after operation. Univariate analysis results showed that the Young-Burgess classification, type of injury, site of injury, type of screw, mode of fixation, and OSTA index might be related to screw loosening (p < 0.05). According to the multivariate logistic regression, vertical shear injuries (Odds ratios [OR] 9.80, 95% Confidence intervals [CI] [1.96-73.28], p = 0.008), type of injury (OR 0.25, 95% CI [0.13-0.79], p = 0.027), common screws (OR 6.94, 95% CI [1.53-31.40], p = 0.012), screws insertion only at the level of the first sacral segment (S1) (OR 8.79, 95% CI [1.18-65.46], p = 0.034), injury site located in the medial sacral foramina (OR 6.28, 95% CI [1.16-34.06], p = 0.033), and lower OSTA index [OR 0.41, 95% CI [0.24-0.71], p = 0.001] were significantly related to screw loosening. Vertical shear injuries, sacral fractures, injury site located in the medial sacral foramina, and lower OSTA index are significantly associated with the postoperative occurrence of screw loosening. Transiliac-transsacral screw fixation and screws insertion both at the level of the S1 and second sacral segment can prevent screw loosening.

Sacral Stress Fracture in Athletes With Overuse: A Clinical Series of 11 Patients and Literature Review.

This was a narrative review. The purpose of this study was to report the physical and radiologic characteristics of sacral stress fractures in 11 athletes and to review the current literature on sacral stress fractures. Sacral stress fractures are rarely reported as a cause of low back pain in athletes. We retrospectively analyzed 11 athlete patients with sacral stress fractures and low back pain. All patients received conservative treatments, such as rest from sporting activities and physical therapy. Clinical data, such as age, sex, athletic activity, region of tenderness, and duration of low back pain, and radiologic data, such as information from plain radiographs and fracture lines on magnetic resonance imaging (MRI), were evaluated. The study included 11 athlete patients (5 males and 6 females) with sacral stress fractures, and their mean age was 18.7 years (range, 15-38y). The sports that caused the stress fractures were baseball, badminton, and basketball in 2 patients each and football, judo, marathon, volleyball, and dance in 1 patient each. All patients had tenderness on the sacrum. The mean duration of low back pain was 1.8 weeks (range, 1-4wk). Fracture lines on MRI were observed only in the caudal-ventral part of the sacrum in 7 patients and extended from the inferolateral angle of the sacrum to the superior lateral sacral alar in 4 patients. The study findings demonstrated that MRI and tenderness were useful for detecting the presence of sacral stress fractures in athletes. Moreover, fracture lines in the sacrum may progress from the caudal-ventral part of the sacrum to the cranio-dorsal direction.

Robotic-Assisted Minimally Invasive Spinopelvic Fixation for Traumatic Sacral Fractures: Case Series Investigating Early Safety and Efficacy

High-energy traumatic sacral fractures, particularly U-type or AOSpine classification type C fractures, may lead to significant functional deficits. Traditionally, spinopelvic fixation for unstable sacral fractures was performed with open reduction and fixation, but robotic-assisted minimally invasive surgical methods now present new, less invasive approaches. The objective here was to present a series of patients with traumatic sacral fractures treated with robotic-assisted minimally invasive spinopelvic fixation and discuss early experience, considerations, and technical challenges. Between June 2022 and January 2023, 7 consecutive patients met the inclusion criteria. Intraoperative fluoroscopic images were merged with intraoperative computed tomography images using a robotic system to plan the trajectories for placement of bilateral lumbar pedicle and iliac screws. Intraoperative computed tomography was performed after pedicle and pelvic screw insertion to confirm appropriate placement before insertion of rods percutaneously without the need for a side connector. The cohort consisted of 7 patients (4 female, 3 male) with ages ranging from 20 to 74. Intraoperatively, the mean blood loss was 85.7 ± 84.0 mL, and mean operative time was 178.4 ± 63.9 minutes. There were no complications in 6 patients; 1 patient experienced both a medially breached pelvic screw and a complicated rod pullout. All patients were safely discharged to their homes or an acute rehabilitation facility. Our early experience reveals that robotic-assisted minimally invasive spinopelvic fixation for traumatic sacral fractures is a safe and feasible treatment option with the potential to improve outcomes and reduce complications.

Comparison of patterns and rates of cement leakage in percutaneous sacroplasty for sacral insufficiency fractures versus neoplasia.

Percutaneous sacroplasty is a minimally invasive procedure which utilises injection of bone cement into the sacrum for stabilisation of osteoporotic sacral insufficiency fractures (SIF) and neoplastic lesions to relieve pain and improve function. While effective, cement leakage is an important complication associated with the procedure. This study aims to compare the incidence and patterns of the cement leakages following sacroplasty for SIF versus neoplasia and discuss the various patterns of cement leakage and their implications. This retrospective study analysed 57 patients who underwent percutaneous sacroplasty at a tertiary orthopaedic hospital. Patients were divided into 2 groups of SIF (n=46) and neoplastic lesions (n=11) based on their indication for sacroplasty. Pre- and post-procedural CT fluoroscopy was used to assess for cement leakage. The incidence and patterns of cement leakage were both compared among the two groups. A Fisher's exact test was used for statistical analysis. Eleven (19%) patients had cement leakage on post-procedural imaging. The most common sites of cement leakage were into the presacral region (6), followed by sacroiliac joints (4), sacral foramina (3) and posterior sacral (1). There was a statistically significant higher incidence of leakage in the neoplastic group in comparison to SIF group (P-value <0.05). The incidence of cement leakage in the neoplastic group was 45% (n = 5/11) versus SIF 13% (n=6/46). There was a statistically significant higher incidence of cement leak in sacroplasties conducted for the treatment of neoplastic lesions compared to those with sacral insufficiency fracture.

Novel Standalone Motion-Sparing Pelvic Fixation Prevents Short-Term Insufficiency Fractures After Midsacrectomies Without Sacrificing Normal, Mobile Lumbar Segments Traditionally Used for Stabilization.

Sacrectomy is often the treatment of choice to provide the greatest chance of progression-free and overall survival for patients with primary malignant bone tumors of the sacrum. After midsacrectomy, the stability of the sacropelvic interface is diminished, resulting in insufficiency fractures. Traditional stabilization involves lumbopelvic fixation but subjects normal mobile segments to fusion. The purpose of this study was to determine whether standalone intrapelvic fixation is a safe adjunct to midsacrectomy, avoiding both sacral insufficiency fractures and the morbidity of instrumenting into the mobile spine. A retrospective study identified all patients who underwent resection of sacral tumors at 2 comprehensive cancer centers between June 2020 and July 2022. Demographic, tumor-specific, operative characteristics and outcome data were collected. The primary outcome was presence of sacral insufficiency fractures. A retrospective data set of patients undergoing midsacrectomy without hardware placement was collected as a control. Nine patients (5 male, 4 female), median age 59 years, underwent midsacrectomy with concomitant placement of standalone pelvic fixation. No patients developed insufficiency fractures during the 216 days of clinical and 207 days of radiographic follow-up. There were no adverse events attributable to the addition of standalone pelvic fixation. In our historical cohort of partial sacrectomies without stabilization, there were 4/25 patients (16%) with sacral insufficiency fractures. These fractures appeared between 0 and 5 months postoperatively. A novel standalone intrapelvic fixation after partial sacrectomy is a safe adjunct to prevent postoperative sacral insufficiency fractures in patients undergoing midsacrectomy for tumor. Such a technique may allow for long-term sacropelvic stability without sacrificing mobile lumbar segments.

Sacral Dural Tears as a Cause of Spontaneous Intracranial Hypotension

PurposeDural tears at the level of the cervical, thoracic, and lumbar spine cause spontaneous intracranial hypotension (SIH) in patients with a spinal longitudinal extradural CSF collection (SLEC); however, sacral dural tears have rarely been reported so far. This study focuses on sacral dural tears as a cause of SIH.MethodsRetrospective data from SIH patients with confirmed sacral dural tears studied between October 2020 and November 2022 were analyzed with respect to demographic, clinical and imaging features. Digital subtraction myelography (DSM) and lumbar epidural blood patch (EBP) were modified by placing the patient in reversed Trendelenburg position.ResultsOf the SIH patients, 9 (all women; mean age, 38.5 years; mean body mass index, BMI, 22.9) out of 149 had a sacral dural leak (6%) that occurred spontaneously in 7/9, while 2/9 were likely associated with minor trauma. None had a sacral fracture. The mean SIH score was 6.8. All patients showed SLEC on heavily T2-weighted MR myelography (T2-MRM), 4/9 exclusively sacral and 5/9 with partial or complete involvement of the remaining spine. 4/9 had none, but 5/9 had meningeal sacral cysts, 2/5 had large cysts/ectasia. Confirmation of the sacral origin of the leak was provided in 4/9 by T2-MRM, in 2/9 by DSM and 3/9 by CT myelography (CTM) whereas 0/9 revealed the exact site of leak within the sacrum.ConclusionSacral dural tears should be considered as a possible cause for SIH. It is concluded to implement T2-MRM covering the entire sacrum in the standard MRI protocol and propose EBP in the reverse Trendelenburg position as a therapeutic approach.

Operative management of stress-positive minimally displaced lateral compression type 1 (LC1) pelvic ring injuries: Analysis of outcomes before and after implementation of a departmental stress protocol.

To compare the hospital course of patients with minimally displaced (<1 cm) lateral compression type 1 (LC1) injuries treated before and after implementation of lateral stress radiographs (LSR) to determine management. Retrospective comparative cohort. Urban level one trauma centerPatients/Participants: Isolated LC1 injuries managed before (n=33) and after implementation of LSR (n=40) to determine management. Patients in a pre-stress cohort managed nonoperatively versus patients in a LSR cohort managed operatively if stress-positive (≥1cm displacement on LSR). Physical therapy (PT) clearance before discharge, discharge location, hospital length of stay (LOS), inpatient opioid morphine milligram equivalents (MME). The pre-stress and LSR protocol groups were similar in demographic/injury characteristics (age, sex, mechanism, ASA score, Nakatani classification, bilateral/unilateral injury, Denis zone, sacral fracture completeness, sacral comminution). 45.0% of LSR protocol patients were stress-positive (n=18) and managed operatively. The LSR protocol group was more likely to clear PT by discharge (97.5% vs. 75.8%, proportional difference (PD): 21.7%, 95% confidence interval (CI): 5.1% to 36.8%, p=0.009), less likely to discharge to a rehabilitation facility (2.5% vs. 18.2%, PD: -15.7%, CI: -30.0 to -0.5%, p=0.04), and had no difference in LOS (MD: 0.0, CI :-1.0 to 1.0, p=0.57) or inpatient opioid MME (MD: 9.0, CI: -60.0 to 101.0, p=0.71). Implementation of a LSR protocol to determine management of minimally displaced stress-positive LC1 injuries was associated with increased rates of operative management, PT clearance by discharge, and a reduction in the number of patients discharging to rehabilitation facilities.

Sex Differences in Blunt Traumatic Aortic Injury from the Aortic Trauma Foundation Global Registry

Trauma is the leading cause of death in people younger than 45 years, and blunt traumatic aortic injury (BTAI) is the second leading cause of death after blunt trauma. There have been reports on variations in physiological response to trauma between men and women, as well as sex/gender disparities in aortic disease outcomes, but there is a gap in the literature on sex differences in patients with traumatic aortic injury. The Aortic Trauma Foundation international prospective multicenter registry was used to examine sex differences in traumatic aortic injury characteristics, management, and outcomes from 2016 to 2022. Data were analyzed by contingency table, stratified and multivariable regression. There were 781 patients with BTAI and complete injury grade information, of whom 182 patients (23%) were female. The mean age was 43.4 ± 18 years, and women were significantly older than men (48 ± 18.6 vs 42.3 ± 17.6 years, P < .0001). A total of 464 patients (59%) underwent thoracic endovascular aortic repair with no significant difference between men (61%, 364 of 599) and women (55%, 100 of 182). Injury severity score and Glasgow coma scores did not differ between women and men. Women more often had pelvic fracture (41% vs 30%, P < .004), splenic injury (31% vs 23%, P < .05), renal injury (22% vs 14%, P < .02), sacral spine fracture (12% vs 6%, P < .02), and sternal fracture (17% vs 10%, P < .02), but these injury patterns were not associated with higher grade aortic injuries. There were no sex differences in the distribution of aortic injury grade. In-hospital mortality was 12%, and aortic-related mortality was 4% for the entire cohort, with no differences between men and women. The presence of sternal fracture appeared to predict higher aortic mortality in women (10% with sternal fracture vs 2% without, P = .05) but not in men (9% with sternal fracture vs 10% without P = .9). There is no difference in mortality between men and women with BTAI. Women with BTAI presented more frequently with intra-abdominal and pelvic injuries, and sternal fractures appear to predict a higher mortality in women with BTAI.

An Interim Analysis of the First 102 Patients Treated in the Prospective Vertebral Augmentation Sacroplasty Fracture Registry

PurposeTo evaluate the efficacy of sacroplasty for treating sacral insufficiency fractures, including the effect on pain relief, patient function and adverse event rates in an as-treated on-label prospective data registry. Materials and MethodsObservational data including patient reported outcomes (PROs), patient characteristics, osteoporosis treatment, fracture duration, cause of sacral fractures and image guidance used for treatment were collected for patients undergoing sacroplasty. The PROs were collected at baseline then at one, three, and at six months following the procedure. The primary outcomes were pain as measured by the Numerical Rating Scale (NRS) and function as measured by the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes included adverse events, cement leakage, new neurologic events, readmissions and death. ResultsThe interim results for the first 102 patients included significant pain reduction with mean pain improvement scores at six months decreasing from 7.8 to 0.9 (P < .001) and significant improvement in function with mean RMDQ scores improving from 17.7 to 5.2 (P < .001). Most procedures were performed under fluoroscopy (58%). There was cement leakage in 17.7% of the subjects but only one adverse event which was a new neurologic deficit related to cement extravasation. The readmission rate was 16% mostly due to additional back pain and fractures and there were no subject deaths. ConclusionsSacroplasty with cement augmentation for acute, subacute and chronic painful sacral insufficiency fractures caused by osteoporosis or neoplastic disorders results in highly significant improvements in pain and function with very low rate of procedural related adverse events.

Surgical management of lumbosacral and sacral fractures: roles of the pelvic and spinal surgeons.

In young patients, lumbosacral fractures result primarily from high-energy traumas. Life-threatening lesions (e.g. visceral organs) are frequently associated with these fractures. Management consists of medical intensive care for adequate resuscitation and specialized surgical input. Lumbosacral junction represents a frontier between the spine and pelvic ring. Any injury in this area implies a thorough examination of both spine and pelvis through clinical examinations and CT scans. Patients must be assessed specifically for neurological and bladder/bowel symptoms. Several surgical classifications may be required to describe the entire fracture pattern. In unstable fracture with large displacements, definitive surgical fixation is often recommended. Various pelvic and spine surgery techniques can be used depending on the fracture pattern, surgeon's experience, and available equipment. The use of intraoperative navigation may enhance placement of instrumentation, especially in cases of complex fractures, percutaneous fixations, and/or atypical patients' anatomy. The fracture itself can cause debilitating complications with long-term consequences such as pain, neurological deficits, and bladder/bowel impairments. Wound infection remains the most common postoperative complication and prominent posterior instrumentation is frequently a source of pain. Irrespective of the treatment, leg discrepancy can be problematic in the case of malunion. Management of lumbosacral fractures requires a thorough understanding of both lumbar spine and pelvic injuries. Surgical treatment may involve a combination of spine and pelvic surgery techniques. Therefore, this implies for the surgeon to be trained specifically for these fractures, or else a close cooperation between the pelvic surgeon and the spine surgeon in managing the patients.

Increased incidence of vertebral fractures in German adults from 2009 to 2019 and the analysis of secondary diagnoses, treatment, costs, and in-hospital mortality

The aim of this cross-sectional study was to present the nationwide rates of hospitalized patients with vertebral fractures over one decade and to comprehensively analyze the treatment characteristics and direct costs incurred in 2019. Therefore, the trends in the incidence rate were quantified based on annual ICD-10 diagnosis codes from all German medical facilities between 2009 and 2019, provided by the Federal Statistical Office (Destatis). The ICD-10 Codes “S12.0-2; S22.0-; S32.0-, and S32.1-2” were evaluated. The relative change from 2009 through 2019 was determined. Using data from the Institute for Hospital Remuneration Systems (InEK) for 2019 the secondary diagnoses, OPS-codes, intensive care unit (ICU) treatment, in-hospital mortality, the proportion of G-DRGs and cumulative costs were evaluated. The documented number of vertebral fractures increased by 45.6% between 2009 and 2019 to an incidence of 150.7 per 100,000 inhabitants. The lumbar spine was most commonly affected with an incidence of 70.5/100,000 inhabitants in 2019 (46.8% of all vertebral fractures). The highest increases were seen in the numbers of subaxial cervical fractures (+ 121.2%) and sacral fractures (+ 306.6%). Of all vertebral fractures in 2019, 63.7% were diagnosed in women and 69.0% in patients aged 70 years or older. Osteoporosis was documented in 17.9% of cases as a concomitant diagnosis. In 10.1% of all cases, an ICU treatment was documented. The in-hospital mortality was 2.0% in 2019. I68D was the most frequently used G-DRG code, accounting for 33.3% of cases. The total direct costs for inpatient treatment in 2019 amounted to €589,205,715. The evaluation of 955,091 vertebral fractures showed a sharp increase in the nation-wide incidence rate. The presented age and sex distribution, the comorbidity profile and the in-hospital mortality rate indicate the importance of comprehensive geriatric assessment and emphasize the need for spinal care centers to be established.

To study the outcome of sacro-iliac percutaneous screw fixation in unstable fractures of pelvic injuries

Percutaneous fixation of sacroiliac joint fractures and closed reduction gives advantages of limited blood loss, minimal invasion of compromised soft tissue, decreased infection rates and reduced operation time. The purpose of this study is to determine the outcome of sacroiliac percutaneous screw fixation of pelvic injuries in unstable fractures.This study was conducted at Tirunelveli medical college hospital from 2017 to 2019 in patients underwent sacro-iliac percutaneous screw fixation in unstable fractures of pelvic injuries. Functional assessment of patients with Pelvic fractures was assessed by Majeed Score Scale. Patients follow up was taken at 4, 8, 12 weeks, 6 months and 1 year. The study included 22 patients with ages ranged from 16-70 years with the mean age range of 39 years with 16 males and 6 females. Mode of injury was a road traffic accident in 86.36% of cases and fall from height in 13.64%. As per the Majeed scoring system all patients were clinically evaluated. The overall Majeed score was excellent in 77.27%, while good in 13.63% and poor in 9.09% of cases. As per Matta and tornetta postoperative radiological evaluation was carried out. Percutaneous iliosacral screw fixation and anatomic reduction give better stability in unstable sacroiliac joint injuries allowing good functional outcomes and early mobility. For sacral fracture and sacroiliac, joint injury with C arm guidance percutaneous iliosacral screw fixation is a minimally invasive and safe technique.

Risk factors for sacral fracture following en bloc chordoma resection.

The purpose of this study was to analyze risk factors for sacral fracture following noninstrumented partial sacral amputation for en bloc chordoma resection. A multicenter retrospective chart review identified patients who underwent noninstrumented partial sacral amputation for en bloc chordoma resection with pre- and postoperative imaging. Hounsfield units (HU) were measured in the S1 level. Sacral amputation level nomenclature was based on the highest sacral level with bone removed (e.g., S1 foramen amputation at the S1-2 vestigial disc is an S2 sacral amputation). Variables collected included basic demographics, patient comorbidities, surgical approach, preoperative radiographic details, neoadjuvant and adjuvant radiation therapy, and postoperative sacral fracture data. A total of 101 patients (60 men, 41 women) were included; they had an average age of 69 years, BMI of 29 kg/m2, and follow-up of 60 months. The sacral amputation level was S1 (2%), S2 (37%), S3 (44%), S4 (9%), and S5 (9%). Patients had a posterior-only approach (77%) or a combined anterior-posterior approach (23%), with 10 patients (10%) having partial sacroiliac (SI) joint resection. Twenty-seven patients (27%) suffered a postoperative sacral fracture, all occurring between 1 and 7 months after the index surgery. Multivariable logistic regression analysis demonstrated S1 or S2 sacral amputation level (p = 0.001), combined anterior-posterior approach (p = 0.0064), and low superior S1 HU (p = 0.027) to be independent predictors of sacral fracture. The fracture rate for patients with superior S1 HU < 225, 225-300, and > 300 was 38%, 15%, and 9%, respectively. An optimal superior S1 HU cutoff of 300 was found to maximize sensitivity (89%) and specificity (42%) in predicting postamputation sacral fracture. In addition, the fracture rate for patients who underwent partial SI joint resection was 100%. Patients with S1 or S2 partial sacral amputations, a combined anterior-posterior surgical approach, low superior S1 HU, and partial SI joint resection are at higher risk for postoperative sacral fracture following en bloc chordoma resection and should be considered for spinopelvic instrumentation at the index procedure.

Pelvic insufficiency fractures revisited

Objectives: There has been a significant increase in insufficiency fractures of the pelvis. Early diagnosis is essential to decrease morbidity and mortality. We describe the incidence of demographics of insufficiency fractures in different parts of the pelvis. Material and Methods: A retrospective search of the radiology database for insufficiency fractures was performed at a tertiary orthopedic center. We analyzed the location of insufficiency fractures and demographics. Results: There were 323 insufficiency fractures, with the majority being in the sacrum and pelvis. Insufficiency fractures of pubis, acetabulum and sacrum were in relatively older patients. Conclusion: Early diagnosis and management are crucial.

Diagnosis, surgical and conservative treatment of unstable sacral fractures (literature review)

Background. In the structure of severe combined trauma, injuries to the pelvic bones, especially the sacrum, are relatively rare but increase steadily with the scientific and technological progress and the urbanization. Despite the widespread use of modern diagnostic methods, such as computer and magnetic resonance imaging, and the ubiquity of X‑ray diagnostics, sacral fractures are diagnosed not in all patients or not in full. In 50 % of patients, sacral fractures are not diagnosed during the initial examination, including anteroposterior X‑ray examination. In addition, in 30 % of the patients, sacral fractures are recognized on a pelvic X‑ray film incorrectly, and the long‑term outcomes of their treatment are unsatisfactory from 30 to 60 % of the cases.Aim. To analyze scientific published sources on the issues of diagnosis, clinical picture, and treatment of patients with severe combined trauma and unstable sacral fractures.Materials and methods. The data of 232 domestic and foreign publications from 1971 to 2020. We present the epidemiology of combined trauma and unstable sacral fractures, consider various classifications, and describe the clinical course and tactics in conservative and surgical treatment of vertically unstable fractures in the posterior pelvic ring.Results. Many foreign publications describe both diagnostics and various methods of treatment for unstable pelvic ring injuries. The publications cover various aspects of diagnosis, clinical course, management tactics, extent and timing of surgery, and conservative treatment for sacral fractures. However, only a few publications in Russian discuss features of diagnostic search, the timing and extent of surgery, as well as the choice of the final tactics to treat patients with sacral fractures.Conclusions. It is necessary to study the problem of diagnosis and treatment of severe combined trauma and vertically unstable fractures of the posterior pelvic ring to develop optimal diagnostic algorithms and final treatment tactics aimed at reduction of the frequency of errors, complications, and deaths, and at improvement in the quality of life of such patients.

Biomechanical analysis of variants of spinopelvic fixation of longitudinal sacral fractures by the finite element method

Objective. To analyze the strength of three types of spinopelvic fixation system configurations in longitudinal fracture of the sacrum by the finite element method.Material and Methods. Biomechanical analysis was carried out by the finite element method. A three-dimensional model of a segment of the spinopelvic complex (SPC), including the pelvic bones, sacrum and L4 and L5 vertebrae, was created on the basis of the CT scan results of a healthy patient. Then, a longitudinal fracture of the sacrum was simulated on the developed model of the sacrum on the left side in zone 1 according to the Denis classification. Further, a comparative assessment of three variants of spinopelvic fixation systems with the help of biomechanical computer modeling was carried out: bilateral spinopelvic system L4–S2Alar, bilateral spinopelvic system L4–S2Alar with transverse connector installation, and bilateral spinopelvic system L4–S2Alar with L-shaped rod installation. The stability of fixation, as well as the amount of loads acting on the fixation elements and bone tissues were determined.Results. As the rigidity of the structure increases by means of a transverse connector or an L-shaped rod, the load is redistributed between the screws located to the left and right of the fracture. The rigidity of the L4–S2Alar system with parallel, unconnected rods is much lower, which leads to a critical increase in loads on instrumentation and vertebrae.Conclusion. Analysis of three variants of spinopelvic fixation of longitudinal fractures of the sacrum by finite element method revealed that bilateral spinopelvic system with pedicle screws installed in the L4 and L5 vertebrae and pelvic screws installed in the iliac bones through the lateral masses of S2, two on each side (L4–S2 Alar) and connected by two parallel rods (variant 1) is the least strong in comparison with the other variants. The strength of the fixation increases when the structure is supplemented with a transverse connector between the rods (variant 2). The L4–S2 Alar design with an L-shaped rod on the side of the longitudinal fracture of the sacrum (variant 3) proved to be the most strong.

Acetabular and sacral insufficiency fractures in a patient with a long-term history of Alendronate consumption; a case report

BackgroundLong-term Bisphosphonate consumption has been reported to be associated with the incidence of atypical or insufficiency fracture, particularly in the proximal femur. We observed a case of acetabular and sacral insufficiency fractures in a patient with a long-term history of Alendronate consumption.Case presentationA 62-year-old woman was admitted with a complaint of pain in right lower limb following low-energy trauma. The patient had a history of Alendronate consumption for more than 10 years. The bone scan revealed increased radiotracer uptake in the right side of the pelvic, proximal right femur, and sacroiliac joint. The radiographs showed type 1 sacrum fracture, acetabulum fracture with femur head protrusion into the pelvis, quadrilateral surface fracture, fracture of the right anterior column, and right superior and inferior pubic fracture. The patient was treated with total hip arthroplasty.ConclusionThis case highlights the concerns regarding long-term bisphosphonate therapy and its potential complications.

Biomechanical comparison of four triangular osteosynthesis fixations for unilateral vertical sacral fractures

To compare the stability and biomechanical characteristics of four commonly used triangular osteosynthesis techniques to treat unilateral vertical sacral fractures and provide a clinical application reference. Finite element models of Tile C-type pelvic ring injury (unilateral Denis II sacral fracture) were produced. In four models, sacral fractures were fixed with a combination of unilateral L5, unilateral L4, and L5 iliac lumbar fixation with lengthened or normal sacroiliac screws. The biomechanical properties of the four fixation models were measured and compared under bipedal stance and lumbar rotation. The fixation stability of the model with the lengthened sacroiliac screw was excellent, and the fracture end was stable. The stability of fixation using unilateral L4 and L5 segments was close to that of unilateral L5 segment fixation. Triangular osteosynthesis transverse stabilization devices using lengthened sacroiliac screws can increase the vertical stability of the sacrum after internal fixation and increase the stability of the fracture. When triangular osteosynthesis lumbar fixation segments were selected, simultaneous fixation of L4 and L5 segments versus only L5 segments did not significantly enhance the vertical stability of the sacrum or the stability of the fracture end.

Biomechanical evaluation of multiple pelvic screws and multirod construct for the augmentation of lumbosacral junction in long spinal fusion surgery.

Background: Posterior long spinal fusion was the common procedure for adult spinal deformity (ASD). Although the application of sacropelvic fixation (SPF), the incidence of pseudoarthrosis and implant failure is still high in long spinal fusion extending to lumbosacral junction (LSJ). To address these mechanical complications, advanced SPF technique by multiple pelvic screws or multirod construct has been recommended. This was the first study to compare the biomechanical performance of combining multiple pelvic screws and multirod construct to other advanced SPF constructs for the augmentation of LSJ in long spinal fusion surgery through finite element (FE) analysis. Methods: An intact lumbopelvic FE model based on computed tomography images of a healthy adult male volunteer was constructed and validated. The intact model was modified to develop five instrumented models, all of which had bilateral pedicle screw (PS) fixation from L1 to S1 with posterior lumbar interbody fusion and different SPF constructs, including No-SPF, bilateral single S2-alar-iliac (S2AI) screw and single rod (SS-SR), bilateral multiple S2AI screws and single rod (MS-SR), bilateral single S2AI screw and multiple rods (SS-MR), and bilateral multiple S2AI screws and multiple rods (MS-MR). The range of motion (ROM) and stress on instrumentation, cages, sacrum, and S1 superior endplate (SEP) in flexion (FL), extension (EX), lateral bending (LB), and axial rotation (AR) were compared among models. Results: Compared with intact model and No-SPF, the ROM of global lumbopelvis, LSJ, and sacroiliac joint (SIJ) was decreased in SS-SR, MS-SR, SS-MR, and MS-MR in all directions. Compared with SS-SR, the ROM of global lumbopelvis and LSJ of MS-SR, SS-MR, and MS-MR further decreased, while the ROM of SIJ was only decreased in MS-SR and MS-MR. The stress on instrumentation, cages, S1-SEP, and sacrum decreased in SS-SR, compared with no-SPF. Compared with SS-SR, the stress in EX and AR further decreased in SS-MR and MS-SR. The most significantly decreased ROM and stress were observed in MS-MR. Conclusion: Both multiple pelvic screws and multirod construct could increase the mechanical stability of LSJ and reduce stress on instrumentation, cages, S1-SEP, and sacrum. The MS-MR construct was the most adequate to reduce the risk of lumbosacral pseudarthrosis, implant failure, and sacrum fracture. This study may provide surgeons with important evidence for the application of MS-MR construct in the clinical settings.