Treatment Of Sacral Fractures Research Articles

S2-Alar-Iliac Screw Fixation versus Iliac Screw Fixation in the Treatment of Sacral Fractures

Purpose To compare the short-term therapeutic effects of S2-alar-iliac (S2AI) screw fixation and iliac screw fixation techniques in managing sacral fractures. Methods From September 2015 to May 2020, 42 patients with sacral fractures who underwent lumbopelvic fixation by a single surgeon were analyzed. The patients were divided into the S2AI screw group (19 patients) and the iliac screw group (23 patients). Operative data, reduction quality, postoperative complications, and functional outcomes were evaluated. Results The incidence of unplanned reoperation was significantly different between patients treated with S2AI screws than in those treated with iliac screws (0 versus 6, p = 0.02). The mean intraoperative estimated blood loss was 405.26 ± 229.67 mL in the S2AI screw group and 539.13 ± 246.32 mL in the iliac screw group (P = 0.08). No significant difference was observed in either group regarding the quality of reduction, functional outcome, or low back pain. The reduction quality based on the Matta criteria and excellent/good outcomes were 21/2 in the iliac screw group and 17/2 in the S2AI screw group. The functional outcomes based on the Majeed score and excellent/good/fair outcomes were 17/3/3 in the iliac screw group and 17/1/1 in the S2AI screw group. No complications, including implant breakage, loosening of the implant, or loss of reduction were found in either group during follow-up. Conclusion Both S2AI screws and iliac screws were effective in the treatment of sacral fractures. The use of S2AI screws, however, was independently associated with fewer unplanned reoperations for surgical site infection, wound dehiscence, and symptoms of screw protrusion than the use of iliac screws.

Efficacy of Surgical Treatment of Unstable Sacral Fractures

Background: The treatment of sacral fractures is challenging and controversial, operative fixation provides stability, a stable sacral fracture fixation construct reduce pelvic pain, allows the patient to be mobilized to a chair or crutches and protects the local neurovascular structures. The purpose of this study was to achieve stability, early mobilization and relieve nerve compression, this done by iliosacral screw, spinopelvic fixation and plate for patients with unsatable sacral fractures. Subjects and Methods: This was prospective study includes 24 patients with unstable sacral fracture surgically treated from June 2017 to April 2019 in orthopedic surgery department Zagazig University Hospital, with mean age 34.2 years (range 18-51), full clinical evaluation was taken, full investigations were done and Radiological assessment with minimum follow up: 6 months. Results: Post-operatively all patients were clinically assessed according to Majeed score. Excellent cases were 10 (41.7%), good results were 12(50%) and fair were 2 (8.3%). Conclusions: Sacral fractures are rare and detection of these potentially complicating fractures is very important.

Minimal-invasive triangular fixation with orthopaedic robot for unilateral unstable sacral fracture

Objective To compare the clinical outcomes between minimal-invasive triangular fixation with orthopedic robot and traditional open fixation method for unilateral unstable sacral fracture patients. Methods Data of 24 consecutive patients with unilateral unstable sacral fracture who were treated from August 2014 to February 2018 were retrospectively analyzed. All patients were associated with anterior ring injuries of pelvis and received magnetic resonance of nerve (MRN) preoperatively to exclude the compression of sacral nerve by bone. All patients received surgical treatment of sacral fractures with triangular fixation and the fixation of pelvic anterior ring injuries simultaneously and two groups were divided according to the different surgical methods of sacral fractures. There were 10 males and 2 females with an average age of 36.3±1.2 years in the orthopaedic robot group. According to Dennis classification, there were 4 type I and 8 type II fractures. Two patients were associated with nerve injuries (Gibbons II 1 case, III 1 case). In traditional posterior-midline open fixation group, there were 11 males and 1 female with an average age of 38.2±1.6 years. According to Dennis classification, there were 3 type I and 9 type II fractures. Three patients were associated with nerve injuries (Gibbons II 2 cases, III 1 case). The clinical data of two group patients were collected and compared statistically. T test was used to compare the operation time, intraoperative bleeding, intraoperative fluoroscopy times, Majeed function assessment which was to evaluate the patients' clinical prognosis and healing time of fracture. χ2 test was used to compare the healing rate of fracture, accuracy assessment of fixation insertion, and Mears radiological assessment which was applied to evaluate the reduction quality of fractures. The rank sum test was used to compare Gibbons score which was applied as the index of neurological deficiency recovery. The Fisher exact test was used to compare the infection rate. Results All patients were followed up continuously for an average time of 21.2±3.2 months. The average operation time of robot group was 100.3±14.5 minutes, meanwhile the open fixation group was 202.0±18.5 min. The average intraoperative bleeding of robot group was 180.0±17.4 ml, meanwhile the open fixation group was 850.0±15.2 ml. The average intraoperative fluoroscopy time of robot group was 23.3±4.5 s, meanwhile the open fixation group was 90.0±7.7 s. All fractures were healed and no loss of reduction or fail of fixation occurred in both groups. The healing time of fracture of robot group was 8.5±1.9 months, meanwhile the open fixation group was 12.8±2.4 months. The satisfaction rates of reduction which was based on Mears-Velyvis radiological criterion of both groups were 91.7%. The accuracy rate of fixation insertion of robot group was 100% meanwhile the open fixation group was 77.78%. Majeed function assessment score of robot group was 86.2±3.4, meanwhile the open fixation group was 84.2±2.7. There was no infection occurred in robot group, meanwhile 3 patients infected in open fixation group. The Gibbons score of one patient changed from II preoperative to I postoperative and one case changed from III preoperative to II postoperative in robot group, meanwhile two patients changed from II preoperative to I postoperative and one case changed from III preoperative to II postoperative in open fixation group. The healing rate of fracture, infection rate, Majeed function assessment, Mears-Velyvis radiological evaluation criterion and Gibbons score of two groups had no significant statistical difference (P >0.05), meanwhile the operation time (t=14.99), intraoperative bleeding (t=100.46), intraoperative fluoroscopy time (t=32.13), healing time of fracture (t=4.87) and accuracy rate of fixation insertion (χ2=9.00) of orthopedic robot group were better than traditional open group and had the significant difference (P< 0.05). Conclusion The minimal-invasive triangular fixation with orthopedic robot for unilateral unstable sacral fracture had the advantages of less operation time, less intraoperative bleeding and less times of fluoroscopy, more accurate of fixation insertion and less healing time of sacral fractures compared to traditional open fixation method and should be recommended as an effective and advanced choice. Key words: Sacrum; Fractures, bone; Fracture fixation, internal; Internal fixators

Operative vs Non-Operative Treatment of Sacral Fractures

Operative vs Non-Operative Treatment of Sacral Fractures

Discussion on the selection of internal fixation methods for unstable sacral fractures

Currently, the internal fixation methods for unstable sacral fractures mainly include posterior tension band screw plate fixation, sacroiliac screw fixation, lumbopelvic fixation and triangular osteosynthesis. The purpose of the above internal fixation is to correct the deformity of the pelvic ring and lumbosacral joint and rebuild its stability, but incorrect selection will increase the risk of loosening or breakage of the internal fixation. However, there are no clear guidelines on how to select appropriate internal fixation according to different fracture types. To this end, the author discussed the selection of internal fixation method, the technique of screw placement, the new auxiliary instrumentation technology as well as internal fixation related infection so as to provide reference for the treatment of unstable sacral fractures. Key words: Sacrum; Fracture fixation, internal; Sacroiliac screw

Sacroplasty: A Ten-Year Analysis of Prospective Patients Treated with Percutaneous Sacroplasty: Literature Review and Technical Considerations

Background: The treatment of sacral fractures has evolved since its first description in 1982. Several techniques for sacral augmentation have been developed since 2001, and the rate of improvement is rapid with over 50% reduction in pain achieved prior to post-procedure discharge of the patient. Pain reduction occurs primarily within the first 3 months and is sustained at 12 months; however, the long-term outcomes have not previously been studied. Objectives: We aim to evaluate the long-term efficacy of sacroplasty versus non-surgical management (NSM) in treating sacral insufficiency fractures (SIFs), including the effect on pain relief, opioid and other analgesic use, patient satisfaction, and complication rates. Additionally, we aim to review the most current sacroplasty literature. Study Design: A 10-year prospective, observational cohort study of patients with SIFs treated with sacral augmentation. Setting: A single-center interventional pain management private practice. Methods: Two-hundred and forty-four patients with SIFs were treated with sacroplasty (210 patients) or NSM (34 patients) beginning in January 2004 and then followed for 10 years. The patients’ gender, age, pre-procedure pain duration, analgesic use, pain level, and satisfaction were recorded at baseline and at post-procedure follow-up intervals of 2, 4, 12, 24, 52 weeks, and 2 years. The experimental group was then contacted at 10 years. Post-procedure complications before discharge and at each follow-up were also evaluated. Results: Both NSM and sacroplasty resulted in statistically significant drops in visual analog scale (VAS) scores from pre-treatment to 2-year follow-up (P &lt; 0.001). When measured from followup to follow-up, the NSM group’s only significant decrease in the mean VAS score was between pre-treatment and 2 weeks (P = 0.002). The experimental group had significant decreases over the periods pre-op through post-op (P &lt; 0.001), post-op through 2 weeks (P &lt; 0.001), 12 weeks through 24 weeks (P = 0.014), and 24 weeks through one year (P = 0.002). The experimental cohort experienced statistically significant drops in the mean VAS scores between follow-ups for a longer period of time. Opioid and non-opioid analgesic use was markedly decreased preoperatively to postoperatively and was sustained at the 10-year follow-up. Limitations: Patients were placed into the control group, NSM, if they did not meet inclusion criteria for sacroplasty. However, the baseline characteristics of the sacroplasty versus NSM group were not statistically different. Additionally, the control group was only followed through 2 years and was not contacted at the 10-year follow-up. Conclusions: Our results and those reported in previous studies establish that sacroplasty allows for decreased use of medications and results in pain relief, greater patient mobility, and improved patient satisfaction. In addition to the published body of literature, our results show strong evidence in support of sacroplasty as a safe and efficacious treatment of SIFs. Key words: Sacroplasty, sacral fracture, fracture, osteoporosis, insufficiency, radiology

Efficacy of homeopathic reduction with minimally invasive adjustable plate for treatment of sacral fractures

Objective To investigate the clinical effect of homeopathic reduction with minimally invasive adjustable plate in treatment of sacral fractures. Methods A retrospective case-control study was conducted to assess the data of 89 patients with sacral fractures treated from January 2013 to January 2015. There were 49 males and 40 females, with a mean age of 37.8 years (range, 18-70 years). Denis classification was type Ⅰ in 24 patients, type Ⅱ in 48, and type Ⅲ in 17. Patients were divided into three groups according to fixation methods: homeopathic reduction with minimally invasive adjustable plate group (Group A, n=30), sacroiliac screw group (Group B, n=31) and iliolumbar rod group (Group C, n=28). Operation time, blood loss, intraoperative radiographic time, and complications were recorded. Reduction quality was assessed using the Matta criteria. Bone healing was evaluated based on X-ray appearance. Functional outcome was evaluated using the Majeed score at last follow-up. Results Operation time was significantly lower in Group A [(109.3±14.4)min] and Group B [(114.2±17.7)min] than Group C [(126.8±15.7)min](P 0.05). Blood loss was significantly lower in Group A [(433.3±121.3)ml] and Group B [(461.3±130.8)ml] than Group C [(785.7±205.0)ml](P 0.05). Radiographic time was (5.6±1.9)s in Group A, (13.4±3.1)s in Group B, and (8.4±2.5)s in Group C, showing significant difference among the three groups (P 0.05). Fracture healing was found in all patients and no nonunion was observed. Excellent rate of Majeed score in Group A [80%(24/30)] and Group C [82%(23/28)] was higher than that in Group B [54%(17/31)], but the there was no significant difference between Groups A and C (P>0.05). Complication rate in Group B [29%(9/31)] and Group C [29%(8/28)] were higher than that in Group C [3%(1/30)], but the there was no significant difference between Groups B and C (P>0.05). Conclusion For sacral fractures, homeopathic reduction with minimally invasive adjustable plate can reduce operation time and intraoperative radiographic time, improve reduction rate and lower incidence of complications. Key words: Sacrum; Fracture fixation, internal; Traction

Current classification and treatment of sacral fractures

Sacral fractures are usually caused by high-energy violence, often complicated with injury to the lumbosacral plexus. In severe cases, they may cause instability of the posterior pelvic ring or of the lumbosacral junction. Their classifications commonly used in clinic are Denis, Tile, Isler and refined Denis type Ⅲ ones proposed by Roy-Camille and Gibbons. Recently, classifications of the lumbosacral lesions and scoring systems of the injury severity have often been used clinically. At present, internal instrumentation of sacral fractures is developing along the direction of high efficiency, safety and minimal invasion, but different methods of internal fixation have their own indications which should be strictly followed. This review summarizes the classifications of sacral fractures and their treatment advances. Key words: Sacrum; Fractures, bone; Classification; Therapy

Countermeasures for problems in the treatment of unstable sacral fractures

Countermeasures for problems in the treatment of unstable sacral fractures

Lumbar-sacurm-iliac screws fixtion on the treatment of complicated sacral fractures

Objective To investigate the clinical efficacy of lumbar-sacurm-iliac screws fixation in the treatment of complicated sacral fractures. Methods From January 2012 to October 2012, 18 complicated sacrum fracture patients with unstable pelvic fractures and cauda equina dysfunctionwere retrospectively studied, which Gibbons score were all 4 points. Surgical treatment was performed by posterior lumbar-sacurm-iliac screw fixation combined with sacral decompression. The fixation stage can be extended to L4, S2 level by fracture. According to the patient's nerve injury and fracture displacement surgery sacral decompression and observation of nerve root injury. After full decompression, correct the vertical displacement and rotate the displacement, and then place the cross further fixed. The first 3 months after surgery, the patient reviewed once a month, 3 months after the patient review once every six months. Results 18 patients underwent surgery for 2-21 d after injury, with an average of 10.2 d. The operation time is 150-240 min, an average of 180 min. Intraoperative blood loss of 600-2 000ml, an average of 1 100ml. The time of follow-up was 13-34 months, with an average of 23.4 months. Gibbons score averaged 4 points from preoperative to 2.78 points, the difference was statistically significant. Preoperative patients with an average angle of 42.89, postoperative 21.94, the difference was statistically significant. Postoperative Majeed scores averaged 64.5 points. Excellent in 3 cases, good in 3 cases, can be 7 cases, poor in 5 cases, excellent rate was 33.33%. Preoperative visual analogue scale (VAS) score averaged from 8.78 points before surgery to 2.22 points, this difference was statistically significant. The results of Tometta and Matto method were excellent in 5 cases, 3 cases were good, 7 cases were available, 5 cases were poor, excellent and good rate was 44.44%. Conclusion Lumbar-sacurm-iliac screw fixation in the treatment of complex sacral fractures can achieve a good reduction of fracture and attain satisfied nerve decompression, and more conducive to patients faster and better recovery. Key words: Sacrum; Fracture fixation, internal; Treatment outcome

Ilio-Sacral (IS) Screw Fixation for Sacral and Sacroiliac Joint (SIJ) Injuries in Children.

Treatment of sacral fractures and sacroiliac joint (SIJ) disruption with percutaneous ilio-sacral (IS) screw fixation had become a more popular treatment option. There has been no study that specifically assessed IS fixation in children. The purpose of this study is present our results with fixation of the sacral fractures and SIJ disruption using IS screw in children 18 years old and younger. This is a retrospective review chart for children with sacral fracture or SIJ disruption who were treated by IS fixation in the period from 2000 to 2012. The patients were assessed for the following (age, sex, type of injury, associated injuries, surgery, complications, postoperative return of function, healing of the injury, and return to function). In the studied period (2000 to 2012), 11 patients who had either sacral fracture (4 patients) or SIJ (7 patients) disruption were treated by IS screws. The average age of these patients was 14 years (range, 6 to 17 y). Six patients had 1 screw and 5 patients had 2 screws. Eight patients had their entire fixation in S1, and 3 patients had 1 screw in S1 and 1 screw in S2. All screws were cannulated and were inserted over a guidewire with fluoroscopy and/or navigation guidance. Five patients had added anterior fixation of the pelvis. One patient was lost for follow-up. All patients (except 1) achieved healing of their injuries with no displacement or implant failure with return of function. One patient had failure of fixation and needed revision. One patient had neurological complication related to screw insertion. IS screws can be safely used to treat sacral fractures and SIJ injuries in children. This was feasible in children as young as 6 years old. The complications of the procedure were minimal with good stability obtained by IS screws.

Digital anatomic study of computer simulated sacral pedicle screw placement for treatment of sacral fracture

Objective To investigate the digitized anatomical structure and application of computer simulated sacral pedicle screw placement for treatment of sacral fracture. Methods Three-dimensional reconstruction from CT data of the 61 adult human pelvises was conducted using the Mimics software. Safe zones for S1-4 pedicle screw placement were defined, imbedding of sacral screw was simulated, and screw entry point, length, diameter and direction were measured. Results Screws entry site of S1 was located on the lateral border of S1 superior articular process basilar part. Screw entry sites of S2-4 was located on the upward of the midpoint of ligature between sacral plate upper and lower foramina sacralia posteriora lateral border, and the screw entry site moved outside gradually from the top to the bottom along with larger camber and smaller diameter and length of the pedicle screws. Significant differences between the female and male patients were noted in the distance between screw entry site of S2 and S3 sacral hole superior border tangent (L2), the vertical dimension between screw entry site of S2 and center of the sacral crest (L3), the largest diameter of S3 screw (P 0.05). Conclusion Anatomical measurements of sacral pedicle including the screw entry point, length, diameter, and direction by the Mimics software might be a reference for clinical treatment of sacral fracture. Key words: Sacrum; Bone nails; Computer simulation; Anatomy

Biomechanical comparison of lengthened and conventional sacroiliac screws in treatment of unilateral sacral fracture

Objective To compare the mechanical characteristics of lengthened and conventional sacroiliac screws for fixation of unilateral vertical sacral fracture so as to provide evidences for clinic practice.Methods A three-dimensional finite element model of Tile type C pelvic injury (unilateral vertical fracture of the sacrum) was developed.Six different methods for internal fixation with lengthened and conventional sacroiliac screws were performed.Stability of posterior pelvic ring during stance phase and maximum stress on the screws after different fixation methods were measured and compared.Results Mobilization with one lengthened sacroiliac screw at S1 or S2 single-segment provided better biomechanical properties than with one conventional sacroiliac screw at the same segment.Better biomechanical properties were also observed in the bisegmental stabilization with each one lengthened sacroiliac screw compared to bisegmental stabilization with each one conventional sacroiliac screw; in the bisegmental lengthened sacroiliac screw fixation compared to single-segmental lengthened sacroiliac screw fixation; in the bisegmental stabilization with two conventional sacroiliac screws compared to single-segmental stabilization with one conventional sacroiliac screw.No matter which kind of sacroiliac screw was applied,S2 segment stabilization had better biomechanical properties over S1 segment stabilization.Conclusions For unilateral vertical sacral fracture due to Tile type C pelvic ring injury,S1 or S2 lengthened sacroiliac screws should be selected as possible,the best with combination of lengthened sacroiliac screw and conventional sacroiliac screw.Even if lengthened sacroiliac screws cannot be used due to limited conditions,bisegrnental fixation with conventional sacroiliac screws should be considered whenever possible.No matter which kind of sacroiliac screw is applied in single segment fixation,the fixation of S2 segment is the preferred choice. Key words: Sacrum ; Fractures fixation, internal; Biomechanics ; Finite element analysis

Treatment of sacral fracture by spinal system

Treatment of sacral fracture by spinal system

Treatment of Sacral Fractures with Neurologic Injuries

Sacral fractures occur in two distinctly different patient populations: in individuals with healthy bone as a result of high-energy injury mechanism and in patients with morbid osteopenia that results in insufficiency fractures. Both patient groups share the relatively high propensity for delayed diagnosis of the sacral fracture. In the trauma group, this is due to overriding concerns for care of the multiply injured; in the insufficiency group, it is due to difficulty in interpreting bony landmarks. Both groups share the risk of incurring neurologic deficits and are at significant risk for posttraumatic deformity if sacral fractures are missed or underestimated in the treatment paradigm. Clear diagnostic pathways consisting of systematic physical examination and imaging modalities as well as electrodiagnostics enable the clinician to correctly identify the injury at hand and classify it according to useful systems. Nonoperative care can be successful for patients with minimally displaced fractures and predominately intact lumbosacral ligamentous structures in the presence of little or no neurologic deficits. Most patients with neurologic deficits and sacral disruption will benefit from a timely surgical intervention within the first 2 weeks from injury but rarely on an emergent basis. Surgical stabilization techniques after decompression of neurologic elements where indicated has evolved dramatically from highly morbid procedures with largely improvisational instrumentation techniques to either percutaneous stabilization techniques or devices that allow for comprehensive stabilization of the lumbosacral region as a whole.

The Classification and Treatment of Sacral Fractures

The Classification and Treatment of Sacral Fractures