Unstable Sacral Fractures Research Articles

Surgical management strategies for unstable sacral fractures: Case series and surgical guideline

IntroductionUnstable sacral fractures usually have posterior pelvic and spinopelvic instability, which usually be classified as AO type C. There are many controversial points concerning the management of these fractures due to their rarity. Herein, we retrospectively review cases of this injury and propose a surgical guideline. Case presentationA 37-year-old female experienced back pain after a motor vehicle accident. Diagnostic imaging revealed an AO type C1 sacral fracture, Isler subtype 2a (case No. 7). Preoperative CT scan and CT reconstruction images showed a longitudinal fracture with a simple intraarticular fracture of the left S1 superior facet. Although the patient sustains a lumbosacral facet joint injury, the lumbosacral motion seems preservable after healing. The triangular osteosynthesis was chosen because it provides both transverse plane and vertical plane stability. The patient was allowed to continue weight-bearing ambulation after the operation. To maintain lumbosacral motion, the spinopelvic rod was removed in the postoperative seventh month. DiscussionThe unstable sacral fracture might have instability in both the vertical and transverse planes. The fixation construct should provide both vertical and transverse stability. Regarding vertical fixation, it might cost a loss of lumbosacral motion, which the treating surgeon has to consider. The lumbosacral injury is sometimes trivial, and long-term lumbosacral motion is expectable. So, permanent spinopelvic fixation is not necessary. The patient's character is also an important factor. Whether the patient needs or does not need early progressive weight bearing after the operation determines the fixation method. ConclusionUnstable sacral fractures are rare conditions usually resulting from a high-energy injury. We have proposed a surgical management strategy for this group of fractures with an optimal fixation method based on three factors: 1) fracture morphology, 2) lumbosacral integrity, and 3) concomitant injury.

Lumbopelvic Stabilization with Two Methods of Triangular Osteosynthesis: A Biomechanical Study.

(1) Background: Pelvic fractures, and particularly instabilities of the dorsal pelvic ring, are becoming increasingly prevalent, particularly in orthogeriatric patients. Spino-pelvic triangular osteosynthesis is an effective approach to achieve sufficient stabilization in vertically unstable fractures. This study compares two types of osteosynthesis: the conventional one and a novel instrumentation where the iliosacral screw is placed through a fenestrated iliac screw. (2) Methods: Sixteen artificial osteoporotic L5+pelvis models with an unstable sacral fracture have been instrumented with either an iliac screw connected with a rod to a L5 pedicle screw and an iliosacral screw (TF) or a fenestrated ilium screw connected with a rod to a L5 pedicle screw and an iliosacral screw passing through the fenestra of the iliac screw (TFS). Biomechanical testing was performed using cyclic loading until failure. (3) Results: Both configurations yielded comparable results with regard to initial stiffness, implant loosening, and cycles to failure. The TFS exhibited markedly higher values for cycles to failure and markedly lower values for loosening. However, due to the characteristics of the artificial bone model, these findings were not significant. (4) Conclusions: The novel triangular fixation systems demonstrated comparable results to the standard triangular osteosynthesis configuration.

Functional outcome and analysis of factors affecting health-related quality of life of surgically managed pelvic ring fractures: a cross-sectional study.

Pelvic ring fractures, particularly those involving the posterior pelvis, pose significant challenges due to their inherent instability. The posterior pelvic ring is critical in providing structural support and stability to the pelvis. This study evaluates the functional outcomes and health-related Quality of life (HRQOL) of patients who underwent internal fixation for unstable pelvic fractures. Various factors influencing the outcomes are also investigated. A single-center cross-sectional study was conducted on patients with unstable sacral fractures treated with posterior tension band plate or sacroiliac plating with or without symphyseal plating between 2016 and 2020. Patient demographics, injury mechanisms, associated injuries, surgical details, complications, and return-to-work data were collected. HRQOL was assessed using specific pelvic fracture instruments and general HRQOL questionnaires. Logistic regression analysis was performed to identify factors associated with lower SF-12 and SF-36 scores RESULTS: The study included 54 patients, predominantly males (55.6%), aged 18-70 years, with high-energy trauma mechanisms, such as road traffic accidents and occupational injuries. The majority of patients had lateral compression pelvic fractures. Overall, the functional outcomes were favorable, with excellent or good outcomes observed in 86.1% of cases. Patients with associated injuries, such as abdominal, chest, or head injuries, were likelier to have lower SF-12 physical component scores. Sexual satisfaction scores remained stable for most patients post-surgery. This study highlights the favorable functional outcomes and HRQOL for patients undergoing fixation for unstable pelvic ring fractures. Younger, working-age males were the most commonly affected demographic. Associated injuries significantly affected physical HRQOL scores. Despite high-energy trauma, patients generally reported satisfactory sexual function post-surgery.

Triangular osteosynthesis and lumbopelvic fixation as a valid surgical treatment in posterior pelvic ring lesions: a systematic review.

Unstable fractures of the sacrum often occur in patients with pelvic fractures and represent a real challenge for the orthopedic surgeon. Triangular osteosynthesis (TOS) and lumbopelvic fixation (LP) may represent a valid management option for the treatment of this condition. We present a systematic literature review about lumbopelvic fixation and triangular fixation as treatment option for unstable sacral fractures, to assess clinical and radiological outcomes after surgery and to evaluate appropriate indications and impact on the natural history of sacral fractures. The review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 50 articles out of 108 titles, were considered eligible for the full-text analysis. Finally, 16 studies that met inclusion criteria were included in this review. Overall, 212 patients (87 males, 58 females) with sacral fractures treated with TOS triangular fixation or LP lumbopelvic fixation were collected. The mean age was 37.6 years. Mean follow-up reported in all studies was 24.14 months. The results presented by the different authors, highlight the effectiveness of TOS triangular fixation and LP lumbopelvic fixation for the treatment of unstable sacral fractures associated with other pelvic fractures, in terms of function, stability, cost-effectiveness, and quality of life postoperatively.

Percutaneous Ilioilial Fixator Versus Percutaneous Iliosacral Screw in Managing Unstable Sacral Fractures: A Prospective Randomised Controlled Study.

Unstable sacral fractures with pelvic fractures are challenging to both surgeons and patients, particularly in the immediate post-injury phase and later when definitive fixation is undertaken. Percutaneous iliosacral screw fixation is widely regarded as the gold standard treatment for unstable sacral fractures without spinopelvic dissociation. Closed reduction and percutaneous fixation using iliosacral screws for sacral fractures provide early stabilisation without the need for extensive surgical exposure, thereby mitigating major complications associated with open surgical procedures. A new technique for stabilising unstable sacral fractures is the minimally invasive ilioilial fixator, also called a transiliac internal fixator (TIIF), which has gained more attention for its ability to address challenges associated with sacroiliac screw fixation. The objective of this study is to compare the functional, radiological, and surgical outcomes between the percutaneous iliosacral screw and the ilioilial fixator. A total of 51 patients with sacral fracture injuries sustained between August 2019 and November 2021 were included in this study, with 25 patients in Group A and 26 patients in Group B. Patient randomization was done using computer-generated randomization facilitated by Random Allocation Software (Mahmood Saghaei, Isfahan, Iran). All patients underwent the chosen intervention within 10 days of the trauma. Patients had follow-up at two weeks, six weeks, and 12 months post-treatment. The results of fixation were evaluated radiologically based on the Matta and Tornetta grading system and clinically using the Majeed pelvic scoring system. Complications were detected in both groups during follow-up visits. The study found no statistically significant differences between the two patient groups in terms of final clinical assessment (p=0.79), radiological assessment (p=0.78), or the need for another operation (p=1.0). Moreover, there were no statistically significant differences between the groups with respect to complication rates (p=0.63) or the time of union (p=0.14). No differences were noted in terms of intraoperative blood loss (p=0.93) or operative time (p=0.34) but for longer incision length in the ilioilial fixator group (p<0.001) and an increased risk of intraoperative radiation exposure in the iliosacral screw group (p<00.1). Although the iliosacral screw is considered a gold standard for unstable sacral fracture, a TIIF is a good alternative with a very satisfactory outcome. Although the iliosacral screw still remains the gold standard for the management of sacral fractures, the ilioilial fixator emerges as a good alternative with comparable functional and radiological outcomes.

SURGICAL MANAGEMENT OF UNSTABLE SACRAL FRACTURES

Sacral fractures are often underdiagnosed, but are frequent in the setting of pelvic ring injuries. They are mostly caused by high velocity injuries or they can be pathological in aetiology. We sought to assess the clinical outcomes of the surgically treated unstable sacral fractures, with or without neurological deficits. unstable sacral fractures were included in the study.Single centre, prospectively collected data, retrospective review of patients who sustained vertically unstable fractures of the sacrum who underwent surgical fixation. out of a total of 432 patients with pelvis and acetabulum injuries. fifty six patients met the inclusion criteria. 18 patients had sustained zone one injuries. 14 patients had zone 2 injuries and 10 patients had zone 3 injurie. Operative fixation was performed percutaneously using cannulated screws in 18 patients.. Open fixation of the sacrum using the anterior approach in 6 patients. Posterior approach was indicates in all 10 of the zone 3 injuries of the sacrum. While in 4 patients, combined approaches were used. 3 patients had decompression and spinopelvic fixation.Neurological deficits were present in 16% of the patients. 2 patients presented with neurgenic bladder. Of the 4 patients who had neurological fall out, 3 resolved with posterior decompression and posterior fixation. All 4 neurological deficits were due to taction or compression of the nerve roots. No hardware failures or non unions observed.The rate of neurological deficit was related more to the degree of pelvic ring instability than to a particular fracture pattern. Low rates of complications and successful surgical treatment of sacral fractures is achiavable. Timeous accurate diagnosis mandatory

Treatment of Unstable Sacral Fractures with Robotically-aided Minimally Invasive Triangular Fixation.

The treatment of unstable sacral fractures is huge challenge to surgeons. Robotically-aided minimally invasive triangular fixation (RoboTFX) is the most advanced technique up to now. This study is to evaluate the clinical outcomes of unstable sacral fractures treated with RoboTFX. From March 2017 to October 2021, 48 consecutive patients with unstable sacral fractures were included in the study. All patients received surgical treatment with triangular fixation (TFX). Patients were divided into four groups according to the number of fractures (uni- or bilateral) and surgical method employed (RoboTFX or traditional open TFX). Between these four groups, clinical data on operation time, intraoperative bleeding, intraoperative fluoroscopy time, infection rate, fracture healing rates, insertion accuracy, Majeed pelvic outcome score, Mears' criterion, and Gibbons score were compared. Quantitative data were expressed as mean ± standard deviation and compared using Student's t-test. Categorical variable were compared using the Pearson's χ2 test. Comparing unilateral RoboTFX versus open TFX, neither fracture healing rate, infection rate, Majeed pelvic outcome score, Mears' radiological evaluation criterion, nor Gibbons score of the two groups were statistically significantly different (p > 0.05). However, operation time, intraoperative bleeding, intraoperative fluoroscopy time, and insertion accuracy in the RoboTFX group were all significantly better than those of the traditional open group (p < 0.05). Likewise, operation time, intraoperative bleeding, intraoperative fluoroscopy time, and accuracy of fixation insertion of the bilateral RoboTFX group were significantly better than those of the bilateral open group (p < 0.05). Meanwhile infection rate, fracture healing rate, Majeed score, Mears' criterion, and Gibbons score of two groups were not significantly different (p > 0.05). RoboTFX has the advantages of less operation time, less intraoperative bleeding and fluoroscopy, more accurate fixation insertion, and a higher healing rate compared to traditional open methods in the treatment of unstable sacral fractures. However, RoboTFX requires a few critical considerations, and the indications of its operation should be strictly evaluated.

Comparative study between open lumbopelvic fixation and percutaneous iliosacral fixation for management of sacral fractures

BackgroundThe main aim of surgical intervention for unstable sacral fractures is to obtain a solid construct across the lumbopelvic junction to allow for early mobilization. Both iliosacral screw fixation (ISF) and lumbopelvic fixation (LPF) are widely used surgical techniques used for treatment of unstable sacral fractures. Nevertheless, it is unclear whether one technique provides more favorable postoperative outcomes than the other.ObjectiveTo compare the three-year outcome of ISF versus LPF in patients with unstable sacral fractures as regard effectiveness and safety of both techniques.MethodsThe study included 54 patients with sacral fractures who underwent sacral fusion using either ISF or LPF at a single institution. Patients were followed up for at least 3 years. Operative and postoperative data were collected and statistically calculated.ResultsThirty patients were included in the ISF group and 24 patients in the LPF group. The operative time was notably higher in the LPF group (mean 107 min compared to 33 min in the ISF group; p = 0.002). Blood loss was also higher in the LPF group (mean 320 ml compared to 96 ml in the ISF; p = 0.004). Assessment of pelvic fusion was done via Majeed and Matta scores (pelvic fusion outcome scores). The ISF and LPF groups had a comparable Majeed score at the end of the third year of follow-up (excellent rate = 53.3% vs. 58.3%, respectively; p = 0.93). Likewise, ISF and LPF groups had comparable Matta score at the end of the third year of follow-up (excellent rate = 66.7% vs. 70.8%, respectively; p = 0.27). The most commonly reported postoperative complications in the ISF group were screw malposition in 2 cases out of 30 cases (6.6%) and non-union in 2 cases out of 30 cases (6.6%). On the other hand, the most commonly reported postoperative complications in the LPF group were implant prominence in 3 cases out of 24 cases (12.5%) and infection in 2 cases out of 24 cases (8.3%).ConclusionLPF and ISF have comparable safety and efficacy in patients with sacral fractures. ISF is an excellent and safe method of fixation, especially in old age to avoid open surgery-related complications. LPF is preferred in young active patients to benefit from rapid weight bearing after surgery and in cases with ambiguous sacral anatomy as sacral dysmorphism.

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.

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.

Comparative retrospective study of triangular osteosynthesis with and without robotic assistance for unilateral unstable sacral fractures combined with lumbosacral junction injuries

BackgroundTo compare the clinical efficacy of unilateral unstable sacral fractures (USFs) involving the lumbosacral region treated with and without robot-aided triangular osteosynthesis (TOS).MethodsPatients of the unilateral USF combined with the ipsilateral lumbosacral junction injury (LSJI) treated with TOS were retrospectively analyzed and divided into two groups: the robot group (TOS with robotic assistance) and the conventional group (TOS with open procedure). Screw placement was assessed using the modified Gras criterion. Patients were followed up with routine visits for clinical and radiographic examinations. At the final follow-up, clinical outcomes were recorded and scored using the Majeed scoring system.ResultsEleven patients in the robot group and seventeen patients in the conventional group were recruited into this study. Significant differences in surgical bleeding (P < 0.001) and fluoroscopy time (P = 0.002) were noted between the two groups. Operation time (P = 0.027) and fracture healing time (P = 0.041) was shorter in the robot group. There was no difference in postoperative residual displacement between the two groups (P = 0.971). According to the modified Gras criterion, the percentages of grade I for sacroiliac screws in the two groups were 90.9% (10/11) and 70.6% (12/17), and for pedicle screws were 100% (11/11) and 100% (17/17), respectively. The rate of incision-related complications was 0% (0/11) in the robot group and 11.8% (2/17) in the conventional group. Statistical differences were shown on the Majeed criterion (P = 0.039), with higher scores in the robot group.ConclusionTOS with robotic assistance for the treatment of unilateral USFs combined with ipsilateral LSJIs is safe and feasible, with the advantages of less radiation exposure and fewer incision-related complications.

Comparison of Three-Dimensional Navigation-Guided Percutaneous Iliosacral Screw and Minimally Invasive Percutaneous Plate for the Treatment of Zone II Unstable Sacral Fractures.

The percutaneous IS screws and the minimally invasive percutaneous plate are the most popular internal methods for Zone II unstable sacral fractures. However, the choice of fixation remains controversial for orthopaedic surgeons. The purpose of study was to evaluate and compare the clinical results of percutaneous iliosacral (IS) screw fixation under three-dimensional (3D) navigation and minimally invasive percutaneous plate fixation in the treatment of Zone II unstable sacral fractures. A retrospective study was performed, including 64 patients with Zone II unstable sacral fractures who underwent percutaneous IS screw fixation under 3D navigation (navigation group) and minimally invasive percutaneous plate fixation (plate group) from January 2011 and March 2021 in our department. The age, gender, fracture type, mechanism of injury, injury severity score (ISS), time from admission to operation, operative time, intraoperative blood loss, hospital stay, incision length, follow-up time, time to clinical healing, and complications were recorded and analyzed. Matta standard was used to assess fracture reduction outcomes. The Majeed function system assessed functional outcomes at the last follow-up. The average follow-up time was (14.42 ± 1.57) months in the navigation group and (14.79 ± 1.37) months in the plate group. No statistical difference between the two groups in age, gender, fracture type, mechanism of injury, ISS, time from admission to operation, and time to clinical healing. However, significant differences were detected in operative time, intraoperative blood loss, hospital stay, and incision length (p < 0.001). According to Matta standard at 2 days postoperatively, the excellent and good rate was 91.42% in the navigation group, and it was 93.10% in the plate group. There was no significant difference between the two groups (p=0.961). According to Majeed function system at the follow-up, the excellent and good rate was 97.14% in the navigation group, and 93.10% in the plate group. The difference between the two groups was not statistically significant (p=0.748). There were no neurovascular injuries associated with this procedure. The incidence of complications was 44.82% (13/29) in the plate group, while 14.28% (5/35) in the navigation group (p=0.007). This study found that compared with minimally invasive percutaneous plate fixation, percutaneous IS screw fixation under 3D navigation is a suitable option for the treatment of Zone II unstable sacral fractures. This approach is characterized by its shorter operation time, less surgical trauma, less bleeding, less hospital time, and fewer complications.

Substantation of the method of lumbo-pelvic fixation in verically unstable fractures of the sacrum

Background. According to the literature and our own observations, there is an increase in the number of victims of young, ablebodied age with severe injuries to the pelvic structures. Despite numerous developments and studies in this area, high mortality and a high percentage of unsatisfactory treatment results remain. The publication reflects the advantages of using bilateral lumbopelvic fixation in the treatment of injuries to the cross. Load calculation, biomechanical modeling of damages and displacing factors are presented. Bilateral lumbopelvic fixation has proven to be a reliable method capable of providing reliable fixation of the fracture at all stages of treatment. Aim. To substantiate and test modified lumbopelvic stabilization of the pelvic ring in patients with vertically unstable (C1-2-3 according to Tile M.) sacral fractures. Material and methods. Based on the treatment of 20 patients with severe sacral fractures, it was proved that the best result was achieved with bilateral lumbopelvic stabilization. The use of the author's version (RF Patent No. 2684870 "Method of fixation in unilateral unstable sacral fractures") of osteosynthesis is presented on the example of the treatment of multiple pelvic trauma, a good clinical result was obtained, and neurological symptoms were stopped. Results. Lumbar-iliac osteosynthesis for vertically unstable sacral fractures is the optimal method of fixation. The distribution vector of the levers of the latch corresponds to the biasing force, which ensures maximum reliability of the synthesis. The method, if necessary, creates conditions for decompression of the roots, prevents the early development of arthrosis of the sacroiliac joints. Using it allows you to maintain or correct the sagittal and frontal balance of the spine. The use of bilateral 8-screw lumboiliac fixation with the installation of a transverse tie is recommended, since unilateral fixation or a decrease in the number of fixing elements can lead to loosening of the fixator. Conclusion. Based on biomechanical modeling and the results of treatment of patients with severe injuries of the posterior pelvic ring, the effectiveness of the proposed method of lumbopelvic fixation was proven.

Distal sacral nerve roots severed by a fragility fracture of the sacrum: a case report

BackgroundOwing to the aging population, fragility fractures of the pelvis are occurring more frequently. Fixation of the fracture and stabilization of the pelvic ring usually provide good clinical results. A case of distal sacral nerve roots severed by a fragility fracture of the sacrum is presented.Case presentationA 62-year-old Japanese woman with schizophrenia with low back pain, gait disorder, dysuria, and fecal incontinence presented to an emergency department, and plain X-rays showed no findings. She also complained of dysuria, and neurogenic bladder and cystitis were diagnosed. One month later, she was admitted to a psychiatric hospital for exacerbation of schizophrenia. In hospital, she had a urethral catheter inserted and spent 3 months in bed. She was referred to our orthopedic department because a gait disorder was discovered after her mental condition improved and she was permitted to walk. On examination, she could not walk and had decreased sensation from the buttocks to both posterior thighs and around the anus and perineum. Manual muscle testing of her lower limbs showed mild weakness of about 4 in bilateral flexor hallucis longus and gastrocnemius, and bilateral Achilles tendon reflexes were lost. Her anal sphincter did not contract, and urinary retention continued after urethral catheter removal. Imaging examinations showed an H-shaped sacral fracture consisting of a transverse fracture with displacement of the third sacral vertebra and vertical fractures of the bilateral sacral wings, with severe stenosis of the spinal canal at the site of the transverse fracture. The patient was diagnosed as having bladder and rectal dysfunction due to a displaced, unstable sacral fracture. First to third sacral laminectomy and alar–iliac fixation using percutaneous pedicle screws and sacral alar–iliac screws were then performed. The bilateral distal sacral nerve roots (S3, S4, S5) were completely severed at the second to third sacral levels, but bilateral second sacral nerve roots were not compressed from the bifurcation to the sacral foramen. Postoperatively, bladder and rectal dysfunction remained, but the low back pain was alleviated. Two weeks postoperatively, she could walk with a walker and was discharged. Three months after the operation, bone fusion of the fracture was observed.ConclusionsIn cases of bladder–rectal dysfunction with low back pain, the possibility of sacral fracture should be considered, and computed tomography, magnetic resonance imaging, and X-ray examinations should be performed. Even sacral fractures without displacement require attention because they can cause serious injury in the event of a nerve root being severed if not diagnosed early and given appropriate treatment.

Lumbopelvic Fixation with Bridged Distal Iliac Screws for Vertically Unstable Sacral Fractures.

The purpose of this study is to evaluate preliminary outcomes of vertically unstable sacral fractures treated by lumbopelvic fixation (LPF) augmented transiliac bridged screws. From April 2017 to December 2019, fifteen consecutive patients with vertically unstable sacral fractures who had undergone LPF augmented transiliac bridged screws were enrolled. The radiological assessment included standard lumbopelvic x-rays and pelvic computed tomography (CT) to evaluate the lumbosacral angle (LSA), sacral kyphosis angle (SKA), lumbar lordosis angles (LLA) and Matta's reduction criterias (MRC). Clinical and neurologic impairment outcomes were evaluated by the Majeed grading scale (MGS) and Gibbons criterias, respectively. All patients were followed for an average of 18months (range, 14-25). All sacral fractures eventually healed and implant failure did not occur in any patient, though there were two patients with a loss of reduction (< 5mm) during the follow-up period. According to the MRC, the results were excellent on 14 sides, good on five sides, and fair on one side. The MGS mean score was 82 points (range, 49-98 points); the results were excellent in nine cases, good in four cases, and fair in two cases. There was no statistically significant difference in SKA and LLA in preoperative and postoperative final controls. The preoperative and postoperative LSA were 72 ± 13.9 and 44.1 ± 11.3, respectively, and a statistically significant improvement was observed (p = 0.01). In vertically unstable sacrum fractures, we believe that LPF augmented with transiliac bridging technique may expedite the reduction of vertical sacrum fracture and offers a reinforced fixation choice.

Posterior INFIX for Treating Unilateral Unstable Sacral Fractures.

ObjectiveTo evaluate the clinical outcomes of the treatment of unilateral unstable sacral fractures by fixation with the posterior INFIX (posterior pelvic ring screw‐rod internal fxation).MethodsData of 60 patients with unilateral unstable sacral fractures who underwent surgery from March 2013 to March 2020 were retrospectively analyzed according to the selection criteria. All patients were associated with anterior pelvic ring injuries, and the operations were performed by the same team of surgeons. According to the different types of internal fixation, the patients were divided into two groups, which both included 30 patients: the posterior INFIX group and iliosacral screw fixation group. The demographic and clinical data of the two patient groups, such as age, sex, sacral fracture types based on the Denis classification, operation time, amount of intraoperative bleeding, intraoperative fluoros copy time, Majeed pelvic score at final follow‐up, and quality of fracture reduction based on Mears and Velyvis's imaging classification criteria were collected by the same researcher and compared statistically.ResultsAll patients were continuously followed up for 23.17 ± 3.34 months (range, 12 to 46 months). All sacral fractures healed with an average healing time of 9.3 ± 2.24 months (range, 6 to 18 months). None of the patients had re‐displacement of the fracture or fixation failure. Compared to the iliosacral screw group, the posterior INFIX group patients had more intraoperative bleeding (t = 3.59, P < 0.001), shorter operation time (t = 4.49, P < 0.001), and shorter intraoperative fluoroscopy time (t = 6.26, P < 0.001). There were no statistical differences between the two groups in terms of age, sex, fracture type, Majeed score, and quality of fracture reduction (P > 0.05). In the posterior INFIX group, one patient had a superficial wound infection and one patient complained of discomfort due to a prominent fixation. In the iliosacral screw fixation group, one patient had intraoperative iatrogenic S1 nerve injury and vessel injury. The posterior INFIX fixation was a simpler manipulation with higher safety, shorter time of operation and intraoperative fluoroscopy, and similar clinical outcomes compared to iliosacral screw fixation.ConclusionFor the treatment of unilateral unstable sacral fractures, the posterior INFIX fixation can be recommended in clinic application.

Does surgical treatment for unstable fragility fracture of the pelvis promote early mobilization and improve survival rate and postoperative clinical function?

This retrospective multicenter study aimed to compare rates of early mobilization and survival and functional outcome of surgical treatment (S) with that of conservative treatment (C) according to each unstable fragility fracture of the pelvis (FFP) classification type with displacement of the posterior component ≥ 5mm. We analyzed 64 patients with unstable type III and IV FFP who could move and transfer themselves before injury and had ≥ 5mm displacement of the posterior component. We compared survival rate, early mobilization, walking ability at final follow-up, and complications at admission for each type of surgical and conservative treatment. Most of the unstable FFP were type IIIa and IVb in the study population. Type III comprised 40 cases (group S:13/group C:27) and type IV comprised 24 cases (group S:7/group C:17). There were no significant differences in 3month and 1year survival rates, although group C (III) had the tendency of higher mortality rate (p = 0.08). Mobilization (transferring to a wheelchair) was enabled significantly earlier in group S (III) than in group C (III) (p = 0.02), but in type IV, most patients enabled early mobilization even without surgical intervention. There were no significant differences in hospital complications and walking ability at final follow-up. In this study, the superiority of surgical treatment for unstable FFP was not proven. However, the results suggest that type IVb may be a relatively stable type compared to type III and that type IVb should be considered separately from bilaterally complete unstable sacral fractures due to high-energy trauma.

Role of triangular osteosynthesis in vertically unstable transforaminal sacrum fractures: clinical and radiological outcomes.

We aim to report clinical and radiological results of triangular osteosynthesis for a homogenous group of vertically unstable transforaminal sacral fractures. Between 2013 and 2018, 22 consecutive patients with unstable sacral fractures were treated with triangular osteosynthesis consisting of iliosacral screw augmented by spinopelvic fixation. Patients were followed up prospectively as a single cohort. Bone union, complications, clinical and radiological outcomes were investigated. Mean follow-up was 3.1 years (12-76 months). There was one bilateral fracture. Two patients underwent anterior plating for pubic symphyseal disruption. Based on Majeed and Iowa pelvic scores, 13 patients had excellent, seven had good and two had fair clinical outcome. All the patients could perform squatting, sitting cross-legged and kneeling without any restrictions. There were no additional neurological injuries. One patient had non-union of sacral fracture, one patient had deep infection, one patient had marginal wound necrosis and two patients complained of pain related to implant prominence. Two patients had connecting rod backout. All but one patient attained pre-operative work status. Triangular osteosynthesis is a reliable procedure in treating unstable transforaminal sacral fractures. It permits early weight-bearing and facilitates faster functional recovery. Careful attention to details such as sacral dysmorphism, soft tissue injury, implant placement and anterior pelvic injury helps in keeping complications to an acceptable rate.

A Modified Triangular Osteosynthesis Protocol for the Rod and Pedicle Screw Fixation of Vertical Unstable Sacral Fractures.

The stabilization of vertical unstable sacral fractures has been a complex problem that is a challenge to current standard approaches. Here, we attempted to evaluate a modified technique for sacral fractures. In the modified triangular osteosynthesis technique, we adopted a vertical and transverse fixation with a rod and pedicle screw system to reduce and fix sacral fractures in 28 subjects. The postsurgery effect of this technique was evaluated by physical examination and radiography. In the postoperative day 1, the patients were able to move body position passively from the lateral side to supine and exercise their legs by themselves. After a follow up of 20 months, radiological evaluation showed that fracture fragment reduction was excellent in 18 (64%), good (displacement 5-10 mm) in 8 (29%), and fair (displacement 10-15 mm) in 2 (7%) patients. Three patients with a preoperative perineal neurological impairment had a complete recovery after surgical decompression. All patients had achieved bone union of fractures, and no loss of fracture reduction was detected. The modified procedures offered an easier approach to fix vertical unstable sacral fractures, thereby achieving quicker and stable functionality. This suggests an alternative approach to manage unstable sacral fractures. 4. The stabilization of vertical unstable sacral fractures has been a complex problem that is a challenge to current standard approaches. We attempted to introduce a modified technique for sacral fractures.

Sacral Fracture Completeness in Lateral Compression Type 1 Pelvic Ring Injuries Has Weak Interobserver Reliability.

To determine the agreement between fellowship-trained orthopaedic trauma surgeons in evaluating sacral fracture completeness in the setting of minimally displaced lateral compression type 1 pelvic ring injuries. Survey study. Urban Level 1 trauma center. This study included 10 fellowship-trained orthopaedic trauma surgeons reviewing 10 cases of minimally displaced lateral compression type 1 injuries with proven occult instability (≥10 mm of fracture displacement on lateral stress radiographs). Sacral fractures were considered complete (n = 5; fracture line exiting posterior cortex of sacrum) or incomplete (n = 5). Participants reviewed videos of all axial computed tomography images of the sacrum and were asked if the sacral fracture was complete or incomplete. Interobserver reliability of completeness of sacral fracture. Interobserver reliability among surgeons for completeness of sacral fractures was considered to be weak (k = 0.46) with a 95% confidence interval that ranged from minimal (k = 0.37) to weak (k = 0.55). None of the 5 unstable sacral fractures that were considered to be complete garnered 100% agreement among surgeons. Agreement for each of these cases ranged from 40% to 90%. In contrast, 4 of the 5 unstable sacral fractures considered to be incomplete had 100% agreement. Completeness of sacral fractures had weak interobserver reliability among fellowship-trained orthopaedic trauma surgeons. Sacral fractures that were considered incomplete by all surgeons did have occult instability. These results highlight the large potential for error created by using sacral fracture completeness as a criterion to rule out occult instability. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.