Lateral Compression Sacral Fractures Have Less Favourable Outcome Compared to Crescent Fractures in Patients Less Than 50 Years Old

Background. Lateral compression (LC) accounts for a wide spectrum of pelvic ring injuries (PRIs). The primary aim of this study was to assess the health-related quality of life outcomes of surgically fixed LC crescent versus sacral fractures in patients less than 50 years old after high energy trauma. Material and methods. We retrospectively reviewed the database for PRIs treated surgically from Decem­ber 2011 to January 2019 at our tertiary level trauma centre. The EuroQoL-5D (EQ5D5L) questionnaire was elec­tronically sent to all patients. Multiple linear regression was conducted to determine the predictors of quality-adjusted life-years (QALYs). Results. The study included 37 patients. The mean age was 26 SD 9.46 years. The mean duration of follow-up was 3.78 (r:1-9) years. Twenty-one (56.8%) and 16 (43.2%) patients sustained sacral fractures and crescent fractures, respectively. Multi-regression analysis showed that any patient with LC injury without a sacral fracture is expected to have a utility value of QALY= 0.876. A reduction of 0.072 units in QALYs is expected in the presence of sacral fracture. About 71% of patients with sacral fractures were able to return to work and this probability increased by 40% among patients with crescent fractures (RR=1.4, p=.015). Conclusions. 1. Younger patients with crescent fractures tend to have better quality of life (higher EQ5D and QALYs) compared to those with LC sacral fractures. 2. Moreover, patients with LC sacral fractures have less chan­ce to return to their pre-injury level of work compared to those with crescent fractures.

S2-alar-iliac screw and S1 pedicle screw fixation for the treatment of non-osteoporotic sacral fractures: a finite element study

Background Five different sacral fracture fixation methods were compared using finite element (FE) analysis to study their biomechanical characteristics. Methods Denis type I sacral fractures were created by FE modeling. Five different fixation methods for the posterior pelvic ring were simulated: sacroiliac screw (SIS), lumbopelvic fixation (LPF), transiliac internal fixator (TIFI), S2-alar-iliac (S2AI) screw and S1 pedicle screw fixation (S2AI-S1) and S2AI screw and contralateral S1 pedicle screw fixation (S2AI-CS1). Four different loading methods were implemented in sequence to simulate the force in standing, flexion, right bending and left twisting, respectively. Vertical stiffness, relative displacement and change in relative displacement were recorded and analyzed. Results As predicted by the FE model, the vertical stiffness of the five groups in descending order was S2AI-S1, SIS, S2AI-CS1, LPF and TIFI. In terms of relative displacement, groups S2AI-S1 and S2AI-CS1 displayed a lower mean relative displacement, although group S2AI-CS1 exhibited greater displacement in the upper sacrum than group S2AI-S1. Group SIS displayed a moderate mean relative displacement, although the displacement of the upper sacrum was smaller than the corresponding displacement in group S2AI-CS1, while groups LPF and TIFI displayed larger mean relative displacements. Finally, in terms of change in relative displacement, groups TIFI and LPF displayed the greatest fluctuations in their motion, while groups SIS, S2AI-S1 and S2AI-CS1 displayed smaller fluctuations. Conclusion Compared with SIS, unilateral LPF and TIFI, group S2AI-S1 displayed the greatest biomechanical stability of the Denis type I sacral fracture FE models. When the S1 pedicle screw insertion point on the affected side is damaged, S2AI-CS1 can be used as an appropriate alternative to S2AI-S1.

Comparison of lumbopelvic fixation and iliosacral screw fixation for the treatment of bilateral sacral fractures

Background Bilateral sacral fractures result in traumatic disruption of the posterior pelvic ring. Treatment for unstable posterior pelvic ring fractures should aim for fracture reduction and rigid fixation to facilitate early mobilization. Iliosacral screw fixation (ISF) and lumbopelvic fixation (LPF) were recommended for the treatment of these injuries. No algorithm or gold standard exists for surgery of these fractures. Purpose The purpose of this study was to evaluate the differences between ISF and LPF in bilateral sacral fractures regarding intraoperative procedures, complications and postoperative mobilization. The secondary aim was to determine whether demographics influence surgical treatment. Methods Over a 4-year period (2016–2019), 188 consecutive patients with pelvic ring injuries were treated at one academic level 1 trauma center and retrospectively identified. Fractures were classified according to the AO/OTA classification system. Seventy-seven patients were treated with LPF or ISF in combination with internal fixation of pubic rami fractures and could be included in this study. Comparisons were made between demographic and perioperative data. Infection, hematoma and hardware malpositioning were used as complication variables. Mobilization with unrestricted weight bearing was used as outcome variable. Follow-up was at least 6 months postoperatively. Results Operative stabilization of bilateral posterior pelvic ring injuries was performed in 77 patients. Therefore, 29 patients (females 59%) underwent LPF whereas 48 patients (females 83%) had bilateral ISF. The ISF group was older (76 yrs.) compared to the LPF group (62 yrs.) (p = 0.001), but no differences regarding BMI or comorbidities were detected. Time for surgery was reduced for patients who were treated with ISF compared to lumbopelvic fixation (73 min vs. 165 min; respectively, p < 0.001). But this did not result in reduced fluoroscopic time or radiation exposure. Overall complication rate was not different between the groups. Patients with LPF had a greater length of stay (p = 0.008) but were all weight bearing as tolerated when discharged (p < 0.001). Conclusion Bilateral posterior pelvic ring injuries of the sacrum can be sufficiently treated by LPF or ISF. LPF allows immediate weight bearing which may benefit younger patients and patients with an elevated risk for pneumonia or other pulmonary complications. Treatment with ISF reduces operative time, length of stay and postoperative wound infection. Elderly patients may be better suited for treatment with ISF if there is concern that the patient may not tolerate the increased operative time.

Treatment of Unstable Sacral Fracture with Minimally Invasive Spinopelvic Posterior Fixation and an Internal Anterior Fixator in a 95-Year-Old Patient with Diffuse Idiopathic Skeletal Hyperostosis: A Case Report

Introduction:Spinal fractures related to diffuse idiopathic skeletal hyperostosis (DISH) are almost always caused by a long lever arm, so treatment of the fractures requires stabilization of long segments of the spine. Treatment of unstable sacral fractures in DISH patients with ankylosis of the sacroiliac joints requires a treatment strategy that includes a consideration of the condition of the spine. This article is the first report of an unstable sacral fracture in a patient with DISH. Case Report:A 95-year-old male fell and presented with severe low back pain. An X-ray and computed tomography showed unstable pelvic fracture (AO type C2) and ankylosis of the lumbar spine due to DISH. We performed minimally invasive spinopelvic posterior fixation and internal anterior fixation (INFIX) for stabilization of the pelvic fracture. Initially, due to the long lever arm created from the lumbar spine to the pelvis, we performed L2-iliac posterior stabilization while the patient was in a prone position. After that, we performed INFIX to stabilize the anterior pelvis while the patient was positioned supine. The postoperative clinical course of the patient was uneventful and bony fusion was achieved as seen on X-ray obtained 1 year postoperatively. Conclusion:This patient was ankylosed from spine to pelvis due to DISH and sacroiliac joint ankylosis and sustained bilateral sacral fractures which dissociated the sacrum from the rest of the pelvis. Therefore, this fracture required spinopelvic fixation from the ankylosing spine to the pelvis. Because this patient was so elderly and in poor general health, we performed minimally invasive spinopelvic posterior fixation using percutaneous pedicle screws. We considered that many screw insertions that would equivalently stabilize the spine several segments above and below the fracture would be needed to stabilize the sacral fractures in this patient with DISH. In this case, we stabilized the unstable right pelvis, in a patient with

Management of LC Type I (LC-1) Pelvic Injuries with Complete Sacral Fracture : Is there a Role for Solitary Anterior Fixation?

Background: Management of LC-1 type pelvic injuries, particularly in patients with complete sacral fracture (LC-1 PICSF, OTA type 61-B2.1) remains controversial. Specific indications for solitary fixation remain unclear, and there is a paucity of outcomes data in comparison to combined fixation. We undertook a retrospective study in patients with LC-1 PICSFs to compare outcomes between solitary anterior fixation and combined anterior-posterior fixation.Methods: A retrospective cohort study was conducted with enrollment from 2014 to 2015 at a single tertiary-referral center in China. Adults with operatively managed LC-1 PICSFs were enrolled. Patients with sacral displacement <1 cm as assessed by axial CT received solitary anterior ring fixation (Group A); patients with displacement ≥1 cm received combined fixation of both the anterior and posterior rings (Group B). Reduction was confirmed by manipulation under anesthesia. Patients followed up for at least 24 months post-operatively. Primary outcome was function (Majeed score). Secondary outcomes included intraoperative characteristics, pain (VAS score), quality of fracture reduction (Tornetta and Matta radiographic grading), rate of non-union, early weight-bearing status, and complication rate.Results: 68 (89%) of 76 enrolled patients completed follow-up. Patients in Group A exhibited improved operative times, less time under fluoroscopy, and less blood loss as compared to Group B. There were no significant differences between Groups A and B regarding quality of fracture reduction, rate of union, functional outcomes, or rate of complications. Notably, Group B patients were more likely to achieve full early weight-bearing.Conclusion: LC-1 PFCSFs can get benefits from ORIF; the treatment algorithm should be differently made following the degree of the sacral fractures displacement. Less than 1cm sacral fracture displacement may get good functional outcomes from solitary anterior fixation. However, for the sacral fractures displacement greater or equal to 1cm, both the anterior and posterior pelvic ring should be surgical stabilization.

S2 Alar Iliac Screw and S1 Pedicle Screw Fixation for the Treatment of Sacral Fractures : A Finite Element Study

Background: Five different sacral fracture fixation methods were compared using finite element (FE) analysis to study their biomechanical characteristics.Methods: Denis type I sacral fractures were created by FE modeling. Five different fixation methods for the posterior pelvic ring were simulated: sacroiliac screw (SIS), lumbopelvic fixation (LPF), transiliac internal fixator (TIFI), S2-alar-iliac (S2AI) screw and S1 pedicle screw fixation (S2AI-S1), and S2AI screw and contralateral S1 pedicle screw fixation (S2AI-CS1). Four different loading methods were implemented in sequence to simulate the force in standing, flexion, right bending, and left twisting, respectively. Vertical stiffness, relative displacement, and change in relative displacement were recorded and analyzed.Results: As predicted by the FE model, the vertical stiffness of the five groups in descending order were S2AI-S1, SIS, S2AI-CS1, LPF, TIFI. In terms of relative displacement, S2AI-S1 and S2AI-CS1 groups displayed a smaller mean relative displacement, although the S2AI-CS1 group exhibited greater displacement in the upper sacrum than the S2AI-S1 group. The SIS group displayed a moderate mean relative displacement, although the displacement of the upper sacrum was smaller than that of the S2AI-CS1 group. The LPF and TIFI groups displayed larger mean relative displacements. In terms of change in relative displacement, the TIFI and LPF groups displayed the greatest fluctuations in their motion, while the SIS, S2AI-S1, and S2AI-CS1 groups displayed smaller fluctuations.Conclusion: Compared with SIS, unilateral LPF and TIFI, S2AI-S1 displayed the greatest biomechanical stability of the FE models and can be used as a new method for the treatment of sacral fractures. When the S1 pedicle screw insertion point on the affected side is damaged, S2AI-CS1 can be used as a good alternative to S2AI-S1.