Assessment of efficacy of conservative and surgical treatment methods in patients with unstable sacral fractures

Background. Treatment of patients with combined injury and unstable sacral fractures is a complex interdisciplinary problem due to high risks of mortality and neurological complications, and long rehabilitation. The study is important because of the absence of a consensus on the optimal time and technique of surgical stabilization, as well as on further treatment of patients with unstable sacral fractures.

Aim. To analyze results of treatment of patients with unstable sacral fractures (type С per the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification).

Materials and methods. The retrospective study included 67 patients aged 18 to 65 years with diagnosis of unstable sacral fracture (2014–2023). Depending on treatment tactics, 2 groups were identified: group 1 received surgical treatment (n = 54) with subgroup 1А undergoing sacroiliac fixation (n = 26), group 1B – triangular fixation (n = 25), group 1В – sacral canal decompression (n = 3); group 2 received conservative treatment (n = 13). Assessment of treatment efficacy included analysis of the following parameters: time to mobilization, complications, functional outcomes (Majeed scale), neurological status (Gibbons scale).

Results. Time to mobilization in the group 1 (surgical treatment) was 6.2 ± 3.8 days (subgroup 1А), in the group 2 (conservative treatment) – 31.4 ± 8.3 days (p <0.01). Complication rate in the conservative treatment group reached 100 %, with the most common complications being deep vein thrombosis (100 %), pneumonia (84.6 %), and bedsores (76.9 %). In the surgical treatment group, general complications were reported in 61.1 % of patients, and in the triangular fixation group complication rate was higher (60.0 %) than in the isolated sacroiliac fixation group (46.1 %). In the surgical treatment group, excellent and good functional results per the Majeed scale were observed in 84.0 % of patients, while in the conservative treatment group only in 46.2 % of patients.

Conclusion. The maximal efficacy in treatment of type C3 per AO classification complicated sacral fractures was achieved using triangular fixation technique which allowed to achieve the best neurological outcomes. For uncomplicated fractures, isolated sacroiliac fixation showed excellent results. Conservative treatment is associated with high risk of complications and is the last choice.

1. Tile M. Pelvic ring fractures: should they be fixed? J Bone Joint Surg Br 1988;70(1):1–12. DOI: 10.1302/0301-620X.70B1.3276697

2. Majeed S.A. Grading the outcome of pelvic fractures. Injury 1989;20(3):162–4. DOI: 10.1302/0301-620X.71B2.2925751

3. Gibbons K.J., Soloniuk D.S., Razack N. Neurological injury and patterns of sacral fractures. Neurosurgery 1990;72(6):889–93. DOI: 10.3171/jns.1990.72.6.0889

4. Santolini E., Kanakaris N.K., Giannoudis P.V. Sacral fractures: issues, challenges, solutions. EFOR T Open Rev 2020;5(5):299–311. DOI: 10.1302/2058-5241.5.190064

5. Rodrigues-Pinto R., Kurd M.F., Schroeder G.D. et al. Sacral fractures and associated injuries. Global Spine J 2017;7(7):609–16. DOI: 10.1177/2192568217701097

6. Aprato A., Branca Vergano L., Casiraghi A. et al. Consensus for management of sacral fractures: from the diagnosis to the treatment, with a focus on the role of decompression in sacral fractures. J Orthop Traumatol 2023;24(1):46. DOI: 10.1186/s10195-023-00726-2

7. Denis F., Davis S., Comfort T. Sacral fractures: an important problem. Spine 1988;13(2):137–140.

8. Montana M.A., Richardson M.L., Kilcoyne R.F. et al. CT of sacral injury. Radiology 1986;161(2):499–503. DOI: 10.1148/radiology.161.2.3763921

9. Expert Panel on Major Trauma Imaging; Shyu J.Y., Khurana B., Soto J.A. et al. ACR appropriateness criteria® Major Blunt Trauma. J Am Coll Radiol 2020;17(5):160–S74. DOI: 10.1016/j.jacr.2020.01.024

10. Aganesov N.A., Lazarev A.F., Kuleshov A.A. et al. Injuries to the posterior pelvic ring: classification, diagnostics, and treatment methods. Vestnik travmatologii i ortopedii im. N.N. Priorova = N.N. Priorov Bulletin of Traumatology and Orthopedics 2022;29(2):205–20. DOI: 10.17816/vto109172

11. Vallier H.A., Lowe J.A., Agel J. et al. Surgery for unilateral sacral fractures: are the indications clear? J Orthop Trauma 2019;33(12):619–25. DOI: 10.1097/BOT.0000000000001587

12. Gaskey G.E., Manson T.T., Castillo R.K. et al. Non-operative treatment of pelvic ring injuries with lateral compression type 1 of moderate severity with minimal displacement of complete sacral fracture. J Orthop Trauma 2014:28(12):674–80. DOI: 10.1097/BOT.00000000000000130

13. Tile M. Acute pelvic fractures. I. Causation and classification. J Am Acad Orthop Surg 1996;4(3):143–51. DOI: 10.5435/00124635-199605000-00004

14. Bondarenko A.V., Kruglykhin I.V., Plotnikov I.A. et al. External fixation as the main and final method of treating pelvic ring injuries in polytrauma. Polytrauma 2018;2:41–50.

15. Romoli S., Petrella L., Becattini E. et al. Treatment of unstable spinopelvic fractures: outcome of three surgical techniques – a retrospective single-center case series. Eur Spine J 2023;32(1): 93–100. DOI: 10.1007/s00586-022-07330-8

16. Schildhauer T.A., Josten C., Muhr G. Triangular osteosynthesis of vertically unstable sacrum fractures: a new concept allowing early weight-bearing. J Orthop Trauma 2006;20(1 Suppl):S44–S51.

17. Schildhauer T.A., Ledoux W.R., Chapman J.R. et al. Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads. J Orthop Trauma 2003;17(1):22–31. DOI: 10.1097/00005131-200301000-00004