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Z Orthop Unfall 2023; 161(02): 143-153
DOI: 10.1055/a-1498-2975
Review/Übersicht

Current Minimally Invasive Surgical Concepts for Sacral Insufficiency Fractures

Article in several languages: English | deutsch
Ulrich Josef Albert Spiegl 
1   Department of Orthopaedics, Trauma and Reconstructive Surgery, University of Leipzig, Germany
,
Klaus J. Schnake
2   Zentrum für Wirbelsäulen- und Skoliosetherapie, Malteser Waldkrankenhaus St Marien gGmbH, Erlangen, Germany
3   Klinik für Orthopädie und Unfallchirurgie, Universitätsklinik der Paracelsus Medizinischen Privatuniversität Klinikum Nürnberg, Nürnberg
,
Bernhard Ullrich
4   Unfall- und Wiederherstellungschirurgie, BG Klinikum Bergmannstrost Halle, Germany
,
Max J. Scheyerer 
5   Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinik Köln, Germany
,
Georg Osterhoff
1   Department of Orthopaedics, Trauma and Reconstructive Surgery, University of Leipzig, Germany
,
Holger Siekmann
6   Unfallchirurgie, AMEOS Klinikum Sankt Salvator Halberstadt GmbH, Germany
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Abstract

An increasing incidence of sacral insufficiency fractures in geriatric patients has been documented, representing a major challenge to our healthcare system. Determining the accurate diagnosis requires the use of sectional imaging, including computed tomography and magnetic resonance imaging. Initially, non-surgical treatment is indicated for the majority of patients. If non-surgical treatment fails, several minimally invasive therapeutic strategies can be used, which have shown promising results in small case series. These approaches are sacroplasty, percutaneous iliosacral screw fixation (S1 with or without S2), trans-sacral screw fixation or implantation of a trans-sacral bar, transiliac internal fixator stabilisation, and spinopelvic stabilisation. These surgical strategies and their indications are reported in detail. Generally, treatment-related decision making depends on the clinical presentation, fracture morphology, and attending surgeonʼs experience.

Key words

posterior pelvis - sacral fracture - minimally invasive stabilization - insufficiency fracture - fragility


Publication History

Article published online:
27 July 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References/Literatur

  • 1 Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: Recommendations for surgical treatment. Injury 2013; 44: 1733-1744
    CrossrefPubMedGoogle Scholar
  • 2 Abe H, Nakamura M, Takahashi S. et al. Radiation-induced insufficiency fractures of the pelvis: evaluation with 99 mTc-methylene diphosphonate scintigraphy. AJR Am J Roentgenol 1992; 158: 599-602
    CrossrefPubMedGoogle Scholar
  • 3 Lapina O, Tiskevicius S. Sacral insufficiency fracture after pelvic radiotherapy: a diagnostic challenge for a radiologist. Medicina (Kaunas) 2014; 50: 249-254
    CrossrefPubMedGoogle Scholar
  • 4 Dasgupta B, Shah N, Brown H. et al. Sacral insufficiency fractures: an unsuspected cause of low back pain. Br J Rheumatol 1998; 37: 789-793
    CrossrefPubMedGoogle Scholar
  • 5 Grangier C, Garcia J, Howarth NR. et al. Role of MRI in the diagnosis of insufficiency fractures of the sacrum and acetabular roof. Skeletal Radiol 1997; 26: 517-524
    CrossrefPubMedGoogle Scholar
  • 6 Deschamps Perdomo A, Tome-Bermejo F, Pinera AR. et al. Misdiagnosis of sacral stress fracture: an underestimated cause of low back pain in pregnancy?. Am J Case Rep 2015; 16: 60-64
    CrossrefPubMedGoogle Scholar
  • 7 Finiels H, Finiels PJ, Jacquot JM. et al. [Fractures of the sacrum caused by bone insufficiency. Meta-analysis of 508 cases]. Presse Med 1997; 26: 1568-1573
    PubMedGoogle Scholar
  • 8 Weber M, Hasler P, Gerber H. Insufficiency fractures of the sacrum. Twenty cases and review of the literature. Spine 1993; 18: 2507-2512
    CrossrefPubMedGoogle Scholar
  • 9 Schindler OS, Watura R, Cobby M. Sacral insufficiency fractures. J Orthop Surg (Hong Kong) 2007; 15: 339-346
    CrossrefPubMedGoogle Scholar
  • 10 Burge R, Dawson-Hughes B, Solomon DH. et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res 2007; 22: 465-475
    CrossrefPubMedGoogle Scholar
  • 11 Richards AM, Coleman NW, Knight TA. et al. Bone density and cortical thickness in normal, osteopenic, and osteoporotic sacra. J Osteoporos 2010; 504078
    PubMedGoogle Scholar
  • 12 Linstrom NJ, Heiserman JE, Kortman KE. et al. Anatomical and biomechanical analyses of the unique and consistent locations of sacral insufficiency fractures. Spine 2009; 34: 309-315
    CrossrefPubMedGoogle Scholar
  • 13 De Smet AA, Neff JR. Pubic and sacral insufficiency fractures: clinical course and radiologic findings. AJR Am J Roentgenol 1985; 145: 601-606
    CrossrefPubMedGoogle Scholar
  • 14 Schildhauer TA, 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
    CrossrefPubMedGoogle Scholar
  • 15 Leung KS, Chien P, Shen WY. et al. Operative treatment of unstable pelvic fractures. Injury 1992; 23: 31-37
    CrossrefPubMedGoogle Scholar
  • 16 Dehdashti AR, Martin JB, Jean B. et al. PMMA cementoplasty in symptomatic metastatic lesions of the S1 vertebral body. Cardiovasc Intervent Radiol 2000; 23: 235-237
    CrossrefPubMedGoogle Scholar
  • 17 Marcy PY, Palussiere J, Descamps B. et al. Percutaneous cementoplasty for pelvic bone metastasis. Support Care Cancer 2000; 8: 500-503
    CrossrefPubMedGoogle Scholar
  • 18 Garant M. Sacroplasty: a new treatment for sacral insufficiency fracture. J Vas Interv Radiol 2002; 13: 1265-1267
    CrossrefPubMedGoogle Scholar
  • 19 Heo DH, Park CK. Percutaneous Sacroplasty for Non-neoplastic Osteoporotic Sacral Insufficiency Fractures. Pain Physician 2017; 20: 89-94
    CrossrefPubMedGoogle Scholar
  • 20 Frey ME, Warner C, Thomas SM. et al. Sacroplasty: A Ten-Year Analysis of Prospective Patients Treated with Percutaneous Sacroplasty: Literature Review and Technical Considerations. Pain Physician 2017; 20: E1063-E1072
    PubMedGoogle Scholar
  • 21 Andresen R, Radmer S, Andresen JR. et al. Comparison of the 18-month outcome after the treatment of osteoporotic insufficiency fractures by means of balloon sacroplasty (BSP) and radiofrequency sacroplasty (RFS) in comparison: a prospective randomised study. Eur Spine J 2017; 26: 3235-3240
    CrossrefPubMedGoogle Scholar
  • 22 Andresen R, Radmer S, Andresen JR. et al. Clinical Improvement and Cost-effectiveness of CT-guided Radiofrequency Sacroplasty (RFS) and Cement Sacroplasty (CSP) – a Prospective Randomised Comparison of Methods. Z Orthop Unfall 2019; 157: 524-533
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Yang SC, Tsai TT, Chen HS. et al. Comparison of sacroplasty with or without balloon assistance for the treatment of sacral insufficiency fractures. J Orthop Surg (Hong Kong) 2018; 26: 2309499018782575
    CrossrefPubMedGoogle Scholar
  • 24 Krappinger D, Kaser V, Kammerlander C. et al. Inter- and intraobserver reliability and critical analysis of the FFP classification of osteoporotic pelvic ring injuries. Injury 2019; 50: 337-343
    CrossrefPubMedGoogle Scholar
  • 25 Mendel T, Noser H, Kuervers J. et al. The influence of sacral morphology on the existence of secure S1 and S2 transverse bone corridors for iliosacroiliac screw fixation. Injury 2013; 44: 1773-1779
    CrossrefPubMedGoogle Scholar
  • 26 Laux CJ, Weigelt L, Osterhoff G. et al. Feasibility of iliosacral screw placement in patients with upper sacral dysplasia. J Orthop Surg Res 2019; 14: 418
    CrossrefPubMedGoogle Scholar
  • 27 Hilgert RE, Finn J, Egbers HJ. [Technique for percutaneous iliosacral screw insertion with conventional C-arm radiography]. Unfallchirurg 2005; 108: 954-960
    PubMedGoogle Scholar
  • 28 Höch A, Pieroh P, Henkelmann R. et al. In-screw polymethylmethacrylate-augmented sacroiliac screw for the treatment of fragility fractures of the pelvis: a prospective, observational study with 1-year follow-up. BMC Surg 2017; 17: 132
    CrossrefPubMedGoogle Scholar
  • 29 Hopf JC, Krieglstein CF, Müller LP. et al. Percutaneous iliosacral screw fixation after osteoporotic posterior ring fractures of the pelvis reduces pain significantly in elderly patients. Injury 2015; 46: 1631-1636
    CrossrefPubMedGoogle Scholar
  • 30 Eckardt H, Egger A, Hasler RM. et al. Good functional outcome in patients suffering fragility fractures of the pelvis treated with percutaneous screw stabilisation: assessment of complications and factors influencing failure. Injury 2017; 48: 2717-2723
    CrossrefPubMedGoogle Scholar
  • 31 Osterhoff G, Ossendorf C, Wanner GA. et al. Percutaneous iliosacral screw fixation in S1 and S2 for posterior pelvic ring injuries: technique and perioperative complications. Arch Orthop Trauma Surg 2011; 131: 809-813
    CrossrefPubMedGoogle Scholar
  • 32 Zwingmann J, Hauschild O, Bode G. et al. Malposition and revision rates of different imaging modalities for percutaneous iliosacral screw fixation following pelvic fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2013; 133: 1257-1265
    CrossrefPubMedGoogle Scholar
  • 33 Camino Willhuber G, Zderic I, Gras F. et al. Analysis of sacro-iliac joint screw fixation: does quality of reduction and screw orientation influence joint stability? A biomechanical study. Int Orthop 2016; 40: 1537-1543
    CrossrefPubMedGoogle Scholar
  • 34 van Zwienen CM, van den Bosch EW, Snijders CJ. et al. Biomechanical comparison of sacroiliac screw techniques for unstable pelvic ring fractures. J Orthop Trauma 2004; 18: 589-595
    CrossrefPubMedGoogle Scholar
  • 35 Zwingmann J, Konrad G, Kotter E. et al. Computer-navigated iliosacral screw insertion reduces malposition rate and radiation exposure. Clin Orthop Relat Res 2009; 467: 1833-1838
    CrossrefPubMedGoogle Scholar
  • 36 Osterhoff G, Dodd AE, Unno F. et al. Cement Augmentation in Sacroiliac Screw Fixation Offers Modest Biomechanical Advantages in a Cadaver Model. Clin Orthop Relat Res 2016; 474: 2522-2530
    CrossrefPubMedGoogle Scholar
  • 37 Vanderschot PM, Broens PM, Vermeire JI. et al. Trans iliac-sacral-iliac bar stabilization to treat bilateral sacro-iliac joint disruptions. Injury 1999; 30: 637-640
    CrossrefPubMedGoogle Scholar
  • 38 Trikha V, Gaba S, Kumar A. et al. Safe corridor for iliosacral and trans-sacral screw placement in Indian population: A preliminary CT based anatomical study. J Clin Orthop Trauma 2019; 10: 427-431
    CrossrefPubMedGoogle Scholar
  • 39 Wagner D, Ossendorf C, Gruszka D. et al. Fragility fractures of the sacrum: how to identify and when to treat surgically?. Eur J Trauma Emerg Surg 2015; 41: 349-362
    CrossrefPubMedGoogle Scholar
  • 40 Rommens PM, Ossendorf C, Pairon P. et al. Clinical pathways for fragility fractures of the pelvic ring: personal experience and review of the literature. J Orthop Sci 2015; 20: 1-11
    CrossrefPubMedGoogle Scholar
  • 41 Rommens PM, Arand C, Hopf JC. et al. Progress of instability in fragility fractures of the pelvis: an observational study. Injury 2019; 50: 1966-1973
    CrossrefPubMedGoogle Scholar
  • 42 Mendel T, Ullrich BW, Hofmann GO. et al. Progressive instability of bilateral sacral fragility fractures in osteoporotic bone: a retrospective analysis of X-ray, CT, and MRI datasets from 78 cases. Eur J Trauma Emerg Surg 2021; 47: 11-19
    CrossrefPubMedGoogle Scholar
  • 43 Lattauschke A, Klauke F, Ullrich BW. et al. [Course of operative treatment of a sacral insufficiency fracture: successful or serious treatment?]. Unfallchirurg 2017; 120: 890-895
    PubMedGoogle Scholar
  • 44 Mehling I, Hessmann MH, Rommens PM. Stabilization of fatigue fractures of the dorsal pelvis with a trans-sacral bar. Operative technique and outcome. Injury 2012; 43: 446-451
    CrossrefPubMedGoogle Scholar
  • 45 Moed BR, Whiting DR. Locked transsacral screw fixation of bilateral injuries of the posterior pelvic ring: initial clinical series. J Orthop Trauma 2010; 24: 616-621
    CrossrefPubMedGoogle Scholar
  • 46 Füchtmeier B, Maghsudi M, Neumann C. et al. [The minimally invasive stabilization of the dorsal pelvic ring with the transiliacal internal fixator (TIFI)–surgical technique and first clinical findings]. Unfallchirurg 2004; 107: 1142-1151
    PubMedGoogle Scholar
  • 47 Siekmann H, Becherer L, Neef R. “Iliosacral bridging” – A new alternative minimal invasive fixation of unstable pelvic ring fractures. Arch Surg Clin Res 2018; 2: 29-46
    PubMedGoogle Scholar
  • 48 Schmitz P, Baumann F, Grechenig S. et al. The cement-augmented transiliacal internal fixator (caTIFI): an innovative surgical technique for stabilization of fragility fractures of the pelvis. Injury 2015; 46 (Suppl. 04) S114-S120
    CrossrefPubMedGoogle Scholar
  • 49 Schmitz P, Baumann F, Acklin YP. et al. Clinical application of a minimally invasive cement-augmentable Schanz screw rod system to treat pelvic ring fractures. Int Orthop 2019; 43: 697-703
    CrossrefPubMedGoogle Scholar
  • 50 Ebraheim NA, Lin D, Xu R. et al. Computed tomographic evaluation of the internal structure of the lateral sacral mass in the upper sacra. Orthopedics 1999; 22: 1137-1140
    CrossrefPubMedGoogle Scholar
  • 51 Williams SK, Quinnan SM. Percutaneous Lumbopelvic Fixation for Reduction and Stabilization of Sacral Fractures With Spinopelvic Dissociation Patterns. J Orthop Trauma 2016; 30: e318-e324
    CrossrefPubMedGoogle Scholar
  • 52 Schmitz P, Lüdeck S, Baumann F. et al. Patient-related quality of life after pelvic ring fractures in elderly. Int Orthop 2019; 43: 261-267
    CrossrefPubMedGoogle Scholar
  • 53 Acklin YP, Zderic I, Richards RG. et al. Biomechanical investigation of four different fixation techniques in sacrum Denis type II fracture with low bone mineral density. J Orthop Res 2018; 36: 1624-1629
    CrossrefPubMedGoogle Scholar
  • 54 Schroeder GD, Savage JW, Patel AA. et al. Spinopelvic Fixation in Complex Sacral Fractures. JBJS Reviews 2015; DOI: 10.2106/JBJS.RVW.N.00007.
    CrossrefPubMedGoogle Scholar
  • 55 Spiegl UJA, Schnake KJ, Osterhoff G. et al. Imaging of Sacral Stress and Insufficiency Fractures. Z Orthop Unfall 2019; 157: 144-153
    Article in Thieme ConnectPubMedGoogle Scholar
  • 56 Palm HG, Lang P, Hackenbroch C. et al. Dual-energy CT as an innovative method for diagnosing fragility fractures of the pelvic ring: a retrospective comparison with MRI as the gold standard. Arch Orthop Trauma Surg 2020; 140: 473-480
    CrossrefPubMedGoogle Scholar
  • 57 Chandra V, Wajswol E, Shukla P. et al. Safety and Efficacy of Sacroplasty for Sacral Fractures: A Systematic Review and Meta-Analysis. J Vasc Interv Radiol 2019; 30: 1845-1854
    CrossrefPubMedGoogle Scholar
  • 58 Ghisla S, Napoli F, Lehoczky G. et al. Posterior pelvic ring fractures: Intraoperative 3D-CT guided navigation for accurate positioning of sacro-iliac screws. Orthop Traumatol Surg Res 2018; 104: 1063-1067
    CrossrefPubMedGoogle Scholar
  • 59 Behrendt D, Mutze M, Steinke H. et al. Evaluation of 2D and 3D navigation for iliosacral screw fixation. Int J Comput Assist Radiol Surg 2012; 7: 249-255
    CrossrefPubMedGoogle Scholar
  • 60 Briem D, Windolf J, Rueger JM. [Percutaneous, 2D-fluoroscopic navigated iliosacral screw placement in the supine position: technique, possibilities, and limits]. Unfallchirurg 2007; 110: 393-401
    PubMedGoogle Scholar
  • 61 Takao M, Hamada H, Sakai T. et al. Factors influencing the accuracy of iliosacral screw insertion using 3D fluoroscopic navigation. ArchOrthop Trauma Surg 2019; 139: 189-195
    CrossrefPubMedGoogle Scholar
  • 62 Thakkar SC, Thakkar RS, Sirisreetreerux N. et al. 2D versus 3D fluoroscopy-based navigation in posterior pelvic fixation: review of the literature on current technology. Int J Comput Assist Radiol Surg 2017; 12: 69-76
    CrossrefPubMedGoogle Scholar
  • 63 Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res 1988; 227: 67-81
    CrossrefPubMedGoogle Scholar