Surgical treatment of fragility sacrum fractures with percutaneous sacroiliac (SI) screw fixation is associated with high failure rates in terms of screw loosening, cut-through and turn-out. The latter is a common cause for complications, being detected in up to 20% of the patients. The aim of this study was to develop a new screw-in-screw concept and prototype implant for fragility sacrum fracture fixation and test it biomechanically versus transsacral and SI screw fixations. Twenty-seven artificial pelves with discontinued symphysis and a vertical osteotomy in zone 1 after Denis were assigned to three groups (n = 9) for implantation of their right sites with either an SI screw, the new screw-in-screw implant, or a transsacral screw. All specimens were biomechanically tested to failure in upright position with the right ilium constrained. Validated setup and test protocol were used for complex axial and torsional loading, applied through the S1 vertebral body. Interfragmentary movements were captured via optical motion tracking. Screw motions in the bone were evaluated by means of triggered anteroposterior X-rays. Interfragmentary movements and implant motions in terms of pull-out, cut-through, tilt, and turn-out were significantly higher for SI screw fixation compared to both transsacral screw and screw-in-screw fixations. In addition, transsacral screw and screw-in-screw fixations revealed similar construct stability. Moreover, screw-in-screw fixation successfully prevented turn-out of the implant, that remained at 0° rotation around the nominal screw axis unexceptionally during testing. From biomechanical perspective, fragility sacrum fracture fixation with the new screw-in-screw implant prototype provides higher stability than with the use of one SI screw, being able to successfully prevent turn-out. Moreover, it combines the higher stability of transsacral screw fixation with the less risky operational procedure of SI screw fixation and can be considered as their alternative treatment option

Purpose. To evaluate the use of cutaneous marking of the sacrum for percutaneous iliosacral screw fixation. Iliosacral screw placement is dependent upon spatial perception, multiplanar fluoroscopic imaging, and an appreciation of pelvic anatomy which often makes learning the technique difficult for residents. Cutaneous marking of the sacrum may facilitate iliosacral screw insertion by providing additional cues to the orientation of the sacrum. Method. A cross-over study design was used for placing iliosacral screws in whole cadaver specimens using standardized operative and imaging techniques with and without cutaneous sacral markings. Lateral fluoroscopic imaging and a radio-opaque straight edge were used to trace the lateral profile of the sacrum with a marking pen. Total procedure time and fluoroscopy time were recorded. A total of 14 residents (6 seniors and 8 juniors) each placed two iliosacral screw guide-wires in a total of seven whole cadavers (14 SI joints). Group 1 performed the procedure first with no markings and then with markings. Group 2 performed the procedure first with markings and then without markings. Statistical analysis included T test, Wilcoxon Rank Sum Test, and Signed-Rank Test for Difference (p = 0.05). Participants also reported their opinions on each technique. Results. Mean procedure time for Group 1 was 8.83 minutes (3.77 17.17) and mean fluoroscopy time was 0.77 minutes (0.4 1.2) for the no-marking attempt and 10.33 min (5.88 15.25) and 1.06 min (0.6 2.3) respectively for the marking attempt. Mean procedure time for Group 2 was 11.3 min (6.33 16.5) and mean fluoroscopy time was 1.19 min (0.6 2.3) for the marking attempt and 7.22 min (2.83 17.27) and 0.97 min (0.4 1.8) respectively for the no-marking attempt. There were no significant differences between groups. T test analysis of all marking vs. no marking showed no significant difference for total procedure time (p= O.7020) or fluoroscopy time (p= 0.8297). Wilcoxon Rank Sum Test analysis showed no significant difference for total procedure time (p= 0.4415) or fluoroscopy time (p=0.7486) and Signed-Rank Test for Difference showed no significant difference for total procedure time (p=0.0625) or fluoroscopy time (p=0.1459). Senior residents reported they found the cutaneous marking helpful and would use it again whereas junior residents had mixed feelings on its utility. Conclusion. Cutaneous marking of the sacrum did not significantly impact total procedure time or fluoroscopy time but was generally reported to be helpful for residents learning percutaneous iliosacral screw fixation

Aim: To investigate the outcome of our management of patients with giant cell tumour of the sacrum and draw lessons from this. Method: Retrospective review of medical records and scans for all patients treated at our unit over the past 20 years with a giant cell tumour (GCT) of the sacrum. Results: Of 517 patients treated at our unit for GCT over the past 20 years, only 9 (1.7%) had a GCT in the sacrum. 6 were female, 3 male with a mean age of 34 (range 15–52). All but two tumours involved the entire sacrum and there was only one purely distal to S3. The mean size was 10cm and the most common symptom was back or buttock pain. Five had abnormal neurology at diagnosis but only one presented with cauda equina syndrome. The first four patients were treated by curettage alone but two patients had intra-operative cardiac arrests and although both survived all subsequent curettages were preceeded by embolization of the feeding vessels. Of 7 patients who had curettage, 3 developed local recurrence but all were controlled with a combination of further embolisation, surgery or radiotherapy. One patient elected for treatment with radiotherapy and another had excision of the tumour distal to S3. All the patients are alive and only two patients have worse neurology than at presentation, one being impotent and one with stress incontinence. All are mobile and active at a follow up between 2 and 21 years. Conclusion: GCT of the sacrum can be controlled with conservative surgery rather than sacrectomy. Embolisation and curettage are the preferred first option with radiotherapy as a possible adjunct. Spino-pelvic fusion may be needed if the sacrum collapses

Background: Paget’s disease of the sacrum is rare. A monostotic lesion in the sacrum is reported. A case with an unusual presentation is discussed. Introduction: A 53 years old man was referred to our unit with a 5–6 months history of abdomen discomfort and tenesmus. He had a history of low back pain and was noted to have an area of increasing numbness over the left buttock. A prominence of the left sacroiliac region was noticed and on rectal examination a bony hard mass was palpable posteriorly. A plain x-ray of the pelvis showed a gross expansion and enlargement of the sacrum with lucent area and widespread new bone formation. Biochemical test revealed a raised alkaline phosphatase level. A MRI scan reported a large tumour arising from the sacrum. with a differential of chordoma, paget’s sarcoma or an osteochondroma. In addition a bone scan reported raised uptake in the pelvis. An open incision biopsy was performed and the histology report was consistent with appearance of paget’s disease with no evidence of sarcoma. Interestingly the patient symptoms improved after the biopsy. He was commenced on biphosphonates. A surveillance scan is to be performed in due course. Conclusion: This case was unusual in terms of clinical presentation and location. Furthermore even the most sophisticated imaging modalities may fail to establish the diagnosis and biopsy is then necessary. This should always be performed in specialized centers, in order to minimise complications

Kinematics characteristics of the spine and pelvis are one measure proposed to assess lumbar dysfunction. To extent our knowledge about this matter we described the relationship between the orientation of the sacrum, in the sagittal plane, at upright position and the differential lumbar spine and pelvis range of flexion at the toe touch position in free-pain subjects. Position and motion measurements were recorded by an electrogoniometer. Individuals (n=39), were divided into two groups according to whether they have either pelvis (pelvis -group, n=18) or lumbar spine (spine-group, n=21) dominant movements during flexion. The mean age was 23,67±4,94 years (range18 to 33 years) in the pelvis-group, and 22,55 ± 2,70 years (range 19 to 27 years) in the spine –group. The range of pelvis flexion was significantly greater in the pelvis group than in the spine group, the range of lumbar spine flexion was significantly greater in the spine group than in the pelvis group (α≤.001); however, no differences were found in the range of back flexion (combined lumbar spine and pelvis motion) between the two groups. In the pelvis group the sacrum was significantly more horizontal than in the spine group (α≤.001). In the pelvis-group very strong correlation between sacrum orientation and the maximum range of pelvis flexion was found (r =0, 61). In the Spine group, sacrum orientation showed a negative strong correlation with the maximum range of spine flexion (r= − 0, 71). These results suggest the influence of the individual morphology on the lumbo-pelvic patterns of movements

Purpose of the study: Transversal or «U» fractures of the sacrum are rare. Reported for the first time by Bonin in 1945, such fractures concern less than 1% of spinal fractures. Initially, these injuries were often missed despite their association with neurological disorders such as caudia equina syndrome. This late diagnosis is related to the context of multiple trauma and also to insufficient knowledge of this type of injury. The purpose of this study was to draw clinicians’ attention to this type of injury in order to favor early diagnosis and appropriate treatment. Material and methods: This series included nine cases observed from 1999 to 2002. Mean age was 32 years, range 17–80. Female gender predominated (two-thirds of the patients). Six patients were fall victims, (suicide attempts or scaffold accidents). For eight patients, neurological signs involved a complete S1 or S2 caudia equina syndrome. L5 paralysis was noted in one patient due to a far-out syndrome. The diagnosis was established late in four patients, 2 to 45 days after trauma. Surgical treatment was instituted for six patients with neurological disorders diagnosed early. Treatment consisted in fracture reduction, posterior decompression and posterolateral stabilization. Intraoperative exploration revealed caudia equina contusion and compression in five of six patients with no loss of continuity. The sixth patient presented nearly complete root section. Results: Eight of the nine patients were followed and reviewed at 2 years 4 months on average. The patient with a root section committed suicide four months postoperatively. Neurological recovery was complete for the five other patients who underwent surgery. Motor, sensorial and sphincter function and the urodynamic study were normal at last follow-up. L5 paralysis recovered last. For the two non-operated patients, only one achieved partial recovery. Discussion: U fracture of the sacrum is a triple plane fracture which is difficult to explore with plain x-rays. In the context of a multiple trauma victim or attempted suicide, neurological complications are difficult to detect, further retarding the diagnosis of fracture. Roy Camille, Coutallier, Hessman report frequent misdiagnosis of the initial fracture and emphasize the contribution of computed tomography for correcting the diagnosis and establishing the surgical strategy. Surgery is the best option for improving prognosis, both in terms of neurological recovery and lumbopelvic stability. Conclusion: Emergency physicians, neurosurgeons and orthopedist should be aware of U fractures of the sacrum, particularly in high-energy fall victims. A better clinical approach, particularly systematic examination of the perineum, is the key to successful diagnosis and proper orientation of the x-ray work-up to establish a positive diagnosis and improve the therapeutic approach

Aim. Local treatment of Ewing sarcoma of the hip bones and sacrum remains one of the most difficult tasks in the treatment of bone sarcomas. We investigated the difference between size, local treatment and overall survival in Ewing sarcoma of the sacrum and hip bones. Methods. Patients with Ewing sarcoma of the hip bones or sacrum, diagnosed between 1986 and 2009, were identified through the Scandinavian Sarcoma Group registry. Data regarding tumour size, local treatment (radiation or surgery), local recurrence, surgical margin, metastatic disease, and overall survival were analyzed and compared between the two locations (hip bone or sacrum). Results. 99 patients with Ewing tumour in the hip bones (74 patients) or the sacrum (25 patients) were identified. The mean size was 7.8 cm (sacrum) and 10.6 cm (hip bones), p=0.007. For tumours localised to the sacrum, 9% of the patients underwent surgery, 68 % received radiotherapy and 5% received both. For patients with tumours in the hip bones, 28% underwent surgery, while 32% received radiotherapy and 28% received both. All of the 6 patients with local recurrence died. There was a tendency (p=0.059) for better overall 5 year survival for patients with a tumour localised to the sacrum compared with patients with a tumour localised to the hip bones (58 vs. 32%). Conclusion. Ewing tumours are smaller in the sacrum than in the hip bones. Radiotherapy alone appears to give sufficient local control of Ewing sarcoma of the sacrum. Ewing sarcoma of the sacrum most probably has a better prognosis than Ewing sarcoma of the hip bones

Aim: To review treatment outcomes in patients with sacral chordoma treated at our centre over the past 20 years. Methods: Retrospective review of prospectively kept data. Previously treated patients were excluded. The surgical objective was to obtain clear margins. If sacrifice of S2,3,4 was necessary, this was usually combined with colostomy. Results: 30 patients were treated (20 males, 10 females), median age 63.5 (28 to 94). Median duration of symptoms before presentation was 79 weeks (3–260), mean tumour size 11 cm. Most had neurological symptoms. Eight tumours involved the S2 roots, 1 the entire sacrum. Treatment was palliative in 7 patients, resection in 23. Operation time averaged 4.5 hours (1.5 to 8). Margins were wide in 7, marginal in 12, and intralesional in 4 patients. There was a high rate of postoperative complications, mostly wound problems (61% of patients). In 1 case this resulted in septicaemia and post-operative death. Average operative blood loss was 1600ml (0–3500). 65% of patients were incontinent of urine and/or faeces. Local recurrence (LR) occurred in 52% of operated patients at a median of 32 months (4–134). Incidence of LR was 60% after intralesional, 57% after marginal and 25% after wide surgery (p=0.49). LR was treated with re-excision, radiofrequency ablation, radio- and occasionally chemotherapy. Overall survival (Kaplan-Meier) of all patients was 57% at 5, and 40% at 10 years. Of operated patients this was 67% and 47%. There was a trend for better survival after wide resection margin. Metastatic disease only occurred in 3 patients. Conclusion: Chordoma of the sacrum is frequently diagnosed late. Resection is associated with a high complication rate. Local recurrence is the most common cause of death. Early referral to a specialist centre is recommended to optimize treatment. The role of adjuvant therapy remains unclear

Introduction: Tumours of sacrum are rare. Treatment depends on malignancy or local aggressiveness: resection is indicated for malignant lesions, intralesional surgery for benign. Purpose of this study was to analyse risk of infection and its treatment after surgery for the two most common primary sacral tumours. Material and Methods: Between 1976 and 2005, 82 patients with sacral chordoma or giant cell tumour were treated in our Institution. Demographic data, surgery and adjuvant treatments were analysed in the two histotypes. All patients were periodically checked with imaging studies. Special attention was given to the assessment of deep infections, their treatment and outcome. Patients included 44 females and 38 males, ranging in age from 14 to 74 years. Mean follow-up was 9.5 years (min. 3, max. 27). Histopathological findings included chordomas in 55 cases and giant cell tumor (GCT) in 27. Most pts. had iv antibiotic therapy with amikacin and teicoplanin. Surgery of chordoma was resection, surgery of GCT was intralesional excision. In 6 sacral resections a miocutaneous transabdominal flap of rectus abdominis was used for posterior closure. Results: No deep infections were observed in the GCT series. Three patients with sacral chordoma died for postoperative complications and were excluded from this analysis. Of the remaining 52 patients with chordoma, 23/52 had deep wound infection (44%), that required one or more additional operative procedures. In 16 pts. (70%) infection occurred within 4 weeks postoperatively, in 7 within 6 months. Most frequent bacteria causing infection were Enterococcus (23%), Escherichia Coli (20%), Pseudomonas Aeruginosa (18%). In 74% of cases a multiagent infection was detected. Surgical treatment consisted in 1 (52%) or more (48%) surgical debridements, combined with antibiotics therapy according to coltural results. Mean surgical time was 14 hours for resections and 6 hours for excisions. No significant difference was found comparing deep wound infections with levels of resection (15/33 resections proximal to S3-45% and 8/19 resections below or at S3-42%), previous intralesional surgery elsewhere (4/9 patients previous treated elsewhere-44% and 19/46 primarily treated patients-41%) and age at surgery. Conclusions: Type of surgery was the prominent factor related with a major risk of infection. Operating procedure time correlated as well. Resection of sacral chordomas with wide margins improves survival although extensive soft-tissue resection in proximity to the rectum favours deep infections. Intralesional excision is the recommended surgical treatment for GCT of the sacrum and does not imply a significant risk of infection

Clear cell meningioma is a rare subtype of meningiomas graded II according to the World Health Organisation classification. In spite of its benign appearance, clear cell meningioma has an aggressive behaviour and it is characterized by its inordinately tendency to metastasize. The purpose of this study is to discuss the clinico-pathological features of this subtype of meningiomas as well as the metastatic pathways. We wish to report a rare case of a clear cell meningioma metastasizing to the sacrum 17 years after the removal of the primary tumour. A 26 year-old man was referred to our centre for low back pain related to a lytic lesion of the sacrum. He had a history of a tumour of the forth cervical vertebra that was removed when he was 9 year-old. CT scan revealed an osteolysis of the entire sacrum invading the intrapelvic organs and the sacro-iliac joints. Open biopsy revealed a clear cell meningioma. That was the same pattern of the tumour removed 17 years earlier. Chest CT showed lung metastases. The patient was managed conservatively by palliative radiation therapy. One year later, he experienced improvement of pain and walk. The mass was stable. Clear ell meningioma is an aggressive tumour with a potential to spread via cerebro-spinal fluid and haematologically. Patients with such a tumour should be closely followed for a long time

Giant cell tumors (GCT) of the sacrum have a high recurrence rate, up to 33%. Treatment of Giant Cell Tumors (GCT) of the sacrum has many options. Although curettage is more often performed than partial sacral resection the indications are not well described. Large resection in the sacral area is limited, and adequate local adjuvant therapy potentially damages the nervous system. Therefore the type of surgical treatment of sacral GCT is still under debate. The purpose of this study was to compare clinical outcome after surgical treatment in GCT of the sacrum using two different surgical techniques: curettage and Extended Cortical Excision (ECE). Pre-operative embolisation was routinely performed, followed by curettage or PSR followed by reconstruction if indicated. Between 1994–2005 11 patients were treated for GCT of the sacrum. Eight were female, 3 men. The median age was 43.5 (14–66) years. The median follow-up period was 60 (6–156) months. Five patients were eventually treated by ECE. The other patients were operated on using different techniques, mainly curettage and/or adjuvant therapy. Two patients died disease-related 42 and 6 months after primary treatment, both metastasized. All other patients are alive and currently disease-free. Six patients had a recurrence, after 33 (4–140) months. Three patients had a recurrence twice. Three patients received radiotherapy, 1 as palliative treatment and 2 as (adjuvant) therapy for recurrence. No recurrences were seen after ECE compared to 86% (6/7) after curettage only, and 50% (2/4) after curettage with adjuvant therapy. Extended cortical excision may improve the recurrence rate in sacral GCT

The patients were reviewed with the aim of determining whether extending the fusion to the sacrum was needed or would affect the pelvic obliquity over the long term. Twenty-four patients with quadriplegic cerebral palsy, (non-ambulators) aged between 5–23 who underwent corrective surgery for their scoliosis were included in the study. Twelve patients were stabilized to the sacrum (LUQUE-Galveston technique) and 12 to L4 or L5 in the lumbar spine using pedicle screws. The patients were divided into two groups. Group 1 Pelvic obliquity less than 20° – no stabilisation to the pelvis. Group 2 Pelvic obliquity more than 20° – stabilisation to the pelvis. Group 1 – Patients with pre-operative pelvic obliquity less than 20° maintained their pre-operative pelvic obliquity without significant deterioration (less than 6° change). Group 2 – Patients with pelvic obliquity of 20° or more stabilised to the sacrum maintained or improved their correction until fusion. One patient had a draining sinus six months after the index operation for which removal of metalware (after fusion) was needed. No patient had a non union of the fusion mass. We believe that patients with a pelvic obliquity of less than 20 degrees at the time of surgery don’t need stabilization to the pelvis. Lumbar pedicle screws give sufficient stability to the distal construct and preserve mobility at the lumbosacral junction. Operative times and blood loss were reduced in those patients not fixed to the pelvis. There appears to be no significant loss of correction of the pelvis obliquity over time

Purpose: Transverse fractures of the upper part of the sacrum are exceptional (3–5% of sacral fractures). The neurological implications are serious: loss of the anatomic relation between the pelvic girdle and spine. Material and methods: We reviewed the cases of 50 patients treated between 1997 and 2001 (31 women, 19 men, mean age 31 years). Most of the patients had fallen from windows (n=46) and many had multiple injuries (n=38). There were 31 associated spinal fractures (18 L1 fractures). The Roy Camille classification was: type I (n=6), type II (n=34),and type III (n=20) with involvement of the pelvic girdle in 30, especially for type II and III (3 Tile A, 10 Tile B, 17 Tile C). Neurological lesions were observed in 42 patients: ten patients had paraplegia (seven total, three partial), 38 had L5 and/or S1 radicular pain, and 36 presented perineal involvement. Functional treatment was given in 11 patients (including five with neurological involvement and serious cutaneous lesions). Surgery was performed early in 25 patients (three with no deficit, 22 with neurological deficit), and late (one month) after callus formation in 14 (13 with neurological deficit, 1 for a cutaneous indication). Results: Mean follow-up was nine years. The gravity of the pelvic injury corresponded with the degree of associated neurological deficit. Incomplete functional recovery was observed in three patients given functional treatment. For patients undergoing early surgery, ten achieved functional recovery (six total and four partial) with no case of aggravation. Surgery after formation of a callus was followed by total functional recovery in three and partial recovery in six. Surgical complications included infection (n=9) and cerebrospinal fluid fistula (n=2) which resolved after re-operation. Progress in surgical techniques (subtraction osteotomy, better stabilisation) has improved the mechanical results. Discussion and conclusion : Analysis of these fractures must consider the frontal and sagittal planes to determine the degree of pelvic girdle involvement. The final outcome depends on the time to surgical treatment (particularly for type II and III fractures) and reconstitution of the sagittal alignment of the spine with the pelvis

Purpose of the study: Diagnosis and treatment of primary malignant tumors of the pelvis raise difficult problems. The purpose of this retrospective study was to analyze the functional and cancerological results observed after surgical treatment in a single center.

Material and methods: Between 1973 and 2002, 24 patients (16 men and 8 women) underwent surgery in our unit for histological proven malignant tumors. A posterior approach was used for curettages and sacrectomies of the apex. A combined anterior and posterior approach was used for total sacrectomy and hemisacrectomy. Oncological results were assessed in terms of local recurrence, presence of metastasis and patient status at last follow-up. Overall survival and disease-free survival were calculated with the Kaplan-Meier method.

Results: Mean age was 53.38 years. Mean follow-up in our series was 54 months. Mean time to diagnosis was 16 months. Pain was the predominant symptom. Sixteen patients presented neurological manifestations and the digital rectal examination was positive in all. Chondroma was the most frequent histological type (18/24). None of the patients had metastatic disease at diagnosis. A posterior approach was used for 15 patients and a combined approach for the others. There was a clear correlation between type of resection and volume of blood loss (p=0.0002). Wide dissection was wide in five patients, marginal in five and oncologically insufficient in 14. Mean operative time was 1.34 hours for posterior approaches and 9 hours for combined approaches. The postoperative period was uneventful for ten patients. Infection was the most frequent complication. Adjuvant radiotherapy, delivered in 16 patients, effectively retarded the occurrence of local recurrence. Functional disorders were correlated with the level of the neurological sacrifice. At least one S3 root had to be preserved to limit the urological and digestive incapacity. At last follow-up, local recurrence was present in 12 patients. Mean time to first recurrence was 32 months. There was a strong correlation between quality of the resection and time to local recurrence. There was a significant difference between patients with a wide resection and those with an oncologically insufficient resection (p=0.0312). Five patients had metastases. Five-year actuarial survival was 73±12%. At ten years it was 32±14%. Local recurrence-free survival was 55±11% at five years and zero at 10 years.

Discussion and conclusion: In light of these results, factors of poor prognosis were: late diagnosis, soft tissue invasion, proximal extension, marginal or insufficient resection.

Introduction

Isolated U-shaped sacral fractures are rare entities, mostly seen in polytraumatized patients, and hence, they are difficult to diagnose. While the pelvic ring remains intact across S2/S3, the U-shaped fracture around S1 leads to marked instability between the base of the spine and the pelvis. As severe neurological deficits can occur, timely treatment of these fractures is crucial. We present a novel technique of percutaneous reduction and trans-sacral screw fixation in U-shaped 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

Dysmorphic pelves are a known risk factor for malpositioned iliosacral screws. Improved understanding of pelvic morphology will minimise the risk of screw misplacement, neurovascular injuries and failed fixation. Existing classifications for sacral anatomy are complex and impractical for clinical use. We propose a CT-based classification using variations in pelvic anatomy to predict the availability of transosseous corridors across the sacrum. The classification aims to refine surgical planning which may reduce the risk of surgical complications. The authors postulated 4 types of pelves. The “superior most point of the sacroiliac joint” (sSIJ) typically corresponds with the mid-lower half of the L5 vertebral body. Hence, “the anterior cortex of L5” (L5. a. ) was divided to reference 3 distinct pelvic groups. A 4. th. group is required to represent pelves with a lumbosacral transitional vertebra. The proposed classification:. A – sSIJ is above the midpoint of L5. a. B – sSIJ is between the midpoint and the lowest point of L5. a. C – sSIJ is below the lowest point of L5. a. D – pelves with a lumbosacral transitional vertebra. Specific measures such as the width of the S1 and S2 axial and coronal corridors and the S1 lateral mass angles were used to differentiate between pelvic types. Three-hundred pelvic CT scans were classified into their respective types. Analysis of the specific measures mentioned above illustrated the significant difference between each pelvic type. Changes in the size of S1 and S2 axial corridors formed a pattern that was unique for each pelvic type. The intra- and inter-observer ratings were 0.97 and 0.95 respectively. Distinct relationships between the sizes of S1 and S2 axial corridors informed our recommendations on trans-sacral or iliosacral fixation, number and orientation of screws for each pelvic type. This classification utilises variations in the posterior pelvic ring to offer a planning guide for the insertion of iliosacral screws

Variations in pelvic anatomy are a major risk factor for misplaced percutaneous sacroiliac screws used to treat unstable posterior pelvic ring injuries. A better understanding of pelvic morphology improves preoperative planning and therefore minimises the risk of malpositioned screws, neurological or vascular injuries, failed fixation or malreduction. Hence a classification system which identifies the clinically important anatomical variations of the sacrum would improve communication among pelvic surgeons and inform treatment strategy. 300 Pelvic CT scans from skeletally mature trauma patients that did not have pre-existing posterior pelvic pathology were identified. Axial and coronal transosseous corridor widths at both S1 and S2 were recorded. Additionally, the S1 lateral mass angle were also calculated. Pelvises were classified based upon the sacroiliac joint (SIJ) height using the midpoint of the anterior cortex of L5 as a reference point. Four distinct types could be identified:. Type-A – SIJ height is above the midpoint of the anterior cortex of the L5 vertebra. Type-B – SIJ height is between the midpoint and the lowest point of the anterior cortex of the L5 vertebra. Type-C – SIJ height is below the lowest point of the anterior cortex of the L5 vertebra. Type-D – a subgroup for those with a lumbosacral transitional vertebra, in particular a sacralised L5. Differences in transosseous corridor widths and lateral mass angles between classification types were assessed using two-way ANOVAs. Type-B was the most common pelvic type followed by Type-A, Type-C, and Type-D. Significant differences in the axial and coronal corridors was observed for all pelvic types at each level. Lateral mass angles increased from Types-A to C, but were smaller in Type-D. This classification system offers a guide to surgeons navigating variable pelvic anatomy and understanding how it is associated with the differences in transosseous sacral corridors. It can assist surgeons’ preoperative planning of screw position, choice of fixation or the need for technological assistance

Hip instability is one of the most common causes for total hip arthroplasty (THA) revision surgery. Studies have indicated that lumbar fusion (LF) surgery is a risk factor for hip dislocation. Instrumented spine fusion surgery decreases pelvic tilt, which might lead to an increase in hip motion to accommodate this postural change. To the best of our knowledge, spine-pelvis-hip kinematics during a dynamic activity in patients that previously had both a THA and LF have not been investigated. Furthermore, patients with a combined THA and LF tend to have greater disability. The purpose was to examine spine-pelvis-hip kinematics during a sit to stand task in patients that have had both THA and LF surgeries and compare it to a group of patients that had a THA with no history of spine surgery. The secondary purpose was to compare pain, physical function, and disability between these patients. This cross-sectional study recruited participants that had a combined THA and LF (n=10; 6 females, mean age 73 y) or had a THA only (n=11; 6 females, mean age 72 y). Spine, pelvis, and hip angles were measured using a TrakSTAR motion capture system sampled at 200 Hz. Sensors were mounted over the lateral thighs, base of the sacrum, and the spinous process of the third lumbar,12th thoracic, and ninth thoracic vertebrae. Participants completed 10 trials of a standardized sit-to-stand-to-sit task. Hip, pelvis, lower lumbar, upper lumbar, and lower thoracic sagittal joint angle range of motion (ROM) were calculated over the entire task. In addition, pain, physical function, and disability were measured with clinical outcomes: Hip Disability Osteoarthritis Outcome Score (pain and physical function), Oswestry Low Back Disability Questionnaire (disability), and Harris Hip Score (pain, physical function, motion). Physical function performance was measured using 6-Minute Walk Test, Stair Climb Test, and 30s Chair Test. Angle ROMs during the sit-to-stand-to-sit task and clinical outcomes were compared between THA+LF and THA groups using independent t-tests and effect sizes (d). The difference in hip ROM was approaching statistical significance (p=0.07). Specifically, the THA+LF group had less hip ROM during the sit-to-stand-to-sit task than the THA only group (mean difference=11.17, 95% confidence interval=-1.13 to 23.47), which represented a large effect size (d=0.83). There were no differences in ROM for pelvis (p=0.54, d=0.28) or spinal (p=0.14 to 0.97; d=0.02 to 0.65) angles between groups. The THA+LF group had worse clinical outcomes for all measures of pain, physical function, and disability (p=0.01 to 0.06), representing large effect sizes (d=0.89 to 2.70). Hip ROM was not greater in the THA+LF group, and thus this is unlikely a risk factor for hip dislocation during this specific sit-to-stand-to-sit task. Other functional tasks that demand greater excursions in the joints should be investigated. Furthermore, the lack of differences in spinal and pelvis ROM were likely due to the task and the THA+LF group had spinal fusions at different levels. Combined THA+LF results in worse clinical outcomes and additional rehabilitation is required for these patients

Bertolotti first described articulation of the L5 transverse process with the sacrum as a cause of back pain in 1917. Since then little attention has been payed to these atypical articulations despite their high reported incidence. Here we describe our early experience of surgical treatment and propose a validated CT based classification of lumbosacral segment abnormalities (LSSA). 400 lumbosacral CT scans were reviewed (NBT), a classification devised and incidence of abnormalities recorded. 40 patients were selected and 4 independent observers classified each scan. Case notes for all patients (C&V) who received steroid injections into or surgical excision of LSSAs were reviewed. Results as follows:. 5 types of abnormality were identified. Type 0 - normal. Type 1 - asymmetrical shortening of the iliolumbar ligament. Type 2 - transverse process of L5 within 2mm of the sacrum. Type 3 - diarthrodial joint (3A: no evidence of degeneration 3B: degenerative change). Type 4 - transverse process and sacrum have fused. Type 5 - extends to L4. 54.5% of patients had abnormalities. The kappa values for the intra-observer results were 0.69 to 0.88 and the inter-observer ratings gave a combined score of over 0.7 indicating substantial agreement. Our CT classification of LSSAs is both straight forward to use and repeatable. The incidence of these abnormalities is higher in our population of CT scans compared to previous published series using plain radiographs. All patients treated with surgical excision of established articulations (Type 3A or above) reported good or excellent outcomes following excision