Aims. Concurrent hip and spine pathologies can alter the biomechanics of spinopelvic mobility in primary total hip arthroplasty (THA). This study examines how differences in pelvic orientation of patients with spine fusions can increase the risk of dislocation risk after THA. Patients and Methods. We identified 84 patients (97 THAs) between 1998 and 2015 who had undergone spinal fusion prior to primary THA. Patients were stratified into three groups depending on the length of lumbar fusion and whether or not the sacrum was involved. Mean age was 71 years (40 to 87) and 54 patients (56%) were female. The mean body mass index (BMI) was 30 kg/m. 2. (19 to 45). Mean follow-up was six years (2 to 17). Patients were 1:2 matched to patients with primary THAs without spine fusion. Hazard ratios (HR) were calculated. Results. Dislocation in the fusion group was 5.2% at one year versus 1.7% in controls but this did not reach statistical significance (HR 1.9; p = 0.33). Compared with controls, there was no significant difference in rate of dislocation in patients without a sacral fusion. When the sacrum was involved, the rate of dislocation was significantly higher than in controls (HR 4.5; p = 0.03), with a trend to more dislocations in longer lumbosacral fusions. Patient demographics and surgical characteristics of THA (i.e. surgical approach and femoral head diameter) did not significantly impact risk of dislocation (p > 0.05). Significant radiological differences were measured in mean anterior pelvic tilt between the one-level lumbar fusion group (22°), the multiple-level fusion group (27°), and the sacral fusion group (32°; p < 0.01). Ten-year survival was 93% in the fusion group and 95% in controls (HR 1.2; p = 0.8). Conclusion. Lumbosacral spinal fusions prior to THA increase the risk of dislocation within the first six months. Fusions involving the sacrum with multiple levels of lumbar involvement notably increased the risk of postoperative dislocation compared with a control group and other lumbar fusions. Surgeons should take care with component positioning and may consider higher stability implants in this high-risk cohort

Tumours of the sacrum are difficult to manage. The sacrum provides the structural connection between the torso and lower half of the body and is subject to both axial and rotational forces. Thus, tumours or their treatment can compromise the stability of the spinopelvic junction. Additionally, nerves responsible for lower limb motor groups as well as bowel, bladder, and sexual function traverse or abut the sacrum. Preservation or sacrifice of these nerves in the treatment of sacral tumours has profound implications on the function and quality of life of the patient. This annotation will discuss current treatment protocols for sacral tumours. Cite this article: Bone Joint J 2022;104-B(12):1284–1291

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

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

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

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

The pattern of fracture-dislocation of the upper part of the sacrum is demonstrated in three patients. The fracture line followed the segmental form of the sacrum and was usually caused by a posterior force against the pelvis which had been locked by hip flexion and knee extension. Fractures of the lumbar transverse processes also occurred, presumably from avulsion by the quadratus lumborum muscle. The damage to the sacral plexus found in all three cases recovered after several months. Radiographs of the injury are difficult to obtain in severely injured patients but oblique views of the sacrum help to determine the extent of the forward dislocation

Aims. There is a lack of evidence about the risk factors for local recurrence of a giant cell tumour (GCT) of the sacrum treated with nerve-sparing surgery, probably because of the rarity of the disease. This study aimed to answer two questions: first, what is the rate of local recurrence of sacral GCT treated with nerve-sparing surgery and second, what are the risk factors for its local recurrence?. Methods. A total of 114 patients with a sacral GCT who underwent nerve-sparing surgery at our hospital between July 2005 and August 2017 were reviewed. The rate of local recurrence was determined, and Kaplan-Meier survival analysis carried out to evaluate the mean recurrence-free survival. Possible risks factors including demographics, tumour characteristics, adjuvant therapy, operation, and laboratory indices were analyzed using univariate analysis. Variables with p < 0.100 in the univariate analysis were further considered in a multivariate Cox regression analysis to identify the risk factors. Results. The rate of local recurrence of sacral GCT treated with nerve-sparing surgery was 28.95% (33/114). Multivariate Cox regression analysis showed that large tumour size (> 8.80 cm) (hazard ratio (HR) 3.16; 95% confidence interval (CI) 1.27 to 7.87; p = 0.014), high neutrophil-to-lymphocyte ratio (NLR) (> 2.09) (HR 3.13; 95% CI 1.28 to 7.62; p = 0.012), involvement of a sacroiliac joint (HR 3.09; 95% CI 1.06 to 9.04; p = 0.039), and massive intraoperative blood loss (> 1,550 ml) (HR 2.47; 95% CI 1.14 to 5.36; p = 0.022) were independent risk factors for local recurrence. Conclusion. Patients with a sacral GCT who undergo nerve-sparing surgery have a local recurrence rate of 29%. Large tumour size, high NLR, involvement of a sacroiliac joint, and massive intraoperative blood loss are independent risk factors. Cite this article: Bone Joint J 2020;102-B(10):1392–1398

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

Aims. Minimally invasive fixation of pelvic fragility fractures is recommended to reduce pain and allow early mobilization. The purpose of this study was to evaluate the outcome of two different stabilization techniques in bilateral fragility fractures of the sacrum (BFFS). Methods. A non-randomized, prospective study was carried out in a level 1 trauma centre. BFFS in 61 patients (mean age 80 years (SD 10); four male, 57 female) were treated surgically with bisegmental transsacral stablization (BTS; n = 41) versus spinopelvic fixation (SP; n = 20). Postoperative full weightbearing was allowed. The outcome was evaluated at two timepoints: discharge from inpatient treatment (TP1; Fitbit tracking, Zebris stance analysis), and ≥ six months (TP2; Fitbit tracking, Zebris analysis, based on modified Oswestry Disability Index (ODI), Majeed Score (MS), and the 12-Item Short Form Survey 12 (SF-12). Fracture healing was assessed by CT. The primary outcome parameter of functional recovery was the per-day step count; the secondary parameter was the subjective outcome assessed by questionnaires. Results. Overall, no baseline differences were observed between the BTS and SP cohorts. In total, 58 (BTS = 19; SP = 39) and 37 patients (BTS = 14; SP = 23) could be recruited at TP1 and TP2, respectively. Mean steps per day at TP1 were median 308 (248 to 434) in the BTS group and 254 (196 to 446) in the SP group. At TP2, median steps per day were 3,759 (2,551 to 3,926) in the BTS group and 3,191 (2,872 to 3,679) in the SP group, each with no significant difference. A significant improvement was observed in each group (p < 0.001) between timepoints. BTS patients obtained better results than SP patients in ODI (p < 0.030), MS (p = 0.007), and SF-12 physical status (p = 0.006). In all cases, CT showed sufficient fracture healing of the posterior ring. Conclusion. Both groups showed significant outcome improvement and sufficient fracture healing. Both techniques can be recommended for BFFS, although BTS was superior with respect to subjective outcome. Step-count tracking represents a reliable method to evaluate the mobility level. Cite this article: Bone Joint J 2021;103-B(3):462–468

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

We hypothesised that the use of computer navigation-assisted surgery for pelvic and sacral tumours would reduce the risk of an intralesional margin. We reviewed 31 patients (18 men and 13 women) with a mean age of 52.9 years (13.5 to 77.2) in whom computer navigation-assisted surgery had been carried out for a bone tumour of the pelvis or sacrum. There were 23 primary malignant bone tumours, four metastatic tumours and four locally advanced primary tumours of the rectum. The registration error when using computer navigation was <  1 mm in each case. There were no complications related to the navigation, which allowed the preservation of sacral nerve roots (n = 13), resection of otherwise inoperable disease (n = 4) and the avoidance of hindquarter amputation (n = 3). The intralesional resection rate for primary tumours of the pelvis and sacrum was 8.7% (n = 2): clear bone resection margins were achieved in all cases. At a mean follow-up of 13.1 months (3 to 34) three patients (13%) had developed a local recurrence. The mean time alive from diagnosis was 16.8 months (4 to 48). . Computer navigation-assisted surgery is safe and has reduced our intralesional resection rate for primary tumours of the pelvis and sacrum. We recommend this technique as being worthy of further consideration for this group of patients. Cite this article: Bone Joint J 2013;95-B:1417–24

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

Aims. Iliosacral sarcoma resections have been shown to have high rates of local recurrence (LR) and poor overall survival. There is also no universal classification for the resection of pelvic sarcomas invading the sacrum. This study proposes a novel classification system and analyzes the survival and risk of recurrence, when using this system. Methods. This is a retrospective analysis of 151 patients (with median follow-up in survivors of 44 months (interquartile range 12 to 77)) who underwent hemipelvectomy with iliosacral resection at a single centre between 2007 and 2019. The proposed classification differentiates the extent of iliosacral resection and defines types S1 to S6 (S1 resection medial and parallel to the sacroiliac joint, S2 resection through the ipsilateral sacral lateral mass to the neuroforamina, S3 resection through the ipsilateral neuroforamina, S4 resection through ipsilateral the spinal canal, and S5 and S6 contralateral sacral resections). Descriptive statistics and the chi-squared test were used for categorical variables, and the Kaplan-Meier survival analysis were performed. Results. Resections were S1 in 25/151 patients (17%), S2 in 70/151 (46%), S3 in 33/151 (22%), S4 in 77/151 (11%), S5 in 4/151 (3%), and S6 in 2/151 (1%). An internal hemipelvectomy was performed in 113/151 patients (75%), and 38/151 patients (25%) had an external hemipelvectomy. The predominant types of sarcoma were high-grade osteosarcoma in 48/151 patients (32%), chondrosarcoma in 41/151 (27%), Ewing sarcoma in 33/151 (22%), pleomorphic sarcoma in 17/151 (11%), and others in 2/151 (8%). LR was found in 24/151 patients (15%) with S3, S5, with S6 resections showing the highest rate of LR (p = 0.038). Overall, 19/151 patients (16%) had evidence of metastastic disease at the time of surgery and these patients showed poorer survival when compared to patients with no metastasis. Conclusion. The proposed classification can help to report and compare different surgical and reconstructive approaches in these difficult cases who are still have a considerable risk of LR. Cite this article: Bone Joint J 2022;104-B(2):290–296

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

Transverse fractures of the sacrum with neurological complications have been studied in four patients illustrating the following features: diagnosis is often delayed, there are radiological difficulties in making the diagnosis, and the indications for surgery are not well defined. Specific radiographic views are recommended. All the cases presented in this report responded well to conservative management