Abstract
Background Vertically displaced sacral fractures are complex injuries commonly resulting from high-energy trauma and often complicated by neurological deficits, pelvic instability, and leg length discrepancy. When managed conservatively or under emergent conditions, they are prone to malunion. Surgical correction in these cases is technically demanding due to the intricate sacral anatomy and proximity of neurovascular structures.
Case Description A 26-year-old female war victim had a malunited, vertically displaced left sacral ala fracture. Initial treatment with an anterior external fixator failed to address the vertical displacement. Four months after the injury, the patient presented with severe pelvic pain, inability to walk, and a 6-cm leg length discrepancy. Neurological examination revealed decreased dorsiflexion strength and sensory deficits on the left foot. A 3-stage, single-setting surgical correction was performed: anterior pelvic osteotomy using the Stoppa approach; posterior sacral osteotomy and reduction via a posterior midline approach; and triangular osteosynthesis involving lumbo-pelvic distraction and transverse fixation. The anterior osteotomy site was subsequently stabilized with a reconstruction plate. Intraoperative neuromonitoring was utilized throughout the procedure.
Outcomes The surgery reduced the pelvic asymmetry and reduced the leg length discrepancy from 6 cm to approximately 1 cm. Postoperatively, the patient maintained her preoperative motor status, with dorsiflexion strength of 3/5 initially, improving to 4/5 within 3 weeks. Sensory deficits remained stable without further deterioration. She was mobilized with nonweight-bearing ambulation immediately postoperatively, progressing to full weight bearing by the third postoperative week. One month after surgery, she developed a superficial wound infection that resolved with outpatient wound care and oral antibiotics. At the 6-month follow-up, the patient was walking independently without assistive devices. Radiographs confirmed stable fixation and maintenance of reduction with satisfactory signs of bone healing. No neurological deterioration or implant-related complications were observed. Clinical and radiographic assessments supported a successful outcome.
Conclusion This case illustrates the feasibility and efficacy of a comprehensive, single-session surgical approach for treating a vertically displaced sacral fracture malunion. Triangular osteosynthesis combined with sacral osteotomy provides biomechanical stability and enables early mobilization. Multistage intraoperative positioning and careful dissection are critical for successful outcomes.
Clinical Relevance Malunited vertically displaced sacral fractures are uncommon but highly disabling, often associated with pelvic asymmetry, leg length discrepancy, and neurological deficits. Surgical correction is challenging because of complex sacral anatomy and proximity to critical neurovascular structures. The successful restoration of alignment, early mobilization, and functional improvement in this case highlight the feasibility of this approach. This report offers practical technical guidance of a single-session, staged anterior–posterior osteotomy and triangular osteosynthesis for surgeons managing similarly complex sacral malunion deformities.
Level of Evidence 5.
Introduction
Sacral fractures are considered serious injuries that result from high-energy trauma such as motor vehicle accidents, falls from height, and explosions during war. They are usually associated with significant morbidities, especially when they are displaced, such as neurological deficits, bowel and bladder dysfunction, pelvic instability, nonunion, and malunion, which occur when the fractured sacrum heals in a misaligned position.1,2 This risk is higher when addressed with conservative treatment or external fixation.3–5 This disorder can lead to chronic pain, sacroiliac joint dysfunction, and, in vertically displaced fractures, leg length discrepancy, which can impair patient mobility. Additionally, these fractures often present with multiple associated injuries, and early treatment of these patients often involves focusing on life-threatening bleeding and hemodynamically stabilizing the patient. In this setting, many of these fractures are prone to falling into malunion.6–9
Treatment of malunited, vertically displaced sacral fractures is considered technically challenging, even for experienced spine surgeons, due to several factors such as complex sacral anatomy, risk of neurological and vascular injuries, and difficulties in achieving adequate reduction and stable fixation. It usually requires multiple anterior and posterior pelvic ring osteotomies for proper realignment and fixation with complex techniques not easily available in peripheral settings.6
We present here a rare case of a malunited, vertically displaced sacral fracture in a young female victim of war that was surgically managed with anterior and posterior pelvic ring osteotomies, lumbopelvic distraction to correct the leg length discrepancy, and triangular osteosynthesis with good clinical and radiological outcome. The aim of this case report is to describe the step-by-step surgical approach for the treatment of these sacral fractures.
Report of Case
Presentation
The patient is a 26-year-old woman who presented to the emergency room in a peripheral hospital with multiple traumatic injuries sustained in a war-related incident. Upon arrival at the emergency room, the patient was hemodynamically unstable and in a semiconscious state. She was stabilized and transferred to the intensive care unit. Radiographic investigations demonstrated the following injuries: right parietal lobe brain contusion, facial bone fractures, multiple rib fractures, right femur fracture, bilateral superior and inferior pubic rami fractures, and a vertically displaced left-sided sacral ala fracture. One week later, an external fixator was applied anteriorly through the iliac crest to stabilize the pelvis without any attempt to reduce the vertically displaced sacral bone fracture. The fixator was maintained for approximately 3 months before being removed due to an methicillin-resistant Staphylococcus aureus infection. The patient presented to our hospital in a wheelchair around 4 months after her initial injury with the inability to walk because of pelvic pain and shortening of the left leg by around 6 cm compared to the right leg. Her neurological examination showed decreased sensation at the dorsal aspect of the left foot with slight weakness in the left foot dorsiflexion (3/5). Computed tomography image of the pelvis showed vertically displaced left sacral ala fracture with callus formation around the superior and inferior rami fracture and around the sacral fracture (Figure 1).
Preoperative computed tomography images of the pelvis, including coronal cuts and 3D reconstructed images, showing vertically displaced left sacral ala fracture with callus formation around the superior and inferior rami fracture and around the sacral fracture.
After thorough discussion of the treatment options with the patient and her family, including all the possible complications, the decision was to proceed with a 3-step surgical correction (supine-prone-supine) in a single operative setting.
Surgical Technique
In the first stage, the patient was placed in the supine position on a radiolucent table. A bolster was placed under the pelvis to help in exposure. Scrubbing and draping of the upper thighs, pelvis, and lower abdomen were performed in the usual sterile manner.
Using the Stoppa approach to the anterior pelvic ring, a curvilinear incision was made around 2 cm above the symphysis pubis. The rectus abdominis fascia was exposed, and a longitudinal incision along the linea alba was made through the fascia. The rectus abdominus muscle bellies were then retracted laterally, carefully protecting the peritoneum throughout and remaining in the preperitoneal space. At the inferior part of the incision, the rectus abdominis muscle was detached subperiosteally from the pubic symphysis to expose the entire left superior pubic ramus. The corona mortis was dissected and ligated, allowing further elevation of the periosteum laterally, thus permitting access to the iliopectineal eminence and allowing protection and elevation of the femoral nerve vessels until the entire superior aspect of the left pubic ramus was exposed and the old fracture site with the malunion was identified. Further exposure laterally revealed the obturator neurovascular bundle crossing the quadrilateral space, which was protected. This granted enough exposure of the left superior pubic ramus for the planned osteotomy to be carried out. Using a blunt dissection, the inferior pubic ramus could be reached right under the exposed superior pubic ramus.
Under fluoroscopic guidance and using an oscillating bone saw and osteotomes, osteotomy of the superior and inferior pubic rami was carried out (Figure 2). The incision was then irrigated and packed, and the skin was closed temporarily in preparation for the next stage of the surgery.
Under fluoroscopic guidance and using an oscillating bone saw and osteotomes, osteotomy of the superior and inferior pubic rami was carried out.
Neuromonitoring was applied to the patient, and testing was carried out at every stage of the position switch, osteotomy, and reduction during this part of the surgery. A decreased signal was already present at the level of the left lower limb (tibialis anterior) before any intervention was carried out.
The patient was then switched to the prone position and scrubbed and draped in the usual manner. A midline incision was made from L3 spinous process to S3, and the paraspinal muscles were dissected and retracted laterally on the left side to expose the posterior elements of the spine as far as the tip of the transverse processes. The sacral laminae, sacral foramina, and posterior superior iliac spine were exposed on both sides. The fractured sacral ala on the left side was found to be proximally migrated up to the level of the L4 transverse process, covering the entry site of both L4 and L5 pedicle screws. Part of the proximally migrated alar bone on the left side was removed using a bone rongeur, and pedicle screws at the L4 and L5 levels were inserted on the left side only, followed by the insertion of 2 iliac screws on the left side and 1 iliac screw on the right side. At the inferior aspect of the sacral bone, the sacrotuberous ligament on the left side was released, allowing the surgeon to insert his index finger anterior to the sacrum for blunt dissection of the vital structures anteriorly and to protect them while doing the sacral osteotomy (Figure 3).
At the inferior aspect of the sacral bone, the sacrotuberous ligament on the left side was released, allowing the surgeon to insert his index finger anterior to the sacrum for blunt dissection of the vital structures anteriorly and to protect them while doing the sacral osteotomy.
At this stage, curved and straight osteotomes were used to perform the sacral osteotomy just lateral to the left sacral foramen (Figure 4). The osteotomes were stacked, permitting further opening of the osteotomy site and completely disconnecting the sacrum at the malunion site. All posterior ligaments connecting the sacrum and lower lumbar spine were cut, permitting further mobilization of the superiorly migrated left sacral ala (Figure 5). At this point, rods and transverse dominos were applied, and the reduction was carried out sequentially by longitudinal distraction between the pedicular screws at L4 to L5 and the left iliac screws.
Stacked curved and straight osteotomes were used to perform the sacral osteotomy just lateral to the left sacral foramen.
Mobilization of the superiorly migrated left sacral ala after all posterior ligaments connecting the sacrum and lower lumbar spine were cut.
Once adequate reduction was achieved, the setscrews were tightened to the rods. Another rod was applied transversely, connecting the right iliac screw to one of the left iliac screws. A transverse connector was used to connect the transverse rod to the longitudinal rod, creating a triangular fixation construct (Figure 6). Intraoperative fluoroscopy was done to confirm adequate reduction (Figure 7), and the wound was then irrigated and closed over a drain.
A transverse connector was used to connect the transverse rod to the longitudinal rod, creating a triangular fixation construct.
Intraoperative fluoroscopy confirmed adequate reduction and demonstrated the triangular osteosynthesis construct.
The patient was then switched back to the supine position, and the anterior incision was reopened. The left superior pubic ramus osteotomy was fixed using a reconstruction plate (Figure 8).
Postoperative radiographs. The pelvis anteroposterior view shows fixation of the left superior pubic ramus osteotomy using a reconstruction plate. The anteroposterior and lateral views of the lumbar spine show the final triangular osteosynthesis construct.
Postoperative Care and Follow-up
Postoperatively, it was noted that the patient’s leg length discrepancy decreased from approximately 6 cm to about 1 cm. On examination immediately postoperatively, the motor power of the left ankle and big toe dorsiflexion remained at 3/5, consistent with the preoperative assessment, and showed improvement to 4/5 motor power of the left ankle dorsiflexion and big toe dorsiflexion at around 3 weeks postoperatively. Nonweight-bearing ambulation was permitted immediately postoperatively. Progression to full weight-bearing ambulation as tolerated was initiated at 3 weeks postoperatively. At about 1 month postoperatively, the patient presented with superficial wound dehiscence secondary to a superficial wound infection of the upper part of her lower back wound, which was successfully treated using wound care and empirical oral antibiotics at home. After 1 week, the patient demonstrated healing of her wound and showed no signs of infection at 6-month follow-up (Figure 9). Additionally, at 6 months postoperatively, control radiography were performed showing adequate implant positioning, maintenance of reduction of the deformity, and signs of satisfactory bone healing (Figure 10). A computed tomography scan, however, could not be obtained at that time due to financial constraints. The patient was also able to walk completely independently without crutch aid at that point.
The patient’s lower back wound showed complete healing at about 6 months postoperatively after mild dehiscence at the most proximal end secondary to infection. It was treated using wound care and empirical oral antibiotics.
Postoperative x-ray image at 6-month follow-up. This pelvis anteroposterior view shows fixation of left superior pubic ramus osteotomy using a reconstruction plate with part of the triangular osteosynthesis construct of the lumbar spine. Adequate reduction was maintained with signs of bone healing and no signs of implant failure.
Discussion
Sacral fractures are considered complex injuries in nature that are usually associated with multiple injuries and require a multidisciplinary team to ensure a good clinical outcome. Due to their complexity and rarity, sacral fractures are frequently underdiagnosed and generally not treated properly.10–12 Failure to address acute sacral fractures appropriately might lead to malunion, which can result in chronic pain and functional impairments such as gait disturbance secondary to leg length discrepancy, affecting patient quality of life.7–9
Early operative treatment of sacral fractures may not be available in many peripheral hospitals, which is a driver behind many treating physicians ultimately following a conservative treatment approach, thus predisposing the patient to malunion of their sacral fractures, which can negatively affect the clinical outcome.
Treatment of malunited, vertically displaced sacral fractures is considered a technically challenging procedure, even for highly experienced spine surgeons. Due to the complexity of the sacral anatomy and the presence of nearby vital structures like the major vessels anteriorly and the sacral plexus posteriorly, these surgeries might be associated with major complications.13 On the other hand, patients with malunited vertically displaced sacral fractures have poor functional ability during their daily living activities.14–17 Thus, corrective surgeries may be highly warranted to achieve better functional outcomes.
In the case we presented, the patient showed a strong wish to proceed with the surgical correction of her deformity, aiming to improve her gait, even though all possible complications like infection, major vessel injury, neurological injuries, and failure to achieve acceptable reduction were explained to the patient and her family.
The major challenges with the malunited vertically displaced sacral fractures are the need to osteotomize a healed sacral bone with associated callus formation and the need to release soft tissue contractures to have the ability to reduce the fracture to an appropriate position and to have an adequate and stable fixation.18
Reduction of unilateral vertical displacement is typically done through distraction between the pedicular screws in the lumbar spine and iliac screws. Meanwhile, transverse osteosynthesis is done through the connection of iliac screws on both sides using a transverse rod. The longitudinal rod and the transverse rod are connected through a transverse connector to create a triangular osteosynthesis.6,18
The ideal surgical approach for the treatment of malunited sacral fractures is controversial, as there is a paucity of literature describing treatment algorithms. Multistage reconstruction is often required to address both the anterior and posterior pelvic rings malunion. Ultimately, restoring pelvic ring symmetry and ensuring an ability to commence early rehabilitation remain the mainstays of treatment goals.6,13,18–22
Posterior pelvic ring osteotomy techniques vary between iliac and sacral osteotomies, both significantly employed for the purpose of addressing pelvic deformities and correcting limb length discrepancies. Evidence available in the literature supports the efficacy of these techniques in improving pelvic symmetry and alignment.22–24 Luo et al proposed that iliac osteotomies are particularly beneficial for managing type B fractures, which predominantly affect the ilium, while sacral osteotomies are typically employed for fractures involving vertical displacement of the sacrum, often seen in type C fractures.18 For our patient, who presented with a vertical sacral fracture malunion and unilateral pelvic displacement, a sacral osteotomy was selected as the most appropriate approach to restore pelvic ring symmetry.
Various fixation methods have been proposed for posterior pelvic ring osteotomies, namely transverse, vertical, and triangular osteosynthesis techniques.25 However, the limited number of clinical cases has resulted in an ongoing debate regarding the most effective fixation strategy. Transverse fixation is commonly achieved using sacroiliac screws, sacral rods, or transiliac and trans-sacral plating systems. Despite its widespread use, this approach has demonstrated insufficient resistance to shear forces and is prone to failure when applied in isolation.26 Biomechanical studies have yet to establish a clear superiority of 1 fixation method over others. On the other hand, vertical fixation is usually performed via lumbopelvic distraction osteosynthesis, first introduced by Käch and Trentz in 1994.21 Combining lumbopelvic distraction osteosynthesis with transverse osteosynthesis creates triangular fixation. This triangular osteosynthesis was presented later in 1998 by Schildhauer et al as a response to complications seen with conventional fixation techniques.19 The authors theorized that it significantly improves stability against both longitudinal displacement and rotational forces, facilitating earlier rehabilitation and weight bearing. Later in 2003, Schildhauer et al published their biomechanical in vitro evaluation of the cyclic loading of their triangular osteosynthesis constructs, showing improved stability.20 Sagi et al observed that nerve root damage associated with triangular osteosynthesis was more likely due to fracture manipulation rather than the fixation technique itself, which was specifically designed to minimize iatrogenic nerve injury.13
In cases similar to the one we presented, where unilateral vertical displacement of the pelvis is present, triangular osteosynthesis and distraction can be employed for direct correction of the displacement. In a study published by Luo et al,18 9 patients with vertically displaced pelvic fracture malunions and nonunions were treated with triangular osteosynthesis and sacral osteotomies, with no notable complications reported and improvement in Majeed pelvic score and visual analog scale. The authors also described an algorithm detailing the election of their multistage treatment strategies.
Indirect decompression is also made feasible by this technique, followed by additional direct decompression of the neural elements when deemed necessary.27 This, however, does not ensure neurological healing. Malunion callus may also be compressing the nerve root and occasionally necessitates decompression.28 The need for decompression is usually assessed by the presence of callus or bone fragments or herniated discs after the fracture or osteotomy has been reduced intraoperatively.27
Our case highlights a successful multistage treatment of a vertical sacral fracture malunion with unilateral displacement done in a single operative setting. Sacral fracture malunions present a challenging pathology to treat, especially in the peripheral setting, and preoperative planning is imperative for positive outcomes postoperatively.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
Disclosures The authors have no relevant financial or non-financial interests to disclose.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2025 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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