Mortality following benign sacral insufficiency fracture and associated risk factors

Sacral U-type Fractures in Patients Older Than 65 years

INTRODUCTION

The purpose of this study was to determine the degree of disability that geriatric patients with sacral U-type fractures experience.

METHODS

Patients older than 65 years presenting from 2013 to 2019 with a U-type sacral fracture were included. Patient demographics, treatment type, preinjury domicile, preinjury use of assistive devices, and neurologic deficits were recorded. Outcomes included mortality, return to preinjury domicile, and use of assistive devices for mobility.

RESULTS

Among 46 patients in the treatment period, ground-level fall was the most common mechanism of injury (60.8%). Thirty-four patients (74%) were treated surgically, most commonly with closed percutaneous fixation (n = 27). Thirteen percent of patients died during the admission. At the final follow-up, 14 (45%) had not returned to their prior domicile and 18 (58%) required more supportive assistive devices. Seventy-three percent of patients who presented delayed required a new gait aid, compared with 47% presenting acutely. Between those presenting with low-energy versus high-energy mechanisms, similar rates of need were observed for new assistive devices (50% low and 73% high) and lack of return to preinjury domicile (40% low, 50% high).

DISCUSSION

Many geriatric patients were disabled by or died after sustaining a sacral U-type fracture, highlighting the morbidity regardless of high-energy or low-energy trauma.

Evaluating Treatment Outcomes for Pelvic Insufficiency Fractures: A Systematic Review

Background: Pelvic insufficiency fractures (PIF) are typical in geriatric populations with reduced bone quality, most commonly in elderly postmenopausal women. These fractures are usually caused by low-energy forces over the bones during ordinary life and cause disabling pain. Treatment options range from conservative to operative. The aim of this study is to assess the outcomes of treatments for pelvic insufficiency fractures, determining optimal approaches between surgical intervention and conservative management. Methods: This literature review systematically examines articles focusing on patients with PIF, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and using PubMed, Medline, and the Cochrane Library database. We took into account only full-text articles in indexed journals with available English abstracts, considering data about patient demographics, surgery, and outcomes. Results: After screening 128 articles, this study reviewed 20 manuscripts involving 1499 patients, mostly elderly females and focusing on sacrum fractures. Common treatments included conservative methods and sacroplasty, with a few complications reported. Osteoporosis was the prevalent comorbidity, and the survival rate post-treatment was high at 92.3%. Mobility outcomes varied, with some patients experiencing significant autonomy loss. The average follow-up period was over 17 months. Conclusions: This study found a cautious approach to surgery (timing of three weeks), which is reserved only for specific patterns, and it leads to increased autonomy and a lower risk of mortality. Due to the lack of pre- and postoperative scores as well as conflicting results, it is imperative to undertake further studies and research to be able to compare the alternative treatments efficiently.

Sacral insufficiency fracture: a single-center experience of 185 patients with a minimum 5-year follow-up

PURPOSE

Sacral insufficiency fracture (SIF) is a commonly underdiagnosed etiology of back pain, especially in the geriatric and osteoporotic population. In this clinical study, we present our experience of 185 patients who were diagnosed with SIF and managed either with conservative or surgical treatment with a minimum 5-year follow-up.

MATERIALS AND METHOD

Patients who were diagnosed with SIF, managed either conservatively or surgically, and had a minimum 5-year follow-up medical record were included in this study. CT scans and MR imaging including coronal STIR sequence were obtained from all. Bone densitometry (DEXA) was performed to detect accompanying osteopenia or osteoporosis. Patients were treated either conservatively or surgically. VAS and ODI scores were evaluated prior to the treatment and 1st day, 10th day, 3rd month, and 1st year postoperatively.

RESULTS

The mean age of 185 patients was 69.2 and the mean follow-up period was 7.23 years (range: 5-11 years). 46 (24.9%) patients had a previous spinal or spinopelvic surgery and spinal instrumentation was implemented in 22(11.89%) of them. The time interval between the fusion surgery and the diagnosis of SIF was approximately 9.48 weeks. The fracture line could be detected with the MRI in 164 patients and with the CT in 177 patients. The fracture was bilateral in 120 (64.8%) patients. 102 patients were treated conservatively, and 83 received sacroplasty. VAS and ODI scores showed better improvement in pain and functionality in the surgical management group than in the conservative management group.

CONCLUSION

SIF should be considered in the differential diagnosis of back and pelvic pain, especially in elderly and osteoporotic patients. MRI with coronal STIR imaging should be a standard protocol for patients with a risk of SIF. Our results show that sacroplasty provides better and faster pain relief and recovery than conservative management.

[Sacral H-shaped fractures between traumatic, insufficiency and fatigue fractures : Similarities, differences and controversies]

In the basic entirety of stress fractures, insufficiency fractures are defined as fractures caused by prolonged normal or physiological loading of a bone with insufficient elastic resistance. This clearly distinguishes it from fatigue fractures, in which excessive loads are continuously applied to a bone with normal elastic resistance. According to Pentecost (1964) both entities of stress fracture result from "the inherent inability of the bone to withstand stress applied without violence in a rhythmical, repeated, subthreshold manner". This distinguishes them from acute traumatic fractures. In the clinical routine these differences are not always so clearly presented. The example of the H‑shaped sacral fracture is used to illustrate the relevance of a clear terminology. In this context, current controversies in the treatment of sacral insufficiency fractures are discussed.

Pelvic insufficiency fractures and pelvic bone metastases after neoadjuvant (chemo)radiotherapy for rectal cancer

BACKGROUND

Pelvic insufficiency fractures (PIFs) are a late complication of radiotherapy for pelvic malignancies. We evaluated the incidence, radiologic findings, clinical course, and outcome of PIFs in patients treated with neoadjuvant (chemo)radiotherapy ((C)RT) for rectal cancer.

MATERIAL AND METHODS

Data of patients diagnosed with rectal cancer from a large teaching hospital treated from 2002 to 2012 were extracted from the Dutch Cancer Registry. All hospital records were reviewed for the diagnosis of PIFs or pelvic bone metastases. An expert radiologist reassessed all imaging procedures of the lower back, abdomen, and pelvis.

RESULTS

A total of 513 rectal cancer patients were identified of whom 300 patients (58.5%) were treated with neoadjuvant (C)RT (long- vs. short-course radiotherapy: 91 patients [17.7%] vs. 209 [40.7%], respectively). Twelve PIFs were diagnosed initially according to hospital records and imaging reports of all 513 patients. These 12 patients were treated with neoadjuvant (C)RT. After reassessment of all pelvic imaging procedures done in this patient group (432 patients (84.2%)), 20 additional PIFs were detected in patients treated with neoadjuvant (C)RT, resulting in a 10.7% PIF rate in irradiated patients. One PIF was detected in the group of patients not treated with neoadjuvant (C)RT for rectal cancer. This patient had palliative radiotherapy for prostate cancer and is left out of the analysis. Median follow-up time of 32 PIF patients was 49 months. Median time between start of neoadjuvant (C)RT and diagnosis of PIF was 17 months (IQR 9-28). Overall median survival for patients with PIF was 63.5 months (IQR 44-120).

CONCLUSION

PIFs are a relatively common late complication of neoadjuvant (C)RT for rectal cancer but are often missed or misdiagnosed as pelvic bone metastases. The differentiation of PIFs from pelvic bone metastases is important because of a different treatment and disease outcome.

Surgical treatment of sacral nonunions

Sacral fractures are complex injuries that follow a bimodal distribution, typically involving acute high energy trauma in young adults and low energy trauma in older adults (> 65 years old). Nonunion is a rare but debilitating potential complication of undiagnosed or improperly managed sacral fractures. Various surgical techniques, including open reduction and internal fixation, sacroplasty, and percutaneous screw fixation, have been used to manage these fracture nonunions. In addition to reviewing the initial management of sacral fractures and the risk factors for fracture nonunion, this article describes techniques, specific cases and outcomes of these treatment strategies.

Teriparatide treatment shows faster healing than sacroplasty for postmenopausal women with sacral insufficiency fracture

Objectives

Sacral insufficiency fracture (SIF) is not an uncommon osteoporosis fracture among the elderly. Aside from traditional treatments, sacroplasty and teriparatide (TPTD) injection have been introduced. This report aims to compare the effects of sacroplasty and teriparatide on clinical outcomes of SIF.

Methods

Thirty-one elderly patients with SIF were enrolled in this retrospective observational study. Four male patients were excluded. Fourteen patients who received TPTD for 6 months were classified into the TPTD group (TT), and 13 who underwent sacroplasty were classified into the sacroplasty group (SS). All patients in both groups were instructed to take calcium and vitamin D supplements daily. Their symptoms and signs, visual analog score (VAS), Oswestry disability index (ODI), and radiographic studies were retrospectively reviewed.

Results

The TT group showed significantly lower VAS than SS group after 3 (P < 0.001) and 6 months of treatment (P < 0.001). The TT group also has significant lower ODI than SS group after 1 (P = 0.010), 3 (P = 0.005) and 6 months (P < 0.001) of treatment. Upon generalized estimating equations (GEE) analysis, the TT group showed significantly more reduction in both VAS and ODI compared to the SS group at 1 month (P = 0.022, P = 0.001), 3 months (P < 0.001, P < 0.001), and 6 months (P < 0.001, P < 0.001) post-treatment.

Conclusions

Postmenoposal woman with SIF who received TPTD healed better than those who underwent sacroplasty after 1 month treatment.

Comparative outcome of different treatment options for fragility fractures of the sacrum

BACKGROUND

Fragility fractures of the sacrum (FFS) have been detected more and more frequently in recent times, and the incidence will continue to increase due to increasing life expectancy. The aim of this study was to compare the clinical outcome of conservative, interventional and surgical treatment of FFS.

METHODS

Retrospectively, 292 patients (276 women, 16 men) with confirmed FFS were followed up over a period of 2 years. The age of the women was Ø 81.2 (58 - 99) and that of the men Ø 78.1 (76 - 85) years. The pain was quantified using a VAS. Fractures were classified in accordance with the Rommens and Hofmann and with the Denis classification using conventional X-rays, CT and MRI. A QCT of the lumbar spine was performed to quantify bone mineral density. Concomitant diseases of every patient were recorded. An interdisciplinary case conference determined the individual treatment concept considering the age, type of fracture, pain level and comorbidities with classification into conservative, interventional (any type of sacroplasty) or surgical treatment. Over the course pain and independence were measured, complications and patient satisfaction were documented. A vitamin D determination was done, and existing comorbidities were included.

RESULTS

Patients with a pain level of ≤5 benefited from the conservative therapy measures, with pain levels > 5 significantly delaying the development of mobility. After sacroplasty, the pain reduced significantly, which caused a rapid improvement in mobility without any significant difference being found between vertebro- (VSP), balloon (BSP), radiofrequency (RFS) and cement sacroplasty (CSP). In terms of pain reduction and mobilization, the surgical treated patients benefited from osteosynthesis, although more complex fracture types with lumbopelvic stabilization took longer. Overall, there were no deaths during the hospital stay. Mortality after 12 months was 21.7% for the conservative, 8.4% for the interventional and 13.6% for the surgical therapy group; the differences are significant. For patients in the conservative therapy group who were difficult to mobilize due to pain, the mortality increased to 24.3%. Over 24 months, patients achieved the best independence after sacroplasty. At 12 and 24 months, subjective satisfaction with the therapies was best after sacroplasty, followed by osteosynthesis and conservative measures. All patients had a pronounced vitamin D deficiency and manifest osteoporosis. Cardiovascular pathologies were the main concomitant diseases.

CONCLUSIONS

Patients with FFS with a low level of pain benefit from conservative therapy measures, whereby complications and mortality increase significantly in the case of persistent immobilizing pain. Patients with an unacceptable level of pain resulting from non-dislocated fractures benefit significantly from sacroplasty. Patients with unstable and displaced fractures (Rommens and Hofmann type III and IV) should be operated on promptly. Different techniques are available for sacroplasty and osteosynthesis, which lead to an improvement of independence and a reduction in mortality.

Percutaneous sacroiliac screw fixation in fragility fractures of the pelvis: Comparison of two different augmentation techniques

OBJECTIVE

Fragility fractures of the pelvis (FFP) are becoming increasingly common. Percutaneous sacroiliac screw fixation is an accepted and safe treatment method for FFP. Augmentation is an option to optimize fixation strength of the screws. This study aims to compare patient mobility and the occurrence of complications after operative treatment of FFP utilizing two different augmentation techniques.

METHODS

All patients who received augmented sacroiliac screws for the treatment of FFPs between 01.01.2017 and 31.12.2018 at one of the two participating hospitals were included. The operative techniques only differed with regards to the augmentation method used. At the one hospital cannulated screws were used. Definitive screw placement followed augmentation. At the other hospital cannulated and fenestrated screws were used, permitting definitive screw placement prior to augmentation.

RESULTS

In total, 59 patients were included. The NRS score for pain was significantly lower after surgery. Preoperative mobility levels could be maintained or improved in 2/3 of the patients. There were no fatal complications. Two revision surgeries were performed because of screw misplacement. There were no significant differences between the two augmentation techniques in terms of complications.

CONCLUSION

Both augmentation techniques have a low complication rate and are safe methods to maintain patients' mobility level. The authors advocate early consideration of surgical treatment for patients with FFP. Augmentation can be considered a safe addition when performing percutaneous sacroiliac screw fixation.

[Sacral fragility fractures: risk factors and outcomes after cement sacroplasty]

BACKGROUND

The objective of the present study on patients with fragility fractures of the sacrum (FFS) was to assess existing risk factors and clinical outcomes after cement sacroplasty (CSP).

PATIENTS AND METHODS

68 patients (64 women, 4 men) with previous FFS were followed up retrospectively. CT and MRI images were used to classify fractures according to Denis et al. and Rommens and Hofmann. Bone mineral content was determined by QCT in all patients. Concomitant diseases as well as central and peripheral fractures were recorded, considering the patient's medical history and X‑ray images. Vitamin D levels were also determined. If conservative therapy was unsuccessful, CSP was performed. The results were documented on the basis of pain development, physical independence, patient satisfaction, complication rate and mortality.

RESULTS

The age of the women in the study was Ø 83.2 (72-99) and that of the men Ø 77.8 (76-85) years. 42.4% had a Denis type 1, 4.2% a Denis type 2, 0% a Denis type 3, 43.3% a Denis type 1-2 and 10.1% a Denis type 1-2-3 fracture zone. FFP type II a to II c fractures were found in 88.2%, FFP type III c in 7.4% and FFP type IV b in 4.4%. Bilateral FFS were found in 68.8%. The average bone mineral content (BMC) was 35.4 (2-74) mg/ml, and the average vitamin D value was 8.8 (0-28) nmol/l. Other osteoporosis-associated fractures were found in around 50% of the patients. After CSP, patients showed a rapid and significant (p < 0.001) reduction in pain and sustained clinical improvement.

CONCLUSION

FFS fracture risk factors were found to be female gender, advanced age, existing osteoporosis and severe vitamin‑D deficiency. Patients with non-displaced FFS who could not be mobilised due to pain experienced sustained benefit from CSP.

Diagnostic Significance of 18F-FDG PET/CT Imaging Coupled with Magnetic Resonance Imaging of the Entire Body for Bone Metastases

Objective

To see if 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) imaging paired with MR diffusion imaging can help doctors diagnose bone metastases.

Methods

From September 2020 to December 2021, a total of 30 individuals with probable bone metastases were recruited for the trial. With an average interval of four days, MAGNETIC resonance whole-body diffusion imaging (MR whole-body diffusion imaging) was performed on each of the 30 patients who had 18F-FDG PET/CT. The SUVmax values of the group with bone metastases were compared to those of the group without bone metastases. In this study, 18F-FDG PET/CT imaging, MR whole-body diffusion imaging, and their combination were examined. The researchers compared the results when 18F-FDG PET/CT imaging, whole-body MRI diffusion scans, and their combination indicated abnormal bone lesions. By comparing the diagnostic efficacy of 18F-FDG PET/CT imaging, MR whole-body diffusion imaging, and their combination, as well as accuracy, sensitivity, and specificity, the three techniques for diagnosing bone metastases will be evaluated for diagnostic usefulness. Results: the SUV max values of patients with bone metastases were significantly different from those of patients without bone metastases, as determined by 18F-FDG PET/CT imaging (P < 0.05). Using 18F-FDG PET/CT imaging, MR whole-body diffusion imaging, and their combined detection of aberrant bone lesions in various areas, we found statistically significant differences.

Conclusion

The use of 18F-FDG PET/CT imaging in conjunction with MR whole-body diffusion imaging in the diagnosis of bone metastases can be very helpful.

Sacral Insufficiency Fractures

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Primary osteoporosis is the most common cause of sacral insufficiency fractures (SIFs). Therefore, a multidisciplinary team approach is necessary for treatment of the fracture and the underlying biologic pathology, as well as prevention of future fragility fractures.

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The presentation of SIFs typically includes lower back or buttock pain after a ground-level fall or without an identified trauma. Symptoms often have an insidious onset and are nonspecific; consequently, a delay in diagnosis and treatment is common. Clinicians need to have a high index of suspicion, particularly in high-risk patients.

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Postmenopausal women who are >55 years of age are the most common demographic affected by SIFs. Other risk factors include osteoporosis, history of a prior fragility fracture, local irradiation, long-term corticosteroid use, rheumatoid arthritis, metabolic bone disorders, vitamin D deficiency, pregnancy, history of prior multilevel spinal fusion, and malignancy.

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Typical imaging on computed tomography (CT) shows sclerosis of cancellous bone in the sacral ala, with or without a discrete fracture line or displacement. Magnetic resonance imaging is more sensitive than CT and shows hypointense signal on T1-weighted sequences and hyperintensity on T2-weighted or short tau inversion recovery sequences.

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The treatment of SIFs is dependent on the severity of symptoms, fracture displacement, and instability of the pelvis. Accepted treatments include nonoperative rehabilitation, sacroplasty, iliosacral screw fixation, transsacral bar or screw fixation, transiliac internal fixation, and lumbopelvic fixation.

Short-term outcome of fragility fractures of the pelvis in the elderly treated with screw osteosynthesis and external fixator

Background

The treatment of fragility fractures of the pelvis is rising challenge for orthopedic trauma surgeons. Operative treatment should allow immediate full weight bearing and early mobilisation but should also be as minimal invasive as possible. Sacroiliac (SI) or transsacral transiliac screws (TSTI) alone or depending on the fracture in combination with an external fixator meets both of these criteria.

Material and methods

The outcome of 121 operatively treated patients with fragility fractures of the pelvis were evaluated in this retrospective study. Depending on the type of fracture the patients were treated with navigated SI screw or TSTI screw alone or in combination with an external fixator. All patients were operated in supine position in a hybrid-OR, which consists of a fixed robotic 3D flatpanel detector (Artis zeego, Siemens Healthineers, Germany) and a navigation system (BrainLab Curve, BrainLab, Germany).

Results

37 patients were treated with either one or two SI screws and 57 with one TSTI screw. An additional external fixator was combined with SI screws in 17 patients and with TSTI screws in 10 patients. The preoperative pain score was significantly higher compared to the postoperative score (5.1 ± 2.5 vs 2.2 ± 1.9, p < 0.05). Follow-up at 6 month was possible for 106 patients which showed screw loosening in 16.3% of the SI Screws (n = 49) compared to only 5.2% of TSTI screws (n = 57). No screw loosening was seen in the combination of TSTI-screw and external fixator (n = 10). There were two septic and three aseptic pin loosenings of the external fixator. Overall only one patient needed revision surgery due to screw loosening and local irritation. Overall 75.2% (n = 91) of the patients could be released in their home or in a rehabilitation unit and only 14% (n = 17) were released to a nursing home due to immobility despite the operation. Non-surgical complications rate was 21.5%.

Conclusion

SI or TSTI screws with possible combination with an external fixator show early pain relief and allows most of the patients to keep their former level of independence. With an also low surgical complication rate, it proved to be a safe and reliable treatment for fragility fractures of the pelvis. Due the effective pain relief and the minimal invasive approach, early mobilisation is possible and might prevent typical non-surgical complications which are very common during conservative treatment.

[Minimally invasive lumbopelvic stabilization of sacral fracture and sacroiliac injury]

OBJECTIVE

Rapid mobilization with full weight bearing by minimally invasive fixation of Os ilium to L5 in fractures of the sacrum and disruption of the sacroiliac joint (SIJ).

INDICATIONS

Unstable injuries of the posterior pelvic ring in fractures of the sacrum and disruption of the SIJ.

CONTRAINDICATIONS

Fracture of ilium and not injury related implants in the screw trajectory, neurological deficits regarding the fracture, decubitus in the area of surgical approach.

SURGICAL TECHNIQUE

Minimally invasive screw placement in the pedicles of L5, access of ilium screw via the posterior superior iliac spine. Radiological display for the iliacal screw bearing trajectory in Os Ilium as a drop-shaped/triangle canal. Insert a Jamshidi needle orthograde in the beam path, change to guide wire and placement of iliacal screw after resection of the bone in the screw head area. Submuscular insertion of the longitudinal rods, in case of double-sided instrumentation similar procedure on the opposite side, reduction of the fracture and fixation of the rods to screws.

POSTOPERATIVE MANAGEMENT

Postoperative mobilization with full weight bearing under physiotherapeutic guidance.

RESULTS

Patients treated with lumbopelvic stabilization in our facility between 2012 and 2017 were identified via the hospital database and retrospectively evaluated. In 24 patients with median age of 60.1 years and a follow-up-time of 11.8 months, we found no implant displacement, infection and no wound healing problems. Full weight bearing was permitted in 21 of 24 cases, in 3 cases partial load bearing due to other injuries. Three patients reported moderate mechanical irritation of iliacal screws; 1 patient reported severe irritability with removal of the implants after bony healing of fracture 1 year postoperatively.

Minimally invasive lumbopelvic stabilization of sacral fragility fractures in immobilized geriatric patients: feasibility and early return to mobility

INTRODUCTION

In an aging society, the incidence of sacral fragility fractures is increasing and diagnosis is often delayed. Immobilization has devastating consequences especially in elderly patients. Short-term mobilization of these patients is crucial. The aim of this study is to evaluate the early return to mobility of immobilized geriatric patients with sacral fragility fractures treated with minimally invasive lumbopelvic stabilization.

METHODS

Retrospective analysis of thirteen consecutive patients (13 females) which could not be mobilized with conservative treatment, and thus were treated with minimally invasive lumbopelvic stabilization. Pain intensity measurement on an 11-point Numeric Rating Scale (NRS), Tinetti Mobility Test (TMT), and Timed Up and Go Test (TUGT) were performed preoperatively and 4 weeks postoperatively. Surgical and medical complications were analyzed.

RESULTS

Mean age at surgery was 83.92 ± 6.27 years and mean ASA score was 2.77 ± 0.42. NRS improved from a mean of 7.18 ± 0.98 preoperatively to a mean of 2.45 ± 0.93 4 weeks postoperatively (Ρ < 0.001). TMT score improved from a mean of 4.15 ± 3.67 preoperatively to a mean of 16.39 ± 4.61 4 weeks postoperatively (Ρ < 0.001). Due to immobilization, patients were not able finish TUGT preoperatively. Four weeks postoperatively TUGT reached a mean of 31.1 ± 11.08 s. There were two surgical complications (one wound healing disorder, one rod dislocation) in two patients that required revision surgery. Two patients developed pneumonia postoperatively.

CONCLUSIONS

Minimally invasive lumbopelvic stabilization of sacral fragility fractures is feasible in geriatric patients. Early mobilization of these patients is possible after surgery. The rate of complications is acceptable.

Trans-sacral bar osteosynthesis provides low mortality and high mobility in patients with fragility fractures of the pelvis

Operative treatment of osteoporosis-associated fragility fractures of the pelvis (FFP) and the sacrum is advocated with immobilizing or longstanding pain, fracture progression and displacement. We analyzed clinical outcomes regarding mobility, quality of life, and mortality of patients with FFP treated with trans-sacral bar (TB) osteosynthesis through S1. Demographics, clinical data, and operation-related data of patients with an FFP treated with TB were acquired from chart review. We assessed mortality, quality of life (EQ-5D), mobility, and residential status at follow-up. Seventy-nine females and six males with a median age of 78.0 years (IQR 73–84) were included, median follow-up was 3.2 years. Medical complications during hospitalization occurred in 28%. Operative revision was carried out in 15% of patients. One-year survival was 90.4%, this was associated with shorter preoperative and total length of stay in hospital (p 0.006 and 0.025, respectively). At follow-up, 85% lived at home and 82% walked with or without walking aid. Higher EQ-5D was reached with higher mobility status and living at home (p < 0.001 and < 0.001, respectively). TB osteosynthesis is an adequate and reliable method for fixation of FFP in the posterior pelvic ring to ensure timely mobilization. Shorter preoperative and total length of stay had lower mortality rates, advocating a standardized management protocol to limit time delay to operative therapy. Patients treated with TB osteosynthesis had low 1-year mortality of less than 10%.

Global Trends of Researches on Sacral Fracture Surgery: A Bibliometric Study Based on VOSviewer

STUDY DESIGN

Bibliometric analysis.

OBJECTIVE

This study aims to identify and summarize the articles related to sacral fracture surgery, to compare the papers from different countries and journals, to show the trends of researches on sacral fracture surgery.

SUMMARY OF BACKGROUND DATA

In recent years, studies on sacral fracture are growing rapidly, but there were no bibliometric studies regarding sacral fracture surgery.

METHODS

Excel 2016 and VOSviewer were used to identify and summarize the articles from Web of Science between 1900 and 2018. Publication number, publication year, publication country, publication organization, publication source, author, sum of times cited, H-index, and journal's impact factors were recorded and analyzed. Bibliometric maps of co-citations and maps of co-occurrence of keywords are drawn.

RESULTS

A total of 611 publications were extracted. United States published most articles (227, 37.2%), both total citations (3536) and H-index (32) of United States ranked first of all the countries. The most productive organization on sacral fracture surgery is Johns Hopkins University (14). Spine (43) published the most articles on sacral fracture surgery. The latest keyword "patterns" appeared in 2017 in 5 articles. Other relatively new keywords include "proximal junctional kyphosis," "spondylopelvic dissociation," "fragility fracture," "lumbopelvic fixation" that appeared in 2017 in eight, six, six, and 25 articles, respectively.

CONCLUSION

This bibliometric study showed that there is a growing trend both in published articles related to sacral fracture surgery and relative research interest in the last 30 years. United States dominates the research regarding sacral fracture surgery. Johns Hopkins University, Johannes Gutenberg University of Mainz, and Harborview Medical Center are the best institutions related to sacral fracture surgery research. Spine, J Orthop Trauma, and Injury are the top three productive journals on sacral fracture surgery. Sacral fracture patterns, proximal junctional kyphosis, spondylopelvic dissociation, fragility fracture, and lumbopelvic fixation may be the new research hotspot in this field.

LEVEL OF EVIDENCE

5.

Sacral Insufficiency Fractures: a Review of Risk Factors, Clinical Presentation, and Management

PURPOSE OF THE REVIEW

Sacral insufficiency fractures (SIF) are a common and often underdiagnosed source of low back pain. In patients with SIF, there is both a compromised sacroiliac joint and weakened sacrum, resulting in decreased resistance to torsional stress, leading to fracture. While conservative medical management is a safe option, minimally invasive intervention may provide improved short and long-term relief of low back pain in patients presenting with SIF. This comprehensive review is undertaken to provide an update to the current understanding of SIF with description of risk factors, clinical presentation, and management.

RECENT FINDINGS

Sacroplasty is a minimally invasive procedure in which polymethylmethacrylate (PMMA) cement is inserted into bone to improve its structural integrity and alleviate symptoms. Balloon sacroplasty (BSP) has also been successful in alleviating pain with minimal cement leakage in SIF patients. Various other interventional techniques, including navigation-assisted screw fixation have been used to address SIF and have shown improvement in pain with minimal side effects. This review included various modalities of treatments available to manage SIF. This review shows that in comparison with nonsurgical management, sacroplasty has been shown to have greater pain reduction and improved mobility.