Date Published: May 23, 2018
Author(s): Hideto Irifune, Suguru Hirayama, Nobuyuki Takahashi, Mitsumasa Chiba, Toshihiko Yamashita.
Herein, we demonstrate the clinical results of closed reduction in a hyperextended supine position with transsacral-transiliac (TSTI) and iliosacral (IS) screw fixations for Denis zone III sacral fractures.
Sixteen consecutive patients with Denis zone III sacral fractures who were treated between January 2009 and September 2016 were evaluated. All patients were treated using percutaneous TSTI/IS screw fixation during closed reduction performed with patients placed in a hyperextended supine position with body manipulation. The clinical and radiological results were evaluated, and the neurological outcomes were retrospectively assessed using Gibbon’s classification system. The clinical outcomes were evaluated using the German Multicenter Study Group Pelvic Outcome Scale (POS).
The sacral kyphotic angle was reduced by 18.06° ± 15.26° (mean kyphotic angle: pre-OP, 39.44° ± 20.56°; post-OP, 21.38° ± 7.39°), and fracture translation was reduced by 5.93 ± 4.95 mm (mean fracture translation: pre-OP, 8.69 ± 8.03 mm; post-OP 2.75 ± 3.97 mm). The mean initial Gibbon’s score was 3.00 ± 1.32. Among 15 patients with a follow-up duration of over 12 months, the mean reduction loss in the sacral kyphotic angle was 5.87° ± 10.40° and was 1.00 ± 3.00 mm for the fracture translation. The final Gibbon’s score was 1.80 ± 1.21, and 73.3% of patients had good results based on the POS score.
Although closed reduction in a hyperextended supine position with percutaneous posterior screw fixation is associated with some surgical limitations and technical difficulties, the procedure is minimally invasive and highly effective for stabilizing Denis zone III sacral fractures.
Denis zone III sacral fractures are generally due to high-energy traumas such as falls from heights, traffic accidents, and crush injuries, with most of these fractures occurring in patients with polytrauma . Zone III sacral fractures are relatively rare injuries, reportedly accounting for only 3–5% of all sacral fractures [2–4]. Importantly, these fractures are associated with a high rate of neurologic injury, including sensory and motor deficits in the lower legs; saddle anesthesia; and bowel, bladder, and sexual dysfunctions .
Patients with Denis zone III sacral fractures classified as AO/OTA type C pelvic injuries, treated between January 2009 and September 2016, were selected from our trauma database. Patients who had undergone surgical treatment and had been followed up for a minimum of 12 months were selected for analysis. The patients’ medical records were reviewed retrospectively, and the fractures were classified by the sacral level according to the method of Roy-Camille (as modified by Strange-Vognsen and Lebech) and the fracture morphology [1, 14, 15].
The present study aimed to show that closed reduction in a hyperextended supine position with manipulations and percutaneous TSTI/IS screw fixation is useful for treating Denis zone III sacral fractures. Currently, the present study is the largest case series regarding closed reduction and percutaneous screw fixation for these fractures [8, 10, 11, 13]. Furthermore, the present study includes the greatest number of cases involving the supine position maneuver.