# Three-Dimensional Navigated Transsacral Screw Fixation After Failed Conservative Treatment in Patients with Sacral Insufficiency Fractures: A Retrospective Observational Study with a Three-Month Follow-Up

## TL;DR

This study shows that 3D-guided transsacral screw surgery helps older patients with severe sacral fractures who don't improve with rest or medication.

## Contribution

The study introduces 3D navigation for transsacral screw fixation as a novel treatment for sacral insufficiency fractures after conservative failure.

## Key findings

- 3D-navigated transsacral screw fixation significantly reduced pain and opioid use in patients with sacral insufficiency fractures.
- Early mobilization was achieved in 96.2% of patients, with a mean hospital stay of 11.7 days.
- The procedure had a low complication rate (7.5%) and a 7.7% reoperation rate at 3 months.

## Abstract

Objectives: This study evaluated the effectiveness of three-dimensional (3D) navigated transsacral screw fixation in patients with sacral insufficiency fractures (SIF) who experienced inadequate mobilization after conservative management. Methods: We conducted a retrospective analysis of 53 patients (mean [±standard deviation] age 78.7 [±10.8] years; range 43.7–92.4; 81.1% female) with sacral insufficiency fractures confirmed by computed tomography or magnetic resonance imaging. Documented osteoporosis was present in 28 (52.8%) of these patients. All had failed conservative management due to persistent sacral pain or inability to mobilize. Therefore, they underwent 3D-navigated transsacral screw fixation. We collected data on demographics, fracture classification (FFP system), pain levels (Visual Analog Scale [VAS]), opioid consumption, time to mobilization, and length of hospital stay. Clinical outcomes were recorded at discharge, 1 month, and 3 months post-op; telephone interviews were conducted between 1 January and 28 February 2024 to assess longer-term pain relief and functional status. Results: Using the fragility fractures of the pelvis (FFP) classification, 60.8% of patients had FFP IIa fractures, 11.8% had FFP IIc, and 21.6% had FFP IVb. Two transsacral screws were placed in 34.0% of cases and three in 38.0%. We observed significant postoperative pain reduction—median (interquartile range [IQR]) VAS-at-rest decreased from 5 (4) preoperatively to 2 (2) at discharge and 0 (1) at 3 months (p < 0.001)—along with reduced opioid use (from 92.5% of patients on the immediate postoperative day to 45.0% at 3 months, p = 0.003). Early mobilization was achieved in 96.2% of patients. The mean hospital stay was 11.7 ± 5.1 days (95% confidence interval [CI]: 10.3–13.2; range 3–25 days), with the few outlier cases (>21 days) attributable to medical complications or delayed rehabilitation placement. The overall complication rate was low (7.5%, predominantly minor wound issues), and the 3-month reoperation rate was 7.7%. Conclusions: The 3D-navigated transsacral screw fixation is a minimally invasive and effective approach for managing sacral insufficiency fractures. It provides substantial pain relief, enables early mobilization, and demonstrates a low complication rate at 3 months. This technique shows promise in improving short-term outcomes for patients who do not respond to conservative care, regardless of osteoporosis status, although further research is needed to evaluate long-term fracture healing and functional recovery.