JOT - 2026-08-13 - Journal Article
Vertically Unstable Pelvic Ring Injuries: Impact of Multilevel and Transsacral Fixation Strategy on Failure Rate.
Luther L, Maxson R, Moreno-Diaz AF, Chenard SW, Tatman LM, Mitchell PM
Topics
Key Takeaway
Multilevel transsacral fixation (MAT) reduced treatment failure in vertically unstable pelvic ring injuries to 2.6% versus 48.3% with single-level or SI-screw-only constructs (P<0.001).
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Summary
This study asked whether fixation construct type predicts failure in OTA/AO 61C.1-3 pelvic ring injuries treated percutaneously with SI or transsacral screws over 24 years at a single Level I center. MAT constructs (multilevel sacral fixation plus at least one transsacral screw, n=38) were compared to SS constructs (single-level or SI-screw-only, n=29). MAT fixation yielded a 2.6% failure rate and 2.6% revision rate versus 48.3% failure and 31.0% revision in the SS group (both P<0.001 and P=0.002, respectively).
Key Limitation
The 24-year study window almost certainly encompasses significant evolution in surgical technique, implant design, and patient selection, making early and late cohort patients non-comparable and confounding the construct-outcome relationship.
Original Abstract
OBJECTIVES
To evaluate outcomes of percutaneous pelvic fixation in the treatment of displaced vertically unstable pelvic ring injuries and identify fixation constructs that predict success.
METHODS
Design: Retrospective cohort study.
SETTING
Level I trauma center.
PATIENT SELECTION CRITERIA
Patients ≥18 years old who underwent operative management of a vertically unstable pelvic ring injury (OTA/AO 61C.1-3) displaced ≥ 10 millimeters (mm) with sacroiliac (SI) or transsacral (TS) screws over a 24-year period. Exclusion criteria were spinopelvic dissociation, pathologic fracture, treatment with spinopelvic fixation or plate fixation of the posterior pelvic ring, and less than six months follow-up.
OUTCOME MEASURES AND COMPARISONS
The primary outcome was treatment failure, defined as ≥10 mm of radiographic displacement compared to initial post-operative imaging. Secondary outcomes included failure rates stratified by posterior pelvic ring injury type and rates of revision surgery. Outcomes were compared between constructs that included both Multilevel sacral fixation and Transsacral fixation (MAT) versus constructs that lacked one or both of these features; that is, constructs with either Single-level fixation or only SI screws (SS).
RESULTS
The cohort meeting inclusion criteria comprised sixty-seven patients: MAT fixation N=38 (71% male; median age 37 years, IQR 33-53) and SS fixation N=29 (62% male; median age 39 years, IQR 34-47). The posterior ring injury patterns included sacral fractures ( n=36, 53.7%), sacroiliac fracture dislocations (n=17, 25.3%), and sacroiliac dislocations (n=14, 20.9%). MAT fixation had a significantly lower rate of treatment failure compared to SS fixation (2.6% vs 48.3%, P<0.001). Rates of revision surgery were also significantly lower when MAT fixation was utilized (2.6% vs 31.0%, P= 0.002).
CONCLUSIONS
In this cohort of vertically unstable pelvic ring injuries, fixation at multiple sacral levels with at least one TS screw was associated with a significantly lower treatment failure rate (2.6%) compared to single-level fixation or SI screw-only fixation (48.3%). When multilevel transsacral fixation cannot be achieved due to patient anatomy or injury, adjunctive fixation strategies should be considered.
LEVEL OF EVIDENCE
Therapeutic Level III.