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Introduction <p>Vertically unstable pelvic ring injuries with sacral involvement may progress to delayed union or nonunion. We report outcomes after a standardized revision pathway and assess whether the pre-revision CT–measured maximum sacral gap can help discriminate persistent nonunion.</p> Materials and methods <p>We retrospectively reviewed 13 consecutive patients (2017–2024) revised for sacral fracture nonunion or delayed union at a tertiary trauma centre. The protocol emphasized radical debridement to punctate bleeding bone, autologous iliac-crest bone grafting (tricortical structural graft when indicated), and robust, load-sharing fixation (e.g., S1 pedicle + S2 alar–iliac/triangular or lumbopelvic constructs; ± trans-sacral/iliosacral screws; ± anterior reinforcement). Primary outcomes were union at last follow-up and Majeed score. Discrimination of the CT gap for persistent nonunion was evaluated by ROC AUC with bootstrap CIs; the Youden operating point was treated as exploratory.</p> Results <p>Union was achieved in 10/13 (76.9%). Majeed totals favored union (median 86.0 [IQR 73.25–91.5]) over persistent nonunion (23.0 [19.0–30.5]; <i>p</i> = 0.004). After index fixation, the mean residual sacral gap was 16.2 ± 5.8&#xa0;mm (range, 8–27); 11/13 (84.6%) had &gt; 10&#xa0;mm residual gap. Pre-revision gap was smaller in cases that united (mean 13.9 ± 3.8&#xa0;mm; median 13.0 [11.25–16.75]) than in persistent nonunion (23.7 ± 4.7&#xa0;mm; median 27.0 [22.0–27.0]; <i>p</i> = 0.04). The gap showed good discrimination (AUC 0.92, 95% CI 0.67–1.00). The Youden-optimal operating point (~ 16.5&#xa0;mm) yielded sensitivity 1.00 and specificity 0.70, but remained hypothesis-generating (dichotomized Fisher ≈ 0.09; FI = 0; FQ = 0.00).</p> Conclusions <p>A large residual sacral gap is a key risk factor for persistent nonunion. Optimal management centres on meticulous anatomic reduction at the index operation and, when revision is required, a combined biological–mechanical strategy—thorough debridement, autologous iliac-crest graft under compression, and augmented stabilization with robust constructs—to maximize union.</p> Level of evidence <p>Therapeutic Level IV.</p>

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Revision surgery for sacral fracture nonunion/delayed union: debridement, autologous graft, and augmented fixation: a 13-case series

  • 期刊论文

  • 发表日期：

    2026年2月12日

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  • Wei Zhang,
  • Sunwen Pan,
  • Han Chen,
  • Erman Chen,
  • Zhijun Pan,
  • Weixu Li

摘要

Introduction

Vertically unstable pelvic ring injuries with sacral involvement may progress to delayed union or nonunion. We report outcomes after a standardized revision pathway and assess whether the pre-revision CT–measured maximum sacral gap can help discriminate persistent nonunion.

Materials and methods

We retrospectively reviewed 13 consecutive patients (2017–2024) revised for sacral fracture nonunion or delayed union at a tertiary trauma centre. The protocol emphasized radical debridement to punctate bleeding bone, autologous iliac-crest bone grafting (tricortical structural graft when indicated), and robust, load-sharing fixation (e.g., S1 pedicle + S2 alar–iliac/triangular or lumbopelvic constructs; ± trans-sacral/iliosacral screws; ± anterior reinforcement). Primary outcomes were union at last follow-up and Majeed score. Discrimination of the CT gap for persistent nonunion was evaluated by ROC AUC with bootstrap CIs; the Youden operating point was treated as exploratory.

Results

Union was achieved in 10/13 (76.9%). Majeed totals favored union (median 86.0 [IQR 73.25–91.5]) over persistent nonunion (23.0 [19.0–30.5]; p = 0.004). After index fixation, the mean residual sacral gap was 16.2 ± 5.8 mm (range, 8–27); 11/13 (84.6%) had > 10 mm residual gap. Pre-revision gap was smaller in cases that united (mean 13.9 ± 3.8 mm; median 13.0 [11.25–16.75]) than in persistent nonunion (23.7 ± 4.7 mm; median 27.0 [22.0–27.0]; p = 0.04). The gap showed good discrimination (AUC 0.92, 95% CI 0.67–1.00). The Youden-optimal operating point (~ 16.5 mm) yielded sensitivity 1.00 and specificity 0.70, but remained hypothesis-generating (dichotomized Fisher ≈ 0.09; FI = 0; FQ = 0.00).

Conclusions

A large residual sacral gap is a key risk factor for persistent nonunion. Optimal management centres on meticulous anatomic reduction at the index operation and, when revision is required, a combined biological–mechanical strategy—thorough debridement, autologous iliac-crest graft under compression, and augmented stabilization with robust constructs—to maximize union.

Level of evidence

Therapeutic Level IV.