Efficacy Analysis of Anterior versus Posterior Surgical Approaches for Denis Zone III Sacral Fractures: A Retrospective Comparative Study

Efficacy Analysis of Anterior versus Posterior Surgical Approaches for Denis Zone III Sacral Fractures: A Retrospective Comparative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy Analysis of Anterior versus Posterior Surgical Approaches for Denis Zone III Sacral Fractures: A Retrospective Comparative Study Libing Liu, Haixin LI, Fengcheng Zhu, Huanlong Li, Leliang Fu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8313792/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Sacral fractures represent 30–40% of pelvic ring injuries, with Denis Zone III fractures posing the greatest challenge due to their involvement of the central sacral canal and foramina, often resulting in neurological deficits, pelvic instability, and complications such as rectal, bladder, and sexual dysfunction. Surgical management is standard, but the choice between anterior and posterior approaches remains debated, particularly regarding hemorrhage control, neural decompression, and recovery. Methods This retrospective cohort study reviewed 42 patients with Denis Zone III sacral fractures treated from December 2015 to June 2025. Group A (n = 19) underwent anterior sacral approach, including 15 cases with digital subtraction angiography (DSA)-guided temporary abdominal aortic balloon occlusion (AABO) for high-bleeding-risk fractures. Group B (n = 23) underwent traditional posterior open reduction and internal fixation. Outcomes assessed included operative time, intraoperative blood loss, hospital stay, radiographic reduction quality (Matta criteria), neurological recovery, Majeed functional scores, Visual Analog Scale (VAS) pain scores, and complications. Statistical analysis used independent t-tests (P < 0.05 significance threshold). Results All procedures were completed successfully. Group A had longer operative times (159.7 ± 30.3 min vs. 100.8 ± 22.2 min; t = 7.26, P < 0.05) but lower blood loss (423 ± 90 mL vs. 780 ± 145 mL; t = 9.34, P < 0.05) and shorter hospital stays (14.0 ± 4.5 days vs. 17.2 ± 5.4 days; t = 2.09, P 0.05). VAS and Majeed scores improved significantly postoperatively in both groups (VAS at discharge: t = 20.3, P < 0.05; Majeed at 6 months: t = 15.4, P < 0.05), with no intergroup differences. Mean follow-up was 9.7 months (Group A) and 9.1 months (Group B). Conclusions Although more time-intensive, the anterior approach with selective AABO reduces intraoperative blood loss and wound complications while providing equivalent functional and neurological outcomes to the posterior approach. This supports its use in high-risk Denis Zone III fractures, advocating for patient-specific surgical selection. Sacral fracture Denis Zone III Anterior sacral approach Posterior sacral approach Abdominal aortic balloon occlusion VAS score Majeed score Figures Figure 1 Figure 2 Introduction Sacral fractures account for 30–40% of pelvic ring injuries [1], with Denis Zone III fractures representing the most severe subtype due to their traversal through the central sacral canal and foramina [2]. These injuries frequently lead to significant complications, including bowel and bladder dysfunction, sexual impairment, and lower extremity sensorimotor deficits, often associated with poor prognosis [3]. Optimal surgical intervention aims to restore pelvic stability, achieve neural decompression, and minimize perioperative risks such as hemorrhage and infection [4]. The posterior sacral approach has traditionally been preferred for its direct access to the sacral canal and relative simplicity. However, it involves extensive soft-tissue dissection, which can increase risks of wound necrosis, infection, and suboptimal anterior fracture reduction or decompression [5]. In contrast, the anterior sacral approach, enhanced by interventional techniques like DSA-guided temporary abdominal aortic balloon occlusion (AABO), has emerged as a viable alternative, particularly for controlling intraoperative bleeding and improving surgical safety [6,7]. Comparative data on these approaches for Denis Zone III fractures are limited, with existing studies often constrained by small sample sizes or mixed fracture classifications [8]. Given the complexity of Denis Zone III fractures, evidence-based comparisons are essential to clarify the relative advantages of different surgical approaches. This retrospective study evaluates 42 cases of Denis Zone III sacral fractures treated between December 2015 and June 2025, objectively comparing anterior and posterior approaches across perioperative metrics, radiographic outcomes, neurological recovery, and complications to guide surgical decision-making. Materials and Methods Study Design and Patient Selection This single-center retrospective cohort study included patients with sacral Denis Zone III fractures treated at our institutions from December 2015 to June 2025. Inclusion criteria were: (1) CT-confirmed Denis Zone III fracture; (2) age 18–70 years; (3) surgical treatment via anterior or posterior open reduction and internal fixation; (4) complete medical records. Exclusion criteria included: (1) pathological fractures; (2) severe comorbidities (cardiac, pulmonary, hepatic, or renal); (3) pregnancy or lactation; (4) follow-up less than 3 months. A total of 42 patients were enrolled (24 males, 18 females; mean age 44.6 ± 8.9 years, range 25–65). Patients were grouped by surgical approach: Group A (anterior, n = 19; 15 with AABO) and Group B (posterior, n = 23). Baseline characteristics, including demographics, injury mechanisms, and preoperative neurological status, were comparable between groups (P > 0.05 for all). Preoperative Evaluation Injury mechanisms were documented, and comprehensive neurological examinations were performed, assessing anal sphincter tone, perineal sensation, and lower limb motor/sensory function. Imaging modalities included pelvic X-rays, CT with 3D reconstruction, and MRI to delineate fracture patterns and neural compression. High-bleeding-risk cases (e.g., suspected presacral venous plexus involvement) were reviewed by a multidisciplinary team (MDT) comprising orthopedic surgeons, anesthesiologists, interventional radiologists, vascular surgeons, and neurosurgeons to plan AABO. Preoperative management included discontinuation of anticoagulants, correction of coagulopathy, treatment of hypoalbuminemia (albumin < 30 g/L), blood glucose control (≤ 8.0 mmol/L fasting), and blood pressure stabilization. Surgical Techniques Anterior Sacral Approach (Group A) Patients were positioned supine with 15°-20° lumbar elevation under general anesthesia. A 12–15 cm pararectus or left lower abdominal oblique incision was used to access the retroperitoneal space, with careful protection of the ureter and iliac vessels. Hematoma was evacuated to expose the anterior sacrum from the promontory to S3 level. In 15 high-risk cases, AABO was implemented using the Seldinger technique via femoral artery puncture under DSA guidance, with balloon inflation distal to the renal arteries (occlusion duration: 20–30 min, mean 25.4 ± 3.2 min). C-arm fluoroscopy guided fracture reduction to restore sacral contour and foramina morphology; neural decompression was performed if indicated. Internal fixation utilized pre-contoured reconstruction or sacral-specific locking plates spanning S1 to S3, secured with 3.5 mm cortical screws (S1: 15° cephalad-medial angulation, 35–45 mm depth; S2-S3: perpendicular, 25–35 mm depth). A drainage tube was placed prior to layered closure. (Fig. 1 a-d: a. DSA-guided AABO placement post-anesthesia; b. Paramedian incision exposing visceral organs; c. Postoperative patient view; d. Fluoroscopy demonstrating excellent fracture reduction and fixation position.) Posterior Sacral Approach (Group B) Patients were positioned prone with pelvic padding for 20°-30° hip flexion and abdominal decompression. A 15–20 cm midline incision from L5 spinous process to coccyx allowed subperiosteal exposure of the posterior sacrum to the sacroiliac joints. Hematoma was cleared, with protection of S1-S3 posterior foramina and emerging nerve roots. Fluoroscopy-assisted reduction employed laminar spreaders to restore sacral canal volume and foramina shape. Fixation varied by fracture stability: percutaneous iliosacral screws for stable patterns; lumbopelvic screw-rod constructs (L5 pedicle and iliac screws with pre-bent rods) for comminuted fractures. Intraoperative neuromonitoring, including somatosensory evoked potentials and electromyography, was utilized to detect neural compromise. The surgical field was irrigated with saline, dual negative-pressure drains inserted, and closure performed in layers. (Fig. 2 e-h: e. Preoperative CT image; f. Posterior exposure of fracture; g. Postoperative patient view; h. Fluoroscopy showing satisfactory reduction and fixation.) Postoperative Management Standard postoperative care included 24–48 hours of prophylactic antibiotics, anticoagulation for deep vein thrombosis prevention, and monitoring of blood glucose and pressure. Drains were removed within 48 hours. Early mobilization with non-weight-bearing exercises commenced on day 3, progressing to partial weight-bearing based on radiographic evidence of healing. Outcome Measures Perioperative outcomes: operative time, blood loss, hospital stay. Radiographic assessment: Matta criteria for reduction quality (excellent: displacement 20 mm). Functional evaluation: Majeed score (0-100; higher scores indicate better pelvic function) and VAS (0–10; lower scores indicate less pain) at preoperative, discharge, 3-month, and 6-month intervals. Complications monitored: wound infection, neurological deterioration, fixation failure, deep vein thrombosis. Statistical Analysis Data were analyzed using SPSS version 26.0. Continuous variables are presented as mean ± standard deviation (SD). Intergroup comparisons used independent samples t-tests, with P < 0.05 considered statistically significant. Results Baseline patient characteristics were balanced between groups, with no significant differences in age, sex, injury mechanism, or preoperative scores (Table 1 ). Table 1 Baseline Patient Characteristics (mean ± SD or n) Parameter Group A (n = 19) Group B (n = 23) t-value/P-value Age (years) 45.2 ± 9.1 44.1 ± 8.8 > 0.05 Sex (male/female) 11/8 13/10 > 0.05 Injury mechanism (high-energy/low-energy) 14/5 16/7 > 0.05 Preoperative VAS 7.8 ± 1.2 7.6 ± 1.4 > 0.05 Preoperative Majeed 42.3 ± 6.7 43.1 ± 7.2 > 0.05 All surgeries were completed without major intraoperative events. Group A demonstrated significantly longer operative times but reduced blood loss and shorter hospital stays compared to Group B (Table 2 ). Follow-up durations were similar (P > 0.05). Table 2 Perioperative Outcomes (mean ± SD) Parameter Group A Group B t-value P-value Operative time (min) 159.7 ± 30.3 100.8 ± 22.2 7.26 < 0.05 Blood loss (mL) 423 ± 90 780 ± 145 9.34 < 0.05 Hospital stay (days) 14.0 ± 4.5 17.2 ± 5.4 2.09 0.05 Radiographic evaluation per Matta criteria revealed high rates of excellent or good reduction in both groups (Group A: 94.7% [excellent 15/19, good 3/19, fair 1/19]; Group B: 91.3% [excellent 16/23, good 5/23, fair 2/23]), with no significant intergroup difference (P > 0.05). Note The operative time in Group A was significantly longer than that in Group B (P < 0.05), but the intraoperative blood loss was significantly less than that in Group B (P < 0.05). The length of hospital stay in Group A was shorter than that in Group B, and the difference was statistically significant (P < 0.05). VAS scores improved significantly from preoperative levels at discharge (t = 20.3, P < 0.05) and continued to decrease over follow-up in both groups. Majeed scores showed marked postoperative improvement at 6 months (t = 15.4, P < 0.05), with no differences between groups (Table 3 ). Neurological function remained stable or improved in all patients, with no cases of deterioration. Table 3 VAS and Majeed Scores Over Time (mean ± SD) Score/Time Preoperative Discharge 3 Months 6 Months VAS Group A 7.8 ± 1.2 3.2 ± 0.8 1.9 ± 0.4 1.5 ± 0.6 VAS Group B 7.6 ± 1.4 3.4 ± 0.9 1.9 ± 0.9 1.7 ± 0.7 Majeed Group A 42.3 ± 6.7 49.5 ± 6.8 64.0 ± 7.0 84.0 ± 7.0 Majeed Group B 43.1 ± 7.2 50.0 ± 7.3 63.5 ± 7.5 83.9 ± 8.1 Complications were minimal: Group A achieved 100% primary wound healing with no infections. In Group B, 3 patients (13.0%) developed wound infections, resolved with debridement and antibiotics. No instances of deep vein thrombosis, fixation failure, or AABO-related complications (e.g., aortic injury) occurred. Note There was no statistically significant difference in preoperative VAS scores between the two groups (P > 0.05). At discharge, VAS scores in both groups decreased significantly compared to preoperative scores (P 0.05). At postoperative 6 months, Majeed scores in both groups showed significant improvement compared to preoperative scores (t = 15.4, P 0.05). Discussion Denis Zone III sacral fractures are biomechanically disruptive, compromising the pelvic ring's load transmission and sacral nerve roots, which can lead to profound functional impairments [9,10]. The increased operative duration in the anterior approach (mean difference 58.9 min; t = 7.26, P < 0.05 with a significant difference) most likely results from its more demanding anatomy and the incorporation of balloon occlusion procedures. However, this is offset by substantial reductions in blood loss (mean difference: 357 mL, t = 9.34, P < 0.05), which clinically translates to decreased transfusion requirements (potentially reducing risks of transfusion-related acute lung injury or alloimmunization [11]) and improved hemodynamic stability intraoperatively. The shorter hospital stay in Group A (mean difference: 3.2 days, t = 2.09, P < 0.05) may be attributable to lower complication rates, aligning with enhanced recovery after surgery (ERAS) principles [12]. Wound infection rates were notably higher in Group B (13.0% vs. 0%), exceeding typical reported rates of 5–10% in posterior pelvic surgery [13]. This disparity could stem from the posterior approach's greater soft-tissue trauma and exposure to contamination, whereas the anterior incision benefits from superior abdominal wall vascularity and reduced dead space [14]. Statistically, while the sample size limits chi-square analysis for infections, the zero incidence in Group A suggests a clinically meaningful advantage, potentially lowering healthcare costs and morbidity. Functional outcomes, assessed via Majeed and VAS scores, demonstrated significant improvements in both groups (P < 0.05), with no intergroup differences at 6 months. The Majeed score's increase (mean ~ 41 points from baseline) indicates robust recovery in pelvic function, including walking, sitting, and sexual activity, consistent with literature reporting 70–85% good-to-excellent outcomes in stabilized sacral fractures [15]. VAS reductions (mean ~ 6 points) reflect effective pain management, likely due to anatomic reduction (high Matta excellent/good rates > 90%). These findings imply that both approaches achieve core objectives of stability and decompression, with the anterior method offering direct ventral access for anteriorly displaced fragments or compressed nerves, as supported by biomechanical models [16]. AABO's role in 15 Group A cases merits specific analysis: mean occlusion time (25.4 min) was within safe limits (< 30 min), minimizing risks of ischemia or reperfusion injury [17]. The technique's hemostatic effect (reducing blood loss by ~ 46%) is particularly valuable in Zone III fractures, where presacral venous bleeding can be profuse [6]. However, AABO requires MDT expertise and may not be universally available, highlighting the need for resource considerations in clinical application. Limitations This study's retrospective design introduces potential selection bias, as approach choice may have been influenced by surgeon preference or fracture characteristics (e.g., anterior displacement favoring anterior approach). The single-center setting limits generalizability, and the small sample size (n = 42) reduces statistical power for detecting rare complications or subgroup differences (e.g., by sex or injury energy). Follow-up was relatively short (mean ~ 9 months), potentially underestimating late sequelae such as pseudarthrosis, chronic pain, or sexual dysfunction, which may manifest beyond 12–24 months [18]. Lack of randomization precludes causal inference, and unmeasured confounders (e.g., surgeon experience, comorbidity indices) could affect outcomes. Additionally, while Matta criteria assessed reduction, advanced metrics like sacral kyphosis angle or nerve conduction studies were not included, limiting neurological evaluation depth [19]. Future prospective, multicenter randomized controlled trials with longer follow-up (≥ 2 years), larger cohorts, and standardized neuromonitoring are essential to address these limitations and validate findings [20]. These findings indicate that the anterior approach is a reasonable choice for high-bleeding-risk or ventrally displaced Denis Zone III fractures, whereas the posterior approach remains appropriate for cases requiring direct dorsal canal access. Conclusions The anterior sacral approach with selective AABO, despite extended operative duration, offers advantages in reducing blood loss, hospital stay, and infection risk compared to the posterior approach, with comparable radiographic and functional outcomes at 6 months. These findings support tailored surgical strategies for Denis Zone III sacral fractures, emphasizing MDT involvement for optimal patient selection. Larger prospective studies are needed to confirm long-term benefits and refine indications. Declarations Ethics approval and consent to participate: This study was approved by the institutional review boards of Wuhan Fifth Hospital and Kunming Second People's Hospital. As a retrospective analysis, informed consent was waived. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests. Funding: No external funding was received. Author Contribution LL: Conceptualization, data curation, formal analysis, writing-original draft; LH: Data curation, methodology, writing-review & editing; ZF: Investigation, validation; LHL: Formal analysis, visualization; HM: Writing-review & editing, supervision (co-corresponding); FL: Conceptualization, resources, supervision, writing-review & editing (corresponding). Acknowledgement We acknowledge the contributions of the interventional radiology and neurosurgery teams. Availability of data and materials: Data are available from the corresponding authors upon reasonable request. References Gänsslen A, Pohlemann T, Paul C, Lobenhoffer P, Tscherne H. Epidemiology of pelvic ring injuries. Injury. 1996;27(Suppl 1):S–A13. Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;(227):67–81. Robles LA. Sacral fractures and associated injuries. Global Spine J. 2014;4(3):207–12. Bellabarba C, Schildhauer TA, Vaccaro AR, Chapman JR. Complications associated with surgical stabilization of high-grade sacral fracture dislocations with spino-pelvic instability. Spine. 2006;31(11 Suppl):S80–8. Zhang Y, Li C, Zhang L, et al. Efficacy and safety of temporary balloon occlusion of the abdominal aorta in the treatment of complex sacral fractures. J Orthop Surg Res. 2020;15(1):325. Hu X, Pei F, Wang G, et al. Application of aortic balloon occlusion in complex pelvic and sacral tumor resection: a meta-analysis. J Orthop Surg Res. 2019;14(1):228. Lindahl J, Mäkinen TJ, Koskinen SK, Söderlund T. Neurological outcome after surgical treatment of sacral fractures. Eur Spine J. 2014;23(6):1299–304. Sagi HC, Militano U, Caron T, Lindvall E. A comprehensive analysis with minimum 1-year follow-up of vertically unstable transforaminal sacral fractures treated with triangular osteosynthesis. J Orthop Trauma. 2009;23(5):313–9. Yi C, Hak DJ. Traumatic spinopelvic dissociation or U-shaped sacral fracture: a review of the literature. Injury. 2012;43(4):402–8. Kortman K, Ortiz O, Miller T, et al. Multicenter retrospective review of patients with traumatic spinopelvic dissociation. J Neurosurg Spine. 2015;22(6):601–8. Delaney M, Wendel S, Bercovitz RS, et al. Transfusion reactions: prevention, diagnosis, and treatment. Lancet. 2016;388(10061):2825–36. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78(5):606–17. Park YS, Baek SW, Kim HS, Park CS. Management of sacral fractures associated with spinal or pelvic ring injury. J Trauma. 2008;65(3):703–8. Keel MJ, Benneker LM, Siebenrock KA, Bastian JD. The pararectus approach for anterior internal fixation of sacroiliac joint disruption and sacral fractures: a technical note. J Orthop Trauma. 2013;27(11):e262–5. Reilly MC, Bono CM, Litkouhi B, Sirkin M, Behrens FF. The effect of sacral fracture malreduction on the safe placement of iliosacral screws. J Orthop Trauma. 2006;20(1 Suppl):S37–43. Wagner D, Kamer L, Sawaguchi T, et al. Minimally invasive anterior approach to the lumbosacral junction: an anatomical study. Eur Spine J. 2017;26(10):2651–8. Li C, Zhang Y, Zhang L, et al. Safety and efficacy of temporary abdominal aortic balloon occlusion in complex sacral tumor surgery. J Orthop Surg Res. 2018;13(1):301. Lindahl J, Hirvensalo E. Outcome after surgical treatment of unstable sacral fractures. Injury. 2005;36(6):783–90. Zheng Z, Yu B, Zhang Y, et al. Application of temporary aortic balloon occlusion in the treatment of complex pelvic and sacral fractures. Chin J Traumatol. 2017;20(4):222–5. Vaccaro AR, Kim DH, Brodke DS, et al. Diagnosis and management of sacral spine fractures. Instr Course Lect. 2004;53:375–85. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8313792","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":560146230,"identity":"31e3f010-2236-4c1a-8509-f1891a183085","order_by":0,"name":"Libing Liu","email":"","orcid":"","institution":"Wuhan Fifth Hospital","correspondingAuthor":false,"prefix":"","firstName":"Libing","middleName":"","lastName":"Liu","suffix":""},{"id":560146231,"identity":"8aec8307-f285-4e85-a31e-37576018d6a7","order_by":1,"name":"Haixin LI","email":"","orcid":"","institution":"Kunming Second People's 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09:54:36","extension":"xml","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":64944,"visible":true,"origin":"","legend":"","description":"","filename":"883c00f71ab24842a007b5c3af652fa71structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8313792/v1/0778e0bb61ce4577fa6021bd.xml"},{"id":98299858,"identity":"348d35a8-1ea3-418b-a198-97e9b583d8ce","added_by":"auto","created_at":"2025-12-16 09:54:33","extension":"html","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78251,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8313792/v1/13ba01d273343175a79725e3.html"},{"id":98299864,"identity":"7da582f5-d374-4b93-88d5-19fbc8ac9bd3","added_by":"auto","created_at":"2025-12-16 09:54:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":611389,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eIntraoperative and postoperative images of the anterior sacral approach.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(a) Intraoperative digital subtraction angiography (DSA)-guided placement of an abdominal aortic balloon catheter following general anesthesia. The balloon is positioned in the infrarenal abdominal aorta via femoral artery access using the Seldinger technique, inflated to temporarily occlude blood flow (mean occlusion time: 25.4 ± 3.2 minutes), thereby minimizing hemorrhage from the presacral venous plexus during fracture manipulation.\u003c/p\u003e\n\u003cp\u003e(b) Surgical exposure of visceral organs through a paramedian incision along the rectus abdominis sheath (approximately 12-15 cm length, extending from the umbilicus to the pubic symphysis). The peritoneum is retracted medially to enter the retroperitoneal space, with careful identification and protection of the left ureter and iliac vessels, allowing direct access to the anterior sacral promontory and fracture site for hematoma evacuation and reduction.\u003c/p\u003e\n\u003cp\u003e(c) Postoperative external view of the patient, demonstrating primary wound healing of the abdominal incision without erythema, drainage, or signs of infection, typically assessed at discharge (mean hospital stay: 14.0 ± 4.5 days).\u003c/p\u003e\n\u003cp\u003e(d) Postoperative fluoroscopic imaging confirming excellent fracture reduction (per Matta criteria: displacement \u0026lt;4 mm) and optimal positioning of internal fixation hardware, including pre-contoured sacral locking plates spanning S1 to S3 vertebrae, secured with 3.5 mm cortical screws (S1: 15° cephalad-medial angulation, 35-45 mm depth; S2-S3: perpendicular, 25-35 mm depth).\u003c/p\u003e\n\u003cp\u003eFig. a: Placement of a balloon in the abdominal aorta under interventional DSA guidance after patient anesthesia.Fig. b: The patient's visceral organs are exposed via a paramedian incision.Fig. c: Postoperative view of the patient.Fig. d: Postoperative fluoroscopy shows excellent fracture reduction and optimal positioning of the internal fixation hardwares.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8313792/v1/6eba0b0db7f9f6efdaf95fbe.png"},{"id":98299869,"identity":"c4ef7a52-ff8f-4e80-b8e8-d938aef01cc0","added_by":"auto","created_at":"2025-12-16 09:54:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":786466,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative and intraoperative images of the posterior sacral approach.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(e) Preoperative computed tomography (CT) scan of the patient, illustrating the Denis Zone III sacral fracture with transverse involvement of the central canal and foramina, associated displacement, and potential neural compression, used for surgical planning and confirmation of fracture classification.\u003c/p\u003e\n\u003cp\u003e(f) Intraoperative exposure of the sacral fracture through a posterior midline incision (approximately 15-20 cm length, from L5 spinous process to coccyx). Subperiosteal dissection of the erector spinae muscles reveals the posterior sacral surface to the sacroiliac joints, with hematoma clearance and protection of S1-S3 nerve roots emerging from the posterior foramina.\u003c/p\u003e\n\u003cp\u003e(g) Postoperative external view of the patient, showing the healed posterior incision with no evidence of wound dehiscence or infection, evaluated at follow-up (mean: 9.1 months).\u003c/p\u003e\n\u003cp\u003e(h) Postoperative fluoroscopic imaging verifying satisfactory fracture reduction (per Matta criteria: excellent/good rate 91.3%) and proper positioning of internal fixation devices, such as lumbopelvic screw-rod constructs or percutaneous iliosacral screws, ensuring restoration of sacral canal volume and foramina morphology.\u003c/p\u003e\n\u003cp\u003eNote: Figure e: Preoperative CT image of the patient. Figure f: The fracture was exposed through a posterior sacral approach. Figure g: Postoperative image of the patient. Figure h: Postoperative fluoroscopy shows satisfactory fracture reduction and proper positioning of the internal fixation device.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8313792/v1/39a331f2d550aede9007a8a2.png"},{"id":103285692,"identity":"80e6dc7c-d6f8-4d00-bcb3-3f923e4b5842","added_by":"auto","created_at":"2026-02-24 04:40:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2648069,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8313792/v1/1a178668-c417-4290-95db-798a6ccd99bd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy Analysis of Anterior versus Posterior Surgical Approaches for Denis Zone III Sacral Fractures: A Retrospective Comparative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSacral fractures account for 30\u0026ndash;40% of pelvic ring injuries [1], with Denis Zone III fractures representing the most severe subtype due to their traversal through the central sacral canal and foramina [2]. These injuries frequently lead to significant complications, including bowel and bladder dysfunction, sexual impairment, and lower extremity sensorimotor deficits, often associated with poor prognosis [3]. Optimal surgical intervention aims to restore pelvic stability, achieve neural decompression, and minimize perioperative risks such as hemorrhage and infection [4].\u003c/p\u003e \u003cp\u003eThe posterior sacral approach has traditionally been preferred for its direct access to the sacral canal and relative simplicity. However, it involves extensive soft-tissue dissection, which can increase risks of wound necrosis, infection, and suboptimal anterior fracture reduction or decompression [5]. In contrast, the anterior sacral approach, enhanced by interventional techniques like DSA-guided temporary abdominal aortic balloon occlusion (AABO), has emerged as a viable alternative, particularly for controlling intraoperative bleeding and improving surgical safety [6,7].\u003c/p\u003e \u003cp\u003eComparative data on these approaches for Denis Zone III fractures are limited, with existing studies often constrained by small sample sizes or mixed fracture classifications [8]. Given the complexity of Denis Zone III fractures, evidence-based comparisons are essential to clarify the relative advantages of different surgical approaches. This retrospective study evaluates 42 cases of Denis Zone III sacral fractures treated between December 2015 and June 2025, objectively comparing anterior and posterior approaches across perioperative metrics, radiographic outcomes, neurological recovery, and complications to guide surgical decision-making.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Patient Selection\u003c/h2\u003e \u003cp\u003eThis single-center retrospective cohort study included patients with sacral Denis Zone III fractures treated at our institutions from December 2015 to June 2025. Inclusion criteria were: (1) CT-confirmed Denis Zone III fracture; (2) age 18\u0026ndash;70 years; (3) surgical treatment via anterior or posterior open reduction and internal fixation; (4) complete medical records. Exclusion criteria included: (1) pathological fractures; (2) severe comorbidities (cardiac, pulmonary, hepatic, or renal); (3) pregnancy or lactation; (4) follow-up less than 3 months.\u003c/p\u003e \u003cp\u003eA total of 42 patients were enrolled (24 males, 18 females; mean age 44.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9 years, range 25\u0026ndash;65). Patients were grouped by surgical approach: Group A (anterior, n\u0026thinsp;=\u0026thinsp;19; 15 with AABO) and Group B (posterior, n\u0026thinsp;=\u0026thinsp;23). Baseline characteristics, including demographics, injury mechanisms, and preoperative neurological status, were comparable between groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05 for all).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePreoperative Evaluation\u003c/h3\u003e\n\u003cp\u003eInjury mechanisms were documented, and comprehensive neurological examinations were performed, assessing anal sphincter tone, perineal sensation, and lower limb motor/sensory function. Imaging modalities included pelvic X-rays, CT with 3D reconstruction, and MRI to delineate fracture patterns and neural compression. High-bleeding-risk cases (e.g., suspected presacral venous plexus involvement) were reviewed by a multidisciplinary team (MDT) comprising orthopedic surgeons, anesthesiologists, interventional radiologists, vascular surgeons, and neurosurgeons to plan AABO. Preoperative management included discontinuation of anticoagulants, correction of coagulopathy, treatment of hypoalbuminemia (albumin\u0026thinsp;\u0026lt;\u0026thinsp;30 g/L), blood glucose control (\u0026le;\u0026thinsp;8.0 mmol/L fasting), and blood pressure stabilization.\u003c/p\u003e\n\u003ch3\u003eSurgical Techniques\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAnterior Sacral Approach (Group A)\u003c/h2\u003e \u003cp\u003ePatients were positioned supine with 15\u0026deg;-20\u0026deg; lumbar elevation under general anesthesia. A 12\u0026ndash;15 cm pararectus or left lower abdominal oblique incision was used to access the retroperitoneal space, with careful protection of the ureter and iliac vessels. Hematoma was evacuated to expose the anterior sacrum from the promontory to S3 level.\u003c/p\u003e \u003cp\u003eIn 15 high-risk cases, AABO was implemented using the Seldinger technique via femoral artery puncture under DSA guidance, with balloon inflation distal to the renal arteries (occlusion duration: 20\u0026ndash;30 min, mean 25.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2 min). C-arm fluoroscopy guided fracture reduction to restore sacral contour and foramina morphology; neural decompression was performed if indicated. Internal fixation utilized pre-contoured reconstruction or sacral-specific locking plates spanning S1 to S3, secured with 3.5 mm cortical screws (S1: 15\u0026deg; cephalad-medial angulation, 35\u0026ndash;45 mm depth; S2-S3: perpendicular, 25\u0026ndash;35 mm depth). A drainage tube was placed prior to layered closure.\u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea-d: a. DSA-guided AABO placement post-anesthesia; b. Paramedian incision exposing visceral organs; c. Postoperative patient view; d. Fluoroscopy demonstrating excellent fracture reduction and fixation position.)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePosterior Sacral Approach (Group B)\u003c/h3\u003e\n\u003cp\u003ePatients were positioned prone with pelvic padding for 20\u0026deg;-30\u0026deg; hip flexion and abdominal decompression. A 15\u0026ndash;20 cm midline incision from L5 spinous process to coccyx allowed subperiosteal exposure of the posterior sacrum to the sacroiliac joints. Hematoma was cleared, with protection of S1-S3 posterior foramina and emerging nerve roots. Fluoroscopy-assisted reduction employed laminar spreaders to restore sacral canal volume and foramina shape.\u003c/p\u003e \u003cp\u003eFixation varied by fracture stability: percutaneous iliosacral screws for stable patterns; lumbopelvic screw-rod constructs (L5 pedicle and iliac screws with pre-bent rods) for comminuted fractures. Intraoperative neuromonitoring, including somatosensory evoked potentials and electromyography, was utilized to detect neural compromise. The surgical field was irrigated with saline, dual negative-pressure drains inserted, and closure performed in layers.\u003c/p\u003e \u003cp\u003e(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ee-h: e. Preoperative CT image; f. Posterior exposure of fracture; g. Postoperative patient view; h. Fluoroscopy showing satisfactory reduction and fixation.)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative Management\u003c/h2\u003e \u003cp\u003eStandard postoperative care included 24\u0026ndash;48 hours of prophylactic antibiotics, anticoagulation for deep vein thrombosis prevention, and monitoring of blood glucose and pressure. Drains were removed within 48 hours. Early mobilization with non-weight-bearing exercises commenced on day 3, progressing to partial weight-bearing based on radiographic evidence of healing.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcome Measures\u003c/h3\u003e\n\u003cp\u003ePerioperative outcomes: operative time, blood loss, hospital stay. Radiographic assessment: Matta criteria for reduction quality (excellent: displacement\u0026thinsp;\u0026lt;\u0026thinsp;4 mm; good: 4\u0026ndash;10 mm; fair: 10\u0026ndash;20 mm; poor: \u0026gt;20 mm). Functional evaluation: Majeed score (0-100; higher scores indicate better pelvic function) and VAS (0\u0026ndash;10; lower scores indicate less pain) at preoperative, discharge, 3-month, and 6-month intervals. Complications monitored: wound infection, neurological deterioration, fixation failure, deep vein thrombosis.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using SPSS version 26.0. Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Intergroup comparisons used independent samples t-tests, with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBaseline patient characteristics were balanced between groups, with no significant differences in age, sex, injury mechanism, or preoperative scores (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Patient Characteristics (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or n)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B (n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et-value/P-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex (male/female)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13/10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjury mechanism (high-energy/low-energy)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14/5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16/7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative VAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreoperative Majeed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAll surgeries were completed without major intraoperative events. Group A demonstrated significantly longer operative times but reduced blood loss and shorter hospital stays compared to Group B (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Follow-up durations were similar (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative Outcomes (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e159.7\u0026thinsp;\u0026plusmn;\u0026thinsp;30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e100.8\u0026thinsp;\u0026plusmn;\u0026thinsp;22.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e423\u0026thinsp;\u0026plusmn;\u0026thinsp;90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e780\u0026thinsp;\u0026plusmn;\u0026thinsp;145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e9.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRadiographic evaluation per Matta criteria revealed high rates of excellent or good reduction in both groups (Group A: 94.7% [excellent 15/19, good 3/19, fair 1/19]; Group B: 91.3% [excellent 16/23, good 5/23, fair 2/23]), with no significant intergroup difference (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNote\u003c/span\u003e\u003c/strong\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThe operative time in Group A was significantly longer than that in Group B (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but the intraoperative blood loss was significantly less than that in Group B (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The length of hospital stay in Group A was shorter than that in Group B, and the difference was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/span\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003eVAS scores improved significantly from preoperative levels at discharge (t\u0026thinsp;=\u0026thinsp;20.3, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and continued to decrease over follow-up in both groups. Majeed scores showed marked postoperative improvement at 6 months (t\u0026thinsp;=\u0026thinsp;15.4, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with no differences between groups (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Neurological function remained stable or improved in all patients, with no cases of deterioration.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eVAS and Majeed Scores Over Time (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScore/Time\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDischarge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 Months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 Months\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS Group A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e1.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS Group B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e3.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e1.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajeed Group A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e42.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e49.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e64.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e84.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajeed Group B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e43.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e50.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e63.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e83.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComplications were minimal: Group A achieved 100% primary wound healing with no infections. In Group B, 3 patients (13.0%) developed wound infections, resolved with debridement and antibiotics. No instances of deep vein thrombosis, fixation failure, or AABO-related complications (e.g., aortic injury) occurred.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003e\u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eNote\u003c/span\u003e\u003c/strong\u003e \u003cp\u003e \u003cspan type=\"SmallCaps\" class=\"SmallCaps\" name=\"Emphasis\"\u003eThere was no statistically significant difference in preoperative VAS scores between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). At discharge, VAS scores in both groups decreased significantly compared to preoperative scores (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), but no statistically significant difference was found between the groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). At postoperative 6 months, Majeed scores in both groups showed significant improvement compared to preoperative scores (t\u0026thinsp;=\u0026thinsp;15.4, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with no statistically significant for pre- vs. post-op improvement (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/span\u003e \u003c/p\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDenis Zone III sacral fractures are biomechanically disruptive, compromising the pelvic ring's load transmission and sacral nerve roots, which can lead to profound functional impairments [9,10]. The increased operative duration in the anterior approach (mean difference 58.9 min; t\u0026thinsp;=\u0026thinsp;7.26, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 with a significant difference) most likely results from its more demanding anatomy and the incorporation of balloon occlusion procedures. However, this is offset by substantial reductions in blood loss (mean difference: 357 mL, t\u0026thinsp;=\u0026thinsp;9.34, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), which clinically translates to decreased transfusion requirements (potentially reducing risks of transfusion-related acute lung injury or alloimmunization [11]) and improved hemodynamic stability intraoperatively.\u003c/p\u003e \u003cp\u003eThe shorter hospital stay in Group A (mean difference: 3.2 days, t\u0026thinsp;=\u0026thinsp;2.09, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) may be attributable to lower complication rates, aligning with enhanced recovery after surgery (ERAS) principles [12]. Wound infection rates were notably higher in Group B (13.0% vs. 0%), exceeding typical reported rates of 5\u0026ndash;10% in posterior pelvic surgery [13]. This disparity could stem from the posterior approach's greater soft-tissue trauma and exposure to contamination, whereas the anterior incision benefits from superior abdominal wall vascularity and reduced dead space [14]. Statistically, while the sample size limits chi-square analysis for infections, the zero incidence in Group A suggests a clinically meaningful advantage, potentially lowering healthcare costs and morbidity.\u003c/p\u003e \u003cp\u003eFunctional outcomes, assessed via Majeed and VAS scores, demonstrated significant improvements in both groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with no intergroup differences at 6 months. The Majeed score's increase (mean\u0026thinsp;~\u0026thinsp;41 points from baseline) indicates robust recovery in pelvic function, including walking, sitting, and sexual activity, consistent with literature reporting 70\u0026ndash;85% good-to-excellent outcomes in stabilized sacral fractures [15]. VAS reductions (mean\u0026thinsp;~\u0026thinsp;6 points) reflect effective pain management, likely due to anatomic reduction (high Matta excellent/good rates\u0026thinsp;\u0026gt;\u0026thinsp;90%). These findings imply that both approaches achieve core objectives of stability and decompression, with the anterior method offering direct ventral access for anteriorly displaced fragments or compressed nerves, as supported by biomechanical models [16].\u003c/p\u003e \u003cp\u003eAABO's role in 15 Group A cases merits specific analysis: mean occlusion time (25.4 min) was within safe limits (\u0026lt;\u0026thinsp;30 min), minimizing risks of ischemia or reperfusion injury [17]. The technique's hemostatic effect (reducing blood loss by ~\u0026thinsp;46%) is particularly valuable in Zone III fractures, where presacral venous bleeding can be profuse [6]. However, AABO requires MDT expertise and may not be universally available, highlighting the need for resource considerations in clinical application.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study's retrospective design introduces potential selection bias, as approach choice may have been influenced by surgeon preference or fracture characteristics (e.g., anterior displacement favoring anterior approach). The single-center setting limits generalizability, and the small sample size (n\u0026thinsp;=\u0026thinsp;42) reduces statistical power for detecting rare complications or subgroup differences (e.g., by sex or injury energy). Follow-up was relatively short (mean\u0026thinsp;~\u0026thinsp;9 months), potentially underestimating late sequelae such as pseudarthrosis, chronic pain, or sexual dysfunction, which may manifest beyond 12\u0026ndash;24 months [18]. Lack of randomization precludes causal inference, and unmeasured confounders (e.g., surgeon experience, comorbidity indices) could affect outcomes. Additionally, while Matta criteria assessed reduction, advanced metrics like sacral kyphosis angle or nerve conduction studies were not included, limiting neurological evaluation depth [19]. Future prospective, multicenter randomized controlled trials with longer follow-up (\u0026ge;\u0026thinsp;2 years), larger cohorts, and standardized neuromonitoring are essential to address these limitations and validate findings [20].\u003c/p\u003e \u003cp\u003eThese findings indicate that the anterior approach is a reasonable choice for high-bleeding-risk or ventrally displaced Denis Zone III fractures, whereas the posterior approach remains appropriate for cases requiring direct dorsal canal access.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe anterior sacral approach with selective AABO, despite extended operative duration, offers advantages in reducing blood loss, hospital stay, and infection risk compared to the posterior approach, with comparable radiographic and functional outcomes at 6 months. These findings support tailored surgical strategies for Denis Zone III sacral fractures, emphasizing MDT involvement for optimal patient selection. Larger prospective studies are needed to confirm long-term benefits and refine indications.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e This study was approved by the institutional review boards of Wuhan Fifth Hospital and Kunming Second People's Hospital. As a retrospective analysis, informed consent was waived.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eNo external funding was received.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLL: Conceptualization, data curation, formal analysis, writing-original draft; LH: Data curation, methodology, writing-review \u0026amp; editing; ZF: Investigation, validation; LHL: Formal analysis, visualization; HM: Writing-review \u0026amp; editing, supervision (co-corresponding); FL: Conceptualization, resources, supervision, writing-review \u0026amp; editing (corresponding).\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe acknowledge the contributions of the interventional radiology and neurosurgery teams.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e \u003cp\u003eData are available from the corresponding authors upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eG\u0026auml;nsslen A, Pohlemann T, Paul C, Lobenhoffer P, Tscherne H. Epidemiology of pelvic ring injuries. Injury. 1996;27(Suppl 1):S\u0026ndash;A13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDenis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop Relat Res. 1988;(227):67\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobles LA. Sacral fractures and associated injuries. Global Spine J. 2014;4(3):207\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBellabarba C, Schildhauer TA, Vaccaro AR, Chapman JR. Complications associated with surgical stabilization of high-grade sacral fracture dislocations with spino-pelvic instability. Spine. 2006;31(11 Suppl):S80\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Y, Li C, Zhang L, et al. Efficacy and safety of temporary balloon occlusion of the abdominal aorta in the treatment of complex sacral fractures. J Orthop Surg Res. 2020;15(1):325.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu X, Pei F, Wang G, et al. Application of aortic balloon occlusion in complex pelvic and sacral tumor resection: a meta-analysis. J Orthop Surg Res. 2019;14(1):228.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindahl J, M\u0026auml;kinen TJ, Koskinen SK, S\u0026ouml;derlund T. Neurological outcome after surgical treatment of sacral fractures. Eur Spine J. 2014;23(6):1299\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSagi HC, Militano U, Caron T, Lindvall E. A comprehensive analysis with minimum 1-year follow-up of vertically unstable transforaminal sacral fractures treated with triangular osteosynthesis. J Orthop Trauma. 2009;23(5):313\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYi C, Hak DJ. Traumatic spinopelvic dissociation or U-shaped sacral fracture: a review of the literature. Injury. 2012;43(4):402\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKortman K, Ortiz O, Miller T, et al. Multicenter retrospective review of patients with traumatic spinopelvic dissociation. J Neurosurg Spine. 2015;22(6):601\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelaney M, Wendel S, Bercovitz RS, et al. Transfusion reactions: prevention, diagnosis, and treatment. Lancet. 2016;388(10061):2825\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78(5):606\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark YS, Baek SW, Kim HS, Park CS. Management of sacral fractures associated with spinal or pelvic ring injury. J Trauma. 2008;65(3):703\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeel MJ, Benneker LM, Siebenrock KA, Bastian JD. The pararectus approach for anterior internal fixation of sacroiliac joint disruption and sacral fractures: a technical note. J Orthop Trauma. 2013;27(11):e262\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReilly MC, Bono CM, Litkouhi B, Sirkin M, Behrens FF. The effect of sacral fracture malreduction on the safe placement of iliosacral screws. J Orthop Trauma. 2006;20(1 Suppl):S37\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWagner D, Kamer L, Sawaguchi T, et al. Minimally invasive anterior approach to the lumbosacral junction: an anatomical study. Eur Spine J. 2017;26(10):2651\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi C, Zhang Y, Zhang L, et al. Safety and efficacy of temporary abdominal aortic balloon occlusion in complex sacral tumor surgery. J Orthop Surg Res. 2018;13(1):301.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLindahl J, Hirvensalo E. Outcome after surgical treatment of unstable sacral fractures. Injury. 2005;36(6):783\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng Z, Yu B, Zhang Y, et al. Application of temporary aortic balloon occlusion in the treatment of complex pelvic and sacral fractures. Chin J Traumatol. 2017;20(4):222\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaccaro AR, Kim DH, Brodke DS, et al. Diagnosis and management of sacral spine fractures. Instr Course Lect. 2004;53:375\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Sacral fracture, Denis Zone III, Anterior sacral approach, Posterior sacral approach, Abdominal aortic balloon occlusion, VAS score, Majeed score","lastPublishedDoi":"10.21203/rs.3.rs-8313792/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8313792/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSacral fractures represent 30\u0026ndash;40% of pelvic ring injuries, with Denis Zone III fractures posing the greatest challenge due to their involvement of the central sacral canal and foramina, often resulting in neurological deficits, pelvic instability, and complications such as rectal, bladder, and sexual dysfunction. Surgical management is standard, but the choice between anterior and posterior approaches remains debated, particularly regarding hemorrhage control, neural decompression, and recovery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e This retrospective cohort study reviewed 42 patients with Denis Zone III sacral fractures treated from December 2015 to June 2025. Group A (n\u0026thinsp;=\u0026thinsp;19) underwent anterior sacral approach, including 15 cases with digital subtraction angiography (DSA)-guided temporary abdominal aortic balloon occlusion (AABO) for high-bleeding-risk fractures. Group B (n\u0026thinsp;=\u0026thinsp;23) underwent traditional posterior open reduction and internal fixation. Outcomes assessed included operative time, intraoperative blood loss, hospital stay, radiographic reduction quality (Matta criteria), neurological recovery, Majeed functional scores, Visual Analog Scale (VAS) pain scores, and complications. Statistical analysis used independent t-tests (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 significance threshold).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll procedures were completed successfully. Group A had longer operative times (159.7\u0026thinsp;\u0026plusmn;\u0026thinsp;30.3 min vs. 100.8\u0026thinsp;\u0026plusmn;\u0026thinsp;22.2 min; t\u0026thinsp;=\u0026thinsp;7.26, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) but lower blood loss (423\u0026thinsp;\u0026plusmn;\u0026thinsp;90 mL vs. 780\u0026thinsp;\u0026plusmn;\u0026thinsp;145 mL; t\u0026thinsp;=\u0026thinsp;9.34, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and shorter hospital stays (14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5 days vs. 17.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.4 days; t\u0026thinsp;=\u0026thinsp;2.09, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Wound healing was primary in all Group A cases, versus 13.0% infection rate (3/23) in Group B. Radiographic reduction was comparable (excellent/good: 94.7% Group A vs. 91.3% Group B; P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). VAS and Majeed scores improved significantly postoperatively in both groups (VAS at discharge: t\u0026thinsp;=\u0026thinsp;20.3, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Majeed at 6 months: t\u0026thinsp;=\u0026thinsp;15.4, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), with no intergroup differences. Mean follow-up was 9.7 months (Group A) and 9.1 months (Group B).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAlthough more time-intensive, the anterior approach with selective AABO reduces intraoperative blood loss and wound complications while providing equivalent functional and neurological outcomes to the posterior approach. This supports its use in high-risk Denis Zone III fractures, advocating for patient-specific surgical selection.\u003c/p\u003e","manuscriptTitle":"Efficacy Analysis of Anterior versus Posterior Surgical Approaches for Denis Zone III Sacral Fractures: A Retrospective Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-16 09:54:20","doi":"10.21203/rs.3.rs-8313792/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"976c93f2-47de-4ed2-9133-d9ecc2cc3d58","owner":[],"postedDate":"December 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-24T04:39:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-16 09:54:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8313792","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8313792","identity":"rs-8313792","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}