Use of a newly developed minimally invasive bilateral fixed angle locking system in the treatment of pathological pelvic fractures: A case series

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Hofmann, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4680007/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Oct, 2024 Read the published version in World Journal of Surgical Oncology → Version 1 posted 12 You are reading this latest preprint version Abstract Background Metastatic bone disease (MBD) and its complications have a significant impact on patients' quality of life. Pathological fractures are a particular problem as they affect patient mobility and pose a high risk of non-union. The pelvis is frequently affected by MBD and its fixation is challenging. We present a case series of three pathological sacral fractures treated with a new minimally invasive bilateral fixed angle locking system. Case presentation Case 1 and 2 suffered a pathological transforaminal sacral fracture without adequate trauma in stage 4 carcinomas (gastric cancer and breast cancer). Both were initially treated with non-surgical treatment, which had only a limited effect and led to imminent immobility. Both were operated on with fluoroscopic navigation and underwent transsacral SACRONAIL® stabilisation according to CT morphology (S1 + S2 and S1 respectively). Immediately after the operation, pain decreased and mobilisation improved. Case 3 had a pathological transalar sacral fracture during the 2nd cycle of chemotherapy due to non-Hodgkin's lymphoma. He soon became immobile and could only move in a wheelchair. The operation was performed with CT navigation due to the very small corridors and an implant was inserted in S1 and S2. The patient reported immediate pain relief and his ability to walk improved over the following months. Despite continued chemotherapy, no wound complications occurred. Conclusions The cases show the advantages of the minimally invasive bilateral fixed angle locking system SACRONAIL® in the treatment of patients with pathological sacral fractures. It allows immediate full weight bearing and the risk of secondary surgical complications is low. All cases showed an improvement in pain scores and mobility. Pathologic pelvic fracture sacral fracture minimal invasive pelvic surgery Figures Figure 1 Figure 2 Figure 3 Background Metastatic Bone Disease (MBD), the spread of cancer cells from a primary tumour to bone, typically results in pain, pathological fractures, hypercalcaemia, spinal cord compression and other complications with significant impact on patients’ quality of life [1-4]. Due to better cancer survival rates the number of patients presenting with MBD is increasing and projections estimate a total of 2.5 million cancer patients in 2040 in the UK [5]. The most common visceral carcinomas causing orthopaedically relevant bone metastases are breast (28%), lung (17%) and renal (15%) cancers [6]. In addition, a relevant number of patients with haematological tumours (multiple myeloma and lymphoma) require surgical treatment due to the resulting osteolysis. The proximal femur is most frequently operated on, but the pelvis is also affected by relevant MBD in 16% of cases. [Weschenfelder to be published]. Pathological fractures pose a particular problem, as patients are usually already weakened and vulnerable due to the underlying disease. Additionally, pathological fractures have a high rate of non-unions and related implant failures [7, 8]. For this reason, prophylactic treatment of impending pathological fractures is more cost-effective and has a better functional outcome by preserving the patient's independence [9, 10]. While the Mirels’ scoring system (MSS) used for long tubular bones enables a relatively good prediction of pathological fracture risk, no such scoring system has been established for the pelvis to date, which makes the treatment of patients with bone lesions in this area even more difficult [11-13]. Typical surgical options for the treatment of MBD include osteosynthesis, endoprosthesis, cryotherapy, radiofrequency ablation and cementoplasty; typical non-surgical options are radiotherapy, embolization, chemotherapy and bisphosphonates/denosumab [4]. For the surgical treatment of traumatic fractures of the posterior pelvic ring, percutaneous iliosacral screws or, in the case of more complex involvement of the sacrum or spinopelvic dissociation, spinopelvic fixation are traditionally used [14, 15]. In this context, fragility fractures of the pelvis (FFP) pose a particular problem due to poorer bone quality and associated slower bone healing, which is closer to the reality of pathological fractures. Both transsacral stabilisation and spinopelvic fixation are used for FFP, with Mendel et al. 2021 demonstrating significant outcome improvement and fracture healing. However, the subjective outcome in this study was better with transsacral stabilisation [16]. Gras et al. showed in 2015 that 88% of the population had a sufficient S1 or S2 corridor for an intraosseous transsacral implant on CT [17]. Based on this work, an angle-stable transsacral nail (SACRONAIL®, SIGNUS, Alzenau, Germany) was developed that can be locked in both ilia and showed no implant failure or malpositioning in the first pilot study by Marintschev et al. in a 1-year follow-up with immediate postoperative full load-bearing capacity [18]. For pathological fractures of the pelvis, various procedures have been described, particularly minimally invasive ones, which involved filling the defect with bone cement (e.g. sacroplasty) with and without screw fixation or percutaneous screw stabilisation alone, all of which were able to increase the VAS and the patient's mobility [19, 20]. The combination of bone cement and screw fixation showed the highest biomechanical stability in the model [21]. Lee et al. have supplemented this procedure with an additional ablation of the lesion as "Ablation, Osteoplasty, Reinforcement and Internal Fixation" (AORIF) and were able to show good results in their case series [22, 23]. In our view, the disadvantage of cemented screws is their spatial limitation and thus less broad anchoring in the existing pelvic bone than a wide-span intraosseous implant such as the SACRONAIL® could offer. Due to the very good results in the pilot study by Marintschev et al. in FFP, we have used the implant in pathological fractures of the posterior pelvic ring and present this case series below. Case Presentation Case 1, 71 years, female, gastric cancer, adenocarcinoma, stage IV A 71-year-old female presented with gastric cancer, specifically adenocarcinoma, staged as IV based on UICC guidelines. The patient was referred to our clinic after 4 weeks of unsuccessful conservative management for pathological unilateral transforaminal sacral fracture due to MBD (Figure 1). Surgical intervention was deemed necessary. The procedure involved the use of two SACRONAIL® guided by a fluoroscopic navigation system (Brainlab, Munich, Germany), utilizing preoperative CT images. The surgery was successful without any associated complications. Postoperatively, the patient was advised for full weight-bearing, which she achieved with the assistance of walking aids. The patient reported a significant decrease in pain intensity, from 8/10 to 5/10 on the numeric rating scale (NRS). Both postoperative CT and X-ray modalities demonstrated correct implant positioning, without any intraforaminal penetration. Opioid use was notably reduced (Table 1), leading to the patient's discharge after an 11-day hospital stay. Patient satisfaction, as per the NASS patient satisfaction score [24], was reported as 2, indicating an acceptable outcome despite the limited improvement in health status. Unfortunately, the patient passed away 111 days post-surgery due to the aggressive nature of the underlying tumor. Figure 1 Patient 1 A- Axial CT and MRI scan presenting pathological sacral fracture, B- postoperative CT, C- X- ray postoperative Case 2, 47 years, female, invasive ductal breast cancer, stage 4 A 47-year-old female with invasive ductal breast cancer in stage 4, presented with a decline in walking ability and increased pain. Imaging showed a mixed lesion involving the entire sacrum and dorsal ilium with unilateral transforaminal fissure (Figure 2). Non-operative pain treatment showed limited efficacy. Surgical intervention involved the placement of a single SACRONAIL® using fluoroscopic navigation guidance. The patient reported adequate pain relief post-surgery and self-assessment revealed improved function and overall satisfaction with the procedure. Subsequent radiotherapy was administered 6 weeks after surgery. Follow-up evaluations indicated a significant reduction in self-reported pain, with continued improvement at the 3-month mark (Table 1). Minimal opioid use was reported after 12 months, demonstrating satisfactory results with a NASS score of 2. Radiographic assessments at each follow-up up to the 12 months visit showed no signs of implant failure or loosening. Figure 2 Patient 2 A- preoperative CT scan showing sacral fracture, B- postoperative CT scan, C- X-rays demonstrating no implant failure 12 months postoperative Case 3, 59 years, male, Non-Hodgkin lymphoma stage IVB (Ann- Arbor) A 59-year-old male with Non-Hodgkin lymphoma in stage IVB (Ann Arbor) had previously undergone one course of chemotherapy (R-Pola-CHP). During the second chemotherapy cycle, he developed immobility and an inability to walk due to significant pelvic involvement (Figure 3). Four additional chemotherapy courses were planned. The patient struggled to carry out daily activities independently. Surgical intervention provided significant pain relief. The procedure utilized CT navigation (O-arm, Medtronic, Dublin, Ireland), resulting in high patient satisfaction and improved pain management, reflected in a NASS score of 1 (indicating met treatment expectations). The patient could not bear full weight due to overall exhaustion and lumbar plexus invasion. Neurological rehabilitation was initiated. Additionally, a pathological humeral shaft fracture was addressed through osteosynthesis with humeral nailing following the SACRONAIL® placement. No surgical complications were encountered. Chemotherapy resumed 2 weeks post-surgery. Unfortunately, the patient was lost to structured follow-up. During the last consultation 4 months post-surgery, the patient demonstrated full weight-bearing using a walker. Figure 3 Patient 3 A- preoperative CT scan showing sacral fracture, B- intraoperative CT scan, C- X- Rays demonstrating no implant failure 4 months postoperative [TABLE 1] Discussion And Conclusion The cases presented highlight the benefits of utilizing minimally invasive SACRONAIL® implants for pathological fractures in solid tumor metastases and haematological malignancies, such as lymphomas. The stability provided by the SACRONAIL® allows for immediate full weight-bearing, irrespective of the patient's treatment timeline for chemotherapy or radiation therapy. All cases demonstrated a notable reduction in pain levels and opioid requirements post-surgery, with high patient satisfaction and willingness to undergo the same procedure again if required. Further research is warranted to validate the positive outcomes observed with this implant system. Abbreviations AORIF - Ablation, Osteoplasty, Reinforcement and Internal Fixation FFP - Fragility Fracture of the pelvis MBD - Metastatic Bone Disease MSS - Mirels Scoring System NASS - North American Spine Society NRS - numeric rating scale Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of the University of Jena 2020-1975-MPG §23. Consent for publication All participants gave written consent. Availability of data and materials Data generated or analysed during this study are included in this published article. Raw data of the study are not publicly available as the study participants have not given a signed consent for public insight and use and their privacy is respected under the European General Data Protection Regulation. Anonymized raw data are available on request. Competing interests The authors declare that they have no competing interests. Funding The study received no funding. Authors' contributions MU managed, analysed and interpreted the patient data, cowrote manuscript; WW cowrote manuscript and performed analysis and treated those patients, CS treated patients and proofread manuscript, IM codesigned the implant and performed the surgeries, GH codesigned the implant and was initiating the study. References Coleman RE. Metastatic bone disease: clinical features, pathophysiology and treatment strategies. Cancer Treat Rev. 2001;27:165–76. 10.1053/ctrv.2000.0210 . Coleman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res. 2006;12:s6243–9. 10.1158/1078-0432.CCR-06-0931 . Mavrogenis AF, Angelini A, Vottis C, Pala E, Calabro T, Papagelopoulos PJ, Ruggieri P. Modern Palliative Treatments for Metastatic Bone Disease: Awareness of Advantages, Disadvantages, and Guidance. Clin J Pain. 2016;32:337–50. 10.1097/AJP.0000000000000255 . Tsukamoto S, Errani C, Kido A, Mavrogenis AF. What's new in the management of metastatic bone disease. Eur J Orthop Surg Traumatol. 2021;31:1547–55. 10.1007/s00590-021-03136-4 . Trompeter A. Management of metastatic bone disease (MBD). Injury. 2022;53:3869–71. 10.1016/j.injury.2022.09.054 . Kendal JK, Abbott A, Kooner S, Johal H, Puloski SKT, Monument MJ. A scoping review on the surgical management of metastatic bone disease of the extremities. BMC Musculoskelet Disord. 2018;19:279. 10.1186/s12891-018-2210-8 . Gainor BJ, Buchert P. Fracture healing in metastatic bone disease. Clin Orthop Relat Res. 1983;178:297–302. Errani C, Mavrogenis AF, Cevolani L, Spinelli S, Piccioli A, Maccauro G, Baldini N, Donati D. Treatment for long bone metastases based on a systematic literature review. Eur J Orthop Surg Traumatol. 2017;27:205–11. 10.1007/s00590-016-1857-9 . Blank AT, Lerman DM, Patel NM, Rapp TB. Is Prophylactic Intervention More Cost-effective Than the Treatment of Pathologic Fractures in Metastatic Bone Disease? Clin Orthop Relat Res. 2016;474:1563–70. 10.1007/s11999-016-4739-x . Bickels J, Dadia S, Lidar Z. Surgical management of metastatic bone disease. J Bone Joint Surg Am. 2009;91:1503–16. 10.2106/JBJS.H.00175 . Mirels H. (1989) Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res:256–64. Piccioli A, Spinelli MS, Maccauro G. Impending fracture: A difficult diagnosis. Injury 45 Suppl. 2014;6S138–141. 10.1016/j.injury.2014.10.038 . El-Husseiny M, Coleman N. Inter- and intra-observer variation in classification systems for impending fractures of bone metastases. Skeletal Radiol. 2010;39:155–60. 10.1007/s00256-009-0823-6 . Osterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Percutaneous iliosacral screw fixation in S1 and S2 for posterior pelvic ring injuries: technique and perioperative complications. Arch Orthop Trauma Surg. 2011;131:809–13. 10.1007/s00402-010-1230-0 . Mendel T, Kuhn P, Wohlrab D, Brehme K. [Minimally invasive fixation of a sacral bilateral fracture with lumbopelvic dissociation]. Unfallchirurg. 2009;112:590–5. 10.1007/s00113-008-1563-0 . Mendel T, Schenk P, Ullrich BW, Hofmann GO, Goehre F, Schwan S, Klauke F. Mid-term outcome of bilateral fragility fractures of the sacrum after bisegmental transsacral stabilization versus spinopelvic fixation. Bone Joint J. 2021;103–B:462–8. 10.1302/0301-620X.103B3.BJJ-2020-1454.R1 . Gras F, Hillmann S, Rausch S, Klos K, Hofmann GO, Marintschev I. Biomorphometric analysis of ilio-sacro-iliacal corridors for an intra-osseous implant to fix posterior pelvic ring fractures. J Orthop Res. 2015;33:254–60. 10.1002/jor.22754 . Marintschev I, Hofmann GO. Minimally invasive bilateral fixed angle locking fixation of the dorsal pelvic ring: clinical proof of concept and preliminary treatment results. Eur J Trauma Emerg Surg. 2023;49:1873–82. 10.1007/s00068-023-02259-z . Chandra V, Wajswol E, Shukla P, Contractor S, Kumar A. Safety and Efficacy of Sacroplasty for Sacral Fractures: A Systematic Review and Meta-Analysis. J Vasc Interv Radiol. 2019;30:1845–54. 10.1016/j.jvir.2019.06.013 . Yang R, Singh S, Falk A, Wang J, Thornhill B, Fox J, Sen M, Hoang B, Geller DS. Percutaneous Screw Stabilization of Non-Periacetabular Pelvic Lesions Caused by Metastatic Cancer and Multiple Myeloma. J Bone Joint Surg Am. 2022;104:577–85. 10.2106/JBJS.21.00518 . Morris MT, Alder KD, Moushey A, Munger AM, Milligan K, Toombs C, Conway D, Lee I, Chen F, Tommasini SM, Lee FY. Biomechanical restoration of metastatic cancer-induced peri-acetabular bone defects by ablation-osteoplasty-reinforcement-internal fixation technique (AORIF): To screw or not to screw? Clin Biomech (Bristol Avon). 2022;92:105565. 10.1016/j.clinbiomech.2021.105565 . Lee FY, Latich I, Toombs C, Mungur A, Conway D, Alder K, Ibe I, Lindskog D, Friedlaender G. Minimally Invasive Image-Guided Ablation, Osteoplasty, Reinforcement, and Internal Fixation (AORIF) for Osteolytic Lesions in the Pelvis and Periarticular Regions of Weight-Bearing Bones. J Vasc Interv Radiol. 2020;31:649–e658641. 10.1016/j.jvir.2019.11.029 . Lee L, Schutz M, Myhre SL, Tasse J, Blank AT, Brown A, Lerman DM. Minimally invasive management of pathologic fractures of the pelvis and sacrum: Tumor ablation and fracture stabilization. J Surg Oncol. 2023;128:359–66. 10.1002/jso.27284 . Daltroy LH, Cats-Baril WL, Katz JN, Fossel AH, Liang MH. The North American spine society lumbar spine outcome assessment Instrument: reliability and validity tests. Spine (Phila Pa 1976). 1996;21:741–9. 10.1097/00007632-199603150-00017 . Tables Table 1 Patient follow- up after minimally invasive bilateral fixed angle locking system Patient 1, 71years, gastric cancer stage IV (UICC) Patient 2, 47 years, breast cancer stage IV (UICC) Patient 3, 59 years, Non-Hodgkin lymphoma stage IVb (Ann- Arbor) Pre- Treatment Pelvic Pain on NRS (0-10) 8 8 6 Distance of walking in meter 10 100 0 Time of Walking at once in minutes 5 20 0 Pain medication on WHO Analgesic Ladder III daily III daily III daily Quality of Life, SF 12 PCS-12 (Physical Score) 23.4 31.3 24.3 MCS-12 (Mental Score) 17.1 34.1 34.3 Intraoperative Complications No No No Post- Treatment Status at Hospital Discharge Pelvic Pain on NRS (0-10) 5 3 0 Distance of walking in meter 100 500 0 Time of Walking in minutes 10 20 0 Pain medication on WHO Analgesic Ladder III at demand III daily I Patient satisfaction (NASS Score) 2 2 1 Quality of Life, SF 12 - PCS-12 (Physical Score) 22.2 37,9 - MCS-12 (Mental Score) 22.5 26,1 - Status of Ambulation as recommended Full weight bearing Full weight bearing - Status of Ambulation Full- weight bearing, walking aids Full weight bearing, walking aids - Stay in Hospital after surgery in days 11 9 - 3- Months follow Up Pelvic Pain on NRS (0-10) 2 4 - Distance of walking in meter 0 1000 - Time of Walking in minutes 0 - - Pain medication on WHO Analgesic Ladder III daily III daily - Patient satisfaction - 1 - Quality of Life, SF 12 - - PCS-12 (Physical Score) - 28.5 - MCS-12 (Mental Score) - 30.3 - - 12- Months follow Up - Pelvic Pain on NRS (0-10) - 8 - Distance of walking in meter - 1000 - Time of Walking in minutes - - Pain medication on WHO Analgesic Ladder - Stage II daily - Patient satisfaction - 2 - Quality of Life, SF 12 - - PCS-12 (Physical Score) - 27.8 - MCS-12 (Mental Score) - 49.8 - Deceased 111day post-surgery NASS patient satisfaction index (1- the treatment met my expectations, 2- I did not improve as much as I had hoped, but I would undergo the same treatment for the same outcome, 3- I did not improve as much as I had hoped, and I would not undergo the same treatment for the same outcome, 4- I am the same or worse than before treatment) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 08 Oct, 2024 Read the published version in World Journal of Surgical Oncology → Version 1 posted Editorial decision: Revision requested 09 Sep, 2024 Reviewers agreed at journal 01 Sep, 2024 Reviews received at journal 01 Sep, 2024 Reviewers agreed at journal 01 Sep, 2024 Reviewers agreed at journal 14 Aug, 2024 Reviews received at journal 13 Aug, 2024 Reviewers agreed at journal 10 Aug, 2024 Reviewers agreed at journal 07 Aug, 2024 Reviewers invited by journal 21 Jul, 2024 Editor assigned by journal 11 Jul, 2024 Submission checks completed at journal 04 Jul, 2024 First submitted to journal 03 Jul, 2024 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. 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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-4680007","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":332145263,"identity":"63e363ba-f233-4e2b-b57d-19b09233dce3","order_by":0,"name":"Mark Unthan","email":"data:image/png;base64,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","orcid":"","institution":"Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena","correspondingAuthor":true,"prefix":"","firstName":"Mark","middleName":"","lastName":"Unthan","suffix":""},{"id":332145265,"identity":"25324224-9e1a-40ba-8e4c-5cc164000246","order_by":1,"name":"Ivan Marintschev","email":"","orcid":"","institution":"Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena","correspondingAuthor":false,"prefix":"","firstName":"Ivan","middleName":"","lastName":"Marintschev","suffix":""},{"id":332145267,"identity":"b83f6562-b79b-474d-8adf-260e5ba67586","order_by":2,"name":"Christian Spiegel","email":"","orcid":"","institution":"Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"","lastName":"Spiegel","suffix":""},{"id":332145270,"identity":"b4caa0c5-3920-4267-bf0a-6424a10b04aa","order_by":3,"name":"Gunther O. Hofmann","email":"","orcid":"","institution":"Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena","correspondingAuthor":false,"prefix":"","firstName":"Gunther","middleName":"O.","lastName":"Hofmann","suffix":""},{"id":332145271,"identity":"8b84e252-b66c-47c6-a7fa-dd85326b322f","order_by":4,"name":"Wolfram Weschenfelder","email":"","orcid":"","institution":"Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747 Jena","correspondingAuthor":false,"prefix":"","firstName":"Wolfram","middleName":"","lastName":"Weschenfelder","suffix":""}],"badges":[],"createdAt":"2024-07-03 11:21:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4680007/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4680007/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12957-024-03551-x","type":"published","date":"2024-10-08T15:56:56+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61358710,"identity":"f1bc8472-6dac-4b92-a9ad-26112a259d7c","added_by":"auto","created_at":"2024-07-29 21:21:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":2165016,"visible":true,"origin":"","legend":"\u003cp\u003ePatient 1 A- Axial CT and MRI scan presenting pathological sacral fracture, B- postoperative CT, C- X- ray postoperative\u003c/p\u003e","description":"","filename":"Figure1300.png","url":"https://assets-eu.researchsquare.com/files/rs-4680007/v1/db3b6c17f49dff3f01b71919.png"},{"id":61358712,"identity":"720b956b-9267-44bd-92b9-4c81154e40bf","added_by":"auto","created_at":"2024-07-29 21:21:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1484004,"visible":true,"origin":"","legend":"\u003cp\u003ePatient 2 A- preoperative CT scan showing sacral fracture, B- postoperative CT scan, C- X-rays demonstrating no implant failure 12 months postoperative\u003c/p\u003e","description":"","filename":"Figure2300.png","url":"https://assets-eu.researchsquare.com/files/rs-4680007/v1/6a5d92a0d209dba34907afc7.png"},{"id":61358711,"identity":"12e6893b-33d3-402d-8e0c-c9b7b74c9ece","added_by":"auto","created_at":"2024-07-29 21:21:32","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1161661,"visible":true,"origin":"","legend":"\u003cp\u003ePatient 3 A- preoperative CT scan showing sacral fracture, B- intraoperative CT scan, C- X- Rays demonstrating no implant failure 4 months postoperative\u003c/p\u003e","description":"","filename":"Figure3300.png","url":"https://assets-eu.researchsquare.com/files/rs-4680007/v1/4aa7287c3df3b96afdb5cf64.png"},{"id":66597023,"identity":"2c5b1efc-6fd2-4ade-9c9e-eebfc19ddf8b","added_by":"auto","created_at":"2024-10-14 16:04:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6239007,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4680007/v1/03245886-8fa3-443a-90d5-eee35251c6ba.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Use of a newly developed minimally invasive bilateral fixed angle locking system in the treatment of pathological pelvic fractures: A case series","fulltext":[{"header":"Background","content":"\u003cp\u003eMetastatic Bone Disease (MBD), the spread of cancer cells from a primary tumour to bone, typically results in pain, pathological fractures, hypercalcaemia, spinal cord compression and other complications with significant impact on patients\u0026rsquo; quality of life\u0026nbsp;[1-4]. Due to better cancer survival rates the number of patients presenting with MBD is increasing and projections estimate a total of 2.5 million cancer patients in 2040 in the UK\u0026nbsp;[5]. The most common visceral carcinomas causing orthopaedically relevant bone metastases are breast (28%), lung (17%) and renal (15%) cancers\u0026nbsp;[6]. In addition, a relevant number of patients with haematological tumours (multiple myeloma and lymphoma) require surgical treatment due to the resulting osteolysis. The proximal femur is most frequently operated on, but the pelvis is also affected by relevant MBD in 16% of cases. [Weschenfelder to be published].\u003c/p\u003e\n\u003cp\u003ePathological fractures pose a particular problem, as patients are usually already weakened and vulnerable due to the underlying disease. Additionally, pathological fractures have a high rate of non-unions and related implant failures\u0026nbsp;[7, 8]. For this reason, prophylactic treatment of impending pathological fractures is more cost-effective and has a better functional outcome by preserving the patient\u0026apos;s independence\u0026nbsp;[9, 10]. While the Mirels\u0026rsquo; scoring system (MSS) used for long tubular bones enables a relatively good prediction of pathological fracture risk, no such scoring system has been established for the pelvis to date, which makes the treatment of patients with bone lesions in this area even more difficult\u0026nbsp;[11-13]. Typical surgical options for the treatment of MBD include osteosynthesis, endoprosthesis, cryotherapy, radiofrequency ablation and cementoplasty; typical non-surgical options are radiotherapy, embolization, chemotherapy and bisphosphonates/denosumab\u0026nbsp;[4].\u003c/p\u003e\n\u003cp\u003eFor the surgical treatment of traumatic fractures of the posterior pelvic ring, percutaneous iliosacral screws or, in the case of more complex involvement of the sacrum or spinopelvic dissociation, spinopelvic fixation are traditionally used\u0026nbsp;[14, 15]. In this context, fragility fractures of the pelvis (FFP) pose a particular problem due to poorer bone quality and associated slower bone healing, which is closer to the reality of pathological fractures. Both transsacral stabilisation and spinopelvic fixation are used for FFP, with Mendel et al. 2021 demonstrating significant outcome improvement and fracture healing. However, the subjective outcome in this study was better with transsacral stabilisation\u0026nbsp;[16]. Gras et al. showed in 2015 that 88% of the population had a sufficient S1 or S2 corridor for an intraosseous transsacral implant on CT\u0026nbsp;[17]. Based on this work, an angle-stable transsacral nail (SACRONAIL\u0026reg;, SIGNUS, Alzenau, Germany) was developed that can be locked in both ilia and showed no implant failure or malpositioning in the first pilot study by Marintschev et al. in a 1-year follow-up with immediate postoperative full load-bearing capacity\u0026nbsp;[18].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor pathological fractures of the pelvis, various procedures have been described, particularly minimally invasive ones, which involved filling the defect with bone cement (e.g. sacroplasty) with and without screw fixation or percutaneous screw stabilisation alone, all of which were able to increase the VAS and the patient\u0026apos;s mobility\u0026nbsp;[19, 20]. The combination of bone cement and screw fixation showed the highest biomechanical stability in the model\u0026nbsp;[21]. Lee et al. have supplemented this procedure with an additional ablation of the lesion as \u0026quot;Ablation, Osteoplasty, Reinforcement and Internal Fixation\u0026quot; (AORIF) and were able to show good results in their case series\u0026nbsp;[22, 23].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our view, the disadvantage of cemented screws is their spatial limitation and thus less broad anchoring in the existing pelvic bone than a wide-span intraosseous implant such as the SACRONAIL\u0026reg; could offer. Due to the very good results in the pilot study by Marintschev et al. in FFP, we have used the implant in pathological fractures of the posterior pelvic ring and present this case series below.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eCase 1, 71 years, female, gastric cancer, adenocarcinoma, stage IV\u003c/p\u003e\n\u003cp\u003eA 71-year-old female presented with gastric cancer, specifically adenocarcinoma, staged as IV based on UICC guidelines. The patient was referred to our clinic after 4 weeks of unsuccessful conservative management for pathological unilateral transforaminal sacral fracture due to MBD (Figure 1). Surgical intervention was deemed necessary. The procedure involved the use of two SACRONAIL\u0026reg; guided by a fluoroscopic navigation system (Brainlab, Munich, Germany), utilizing preoperative CT images. The surgery was successful without any associated complications. Postoperatively, the patient was advised for full weight-bearing, which she achieved with the assistance of walking aids. The patient reported a significant decrease in pain intensity, from 8/10 to 5/10 on the numeric rating scale (NRS). Both postoperative CT and X-ray modalities demonstrated correct implant positioning, without any intraforaminal penetration. Opioid use was notably reduced (Table 1), leading to the patient\u0026apos;s discharge after an 11-day hospital stay. Patient satisfaction, as per the NASS patient satisfaction score\u0026nbsp;[24], was reported as 2, indicating an acceptable outcome despite the limited improvement in health status. Unfortunately, the patient passed away 111 days post-surgery due to the aggressive nature of the underlying tumor.\u003c/p\u003e\n\u003cp\u003eFigure 1 Patient 1 A- Axial CT and MRI scan presenting pathological sacral fracture, B- postoperative CT, C- X- ray postoperative\u003c/p\u003e\n\u003cp\u003eCase 2, 47 years, female, invasive ductal breast cancer, stage 4\u003c/p\u003e\n\u003cp\u003eA 47-year-old female with invasive ductal breast cancer in stage 4, presented with a decline in walking ability and increased pain. Imaging showed a mixed lesion involving the entire sacrum and dorsal ilium with unilateral transforaminal fissure (Figure 2). Non-operative pain treatment showed limited efficacy. Surgical intervention involved the placement of a single SACRONAIL\u0026reg; using fluoroscopic navigation guidance. The patient reported adequate pain relief post-surgery and self-assessment revealed improved function and overall satisfaction with the procedure. Subsequent radiotherapy was administered 6 weeks after surgery. Follow-up evaluations indicated a significant reduction in self-reported pain, with continued improvement at the 3-month mark (Table 1). Minimal opioid use was reported after 12 months, demonstrating satisfactory results with a NASS score of 2. Radiographic assessments at each follow-up up to the 12 months visit showed no signs of implant failure or loosening.\u003c/p\u003e\n\u003cp\u003eFigure 2 Patient 2 A- preoperative CT scan showing sacral fracture, B- postoperative CT scan, C- X-rays demonstrating no implant failure 12 months postoperative\u003c/p\u003e\n\u003cp\u003eCase 3, 59 years, male, Non-Hodgkin lymphoma stage IVB (Ann- Arbor)\u003c/p\u003e\n\u003cp\u003eA 59-year-old male with Non-Hodgkin lymphoma in stage IVB (Ann Arbor) had previously undergone one course of chemotherapy (R-Pola-CHP). During the second chemotherapy cycle, he developed immobility and an inability to walk due to significant pelvic involvement (Figure 3). Four additional chemotherapy courses were planned. The patient struggled to carry out daily activities independently. Surgical intervention provided significant pain relief. The procedure utilized CT navigation (O-arm, Medtronic, Dublin, Ireland), resulting in high patient satisfaction and improved pain management, reflected in a NASS score of 1 (indicating met treatment expectations). The patient could not bear full weight due to overall exhaustion and lumbar plexus invasion. Neurological rehabilitation was initiated. Additionally, a pathological humeral shaft fracture was addressed through osteosynthesis with humeral nailing following the SACRONAIL\u0026reg; placement. No surgical complications were encountered. Chemotherapy resumed 2 weeks post-surgery. Unfortunately, the patient was lost to structured follow-up. During the last consultation 4 months post-surgery, the patient demonstrated full weight-bearing using a walker.\u003c/p\u003e\n\u003cp\u003eFigure 3 Patient 3 A- preoperative CT scan showing sacral fracture, B- intraoperative CT scan, C- X- Rays demonstrating no implant failure 4 months \u0026nbsp;postoperative\u003c/p\u003e\n\u003cp\u003e[TABLE 1]\u003c/p\u003e"},{"header":"Discussion And Conclusion","content":"\u003cp\u003eThe cases presented highlight the benefits of utilizing minimally invasive SACRONAIL\u0026reg; implants for pathological fractures in solid tumor metastases and haematological malignancies, such as lymphomas. The stability provided by the SACRONAIL\u0026reg; allows for immediate full weight-bearing, irrespective of the patient\u0026apos;s treatment timeline for chemotherapy or radiation therapy. All cases demonstrated a notable reduction in pain levels and opioid requirements post-surgery, with high patient satisfaction and willingness to undergo the same procedure again if required. Further research is warranted to validate the positive outcomes observed with this implant system.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAORIF \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Ablation, Osteoplasty, Reinforcement and Internal Fixation\u003c/p\u003e\n\u003cp\u003eFFP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Fragility Fracture of the pelvis\u003c/p\u003e\n\u003cp\u003eMBD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Metastatic Bone Disease\u003c/p\u003e\n\u003cp\u003eMSS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Mirels Scoring System\u003c/p\u003e\n\u003cp\u003eNASS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;-\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;North American Spine Society\u003c/p\u003e\n\u003cp\u003eNRS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; - \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;numeric rating scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of the University of Jena 2020-1975-MPG \u0026sect;23.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eAll participants gave written consent.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eData generated or analysed during this study are included in this published article. Raw data of the study are not publicly available as the study participants have not given a signed consent for public insight and use and their privacy is respected under the European General Data Protection Regulation. Anonymized raw data are available on request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe study received no funding.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions\u003c/p\u003e\n\u003cp\u003eMU managed, analysed and interpreted the patient data, cowrote manuscript; WW cowrote manuscript and performed analysis and treated those patients, CS treated patients and proofread manuscript, IM codesigned the implant and performed the surgeries, GH codesigned the implant and was initiating the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eColeman RE. Metastatic bone disease: clinical features, pathophysiology and treatment strategies. Cancer Treat Rev. 2001;27:165\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/ctrv.2000.0210\u003c/span\u003e\u003cspan address=\"10.1053/ctrv.2000.0210\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eColeman RE. Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res. 2006;12:s6243\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1158/1078-0432.CCR-06-0931\u003c/span\u003e\u003cspan address=\"10.1158/1078-0432.CCR-06-0931\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMavrogenis AF, Angelini A, Vottis C, Pala E, Calabro T, Papagelopoulos PJ, Ruggieri P. Modern Palliative Treatments for Metastatic Bone Disease: Awareness of Advantages, Disadvantages, and Guidance. Clin J Pain. 2016;32:337\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/AJP.0000000000000255\u003c/span\u003e\u003cspan address=\"10.1097/AJP.0000000000000255\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsukamoto S, Errani C, Kido A, Mavrogenis AF. What's new in the management of metastatic bone disease. Eur J Orthop Surg Traumatol. 2021;31:1547\u0026ndash;55. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00590-021-03136-4\u003c/span\u003e\u003cspan address=\"10.1007/s00590-021-03136-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrompeter A. Management of metastatic bone disease (MBD). Injury. 2022;53:3869\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.injury.2022.09.054\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2022.09.054\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKendal JK, Abbott A, Kooner S, Johal H, Puloski SKT, Monument MJ. A scoping review on the surgical management of metastatic bone disease of the extremities. BMC Musculoskelet Disord. 2018;19:279. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12891-018-2210-8\u003c/span\u003e\u003cspan address=\"10.1186/s12891-018-2210-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGainor BJ, Buchert P. Fracture healing in metastatic bone disease. Clin Orthop Relat Res. 1983;178:297\u0026ndash;302.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErrani C, Mavrogenis AF, Cevolani L, Spinelli S, Piccioli A, Maccauro G, Baldini N, Donati D. Treatment for long bone metastases based on a systematic literature review. Eur J Orthop Surg Traumatol. 2017;27:205\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00590-016-1857-9\u003c/span\u003e\u003cspan address=\"10.1007/s00590-016-1857-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlank AT, Lerman DM, Patel NM, Rapp TB. Is Prophylactic Intervention More Cost-effective Than the Treatment of Pathologic Fractures in Metastatic Bone Disease? Clin Orthop Relat Res. 2016;474:1563\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11999-016-4739-x\u003c/span\u003e\u003cspan address=\"10.1007/s11999-016-4739-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBickels J, Dadia S, Lidar Z. Surgical management of metastatic bone disease. J Bone Joint Surg Am. 2009;91:1503\u0026ndash;16. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.H.00175\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.H.00175\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMirels H. (1989) Metastatic disease in long bones. A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop Relat Res:256\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiccioli A, Spinelli MS, Maccauro G. Impending fracture: A difficult diagnosis. Injury 45 Suppl. 2014;6S138\u0026ndash;141. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.injury.2014.10.038\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2014.10.038\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl-Husseiny M, Coleman N. Inter- and intra-observer variation in classification systems for impending fractures of bone metastases. Skeletal Radiol. 2010;39:155\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00256-009-0823-6\u003c/span\u003e\u003cspan address=\"10.1007/s00256-009-0823-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsterhoff G, Ossendorf C, Wanner GA, Simmen HP, Werner CM. Percutaneous iliosacral screw fixation in S1 and S2 for posterior pelvic ring injuries: technique and perioperative complications. Arch Orthop Trauma Surg. 2011;131:809\u0026ndash;13. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00402-010-1230-0\u003c/span\u003e\u003cspan address=\"10.1007/s00402-010-1230-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMendel T, Kuhn P, Wohlrab D, Brehme K. [Minimally invasive fixation of a sacral bilateral fracture with lumbopelvic dissociation]. Unfallchirurg. 2009;112:590\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00113-008-1563-0\u003c/span\u003e\u003cspan address=\"10.1007/s00113-008-1563-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMendel T, Schenk P, Ullrich BW, Hofmann GO, Goehre F, Schwan S, Klauke F. Mid-term outcome of bilateral fragility fractures of the sacrum after bisegmental transsacral stabilization versus spinopelvic fixation. Bone Joint J. 2021;103\u0026ndash;B:462\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1302/0301-620X.103B3.BJJ-2020-1454.R1\u003c/span\u003e\u003cspan address=\"10.1302/0301-620X.103B3.BJJ-2020-1454.R1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGras F, Hillmann S, Rausch S, Klos K, Hofmann GO, Marintschev I. Biomorphometric analysis of ilio-sacro-iliacal corridors for an intra-osseous implant to fix posterior pelvic ring fractures. J Orthop Res. 2015;33:254\u0026ndash;60. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jor.22754\u003c/span\u003e\u003cspan address=\"10.1002/jor.22754\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarintschev I, Hofmann GO. Minimally invasive bilateral fixed angle locking fixation of the dorsal pelvic ring: clinical proof of concept and preliminary treatment results. Eur J Trauma Emerg Surg. 2023;49:1873\u0026ndash;82. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00068-023-02259-z\u003c/span\u003e\u003cspan address=\"10.1007/s00068-023-02259-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChandra V, Wajswol E, Shukla P, Contractor S, Kumar A. Safety and Efficacy of Sacroplasty for Sacral Fractures: A Systematic Review and Meta-Analysis. J Vasc Interv Radiol. 2019;30:1845\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jvir.2019.06.013\u003c/span\u003e\u003cspan address=\"10.1016/j.jvir.2019.06.013\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang R, Singh S, Falk A, Wang J, Thornhill B, Fox J, Sen M, Hoang B, Geller DS. Percutaneous Screw Stabilization of Non-Periacetabular Pelvic Lesions Caused by Metastatic Cancer and Multiple Myeloma. J Bone Joint Surg Am. 2022;104:577\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.21.00518\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.21.00518\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorris MT, Alder KD, Moushey A, Munger AM, Milligan K, Toombs C, Conway D, Lee I, Chen F, Tommasini SM, Lee FY. Biomechanical restoration of metastatic cancer-induced peri-acetabular bone defects by ablation-osteoplasty-reinforcement-internal fixation technique (AORIF): To screw or not to screw? Clin Biomech (Bristol Avon). 2022;92:105565. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.clinbiomech.2021.105565\u003c/span\u003e\u003cspan address=\"10.1016/j.clinbiomech.2021.105565\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee FY, Latich I, Toombs C, Mungur A, Conway D, Alder K, Ibe I, Lindskog D, Friedlaender G. Minimally Invasive Image-Guided Ablation, Osteoplasty, Reinforcement, and Internal Fixation (AORIF) for Osteolytic Lesions in the Pelvis and Periarticular Regions of Weight-Bearing Bones. J Vasc Interv Radiol. 2020;31:649\u0026ndash;e658641. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jvir.2019.11.029\u003c/span\u003e\u003cspan address=\"10.1016/j.jvir.2019.11.029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee L, Schutz M, Myhre SL, Tasse J, Blank AT, Brown A, Lerman DM. Minimally invasive management of pathologic fractures of the pelvis and sacrum: Tumor ablation and fracture stabilization. J Surg Oncol. 2023;128:359\u0026ndash;66. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jso.27284\u003c/span\u003e\u003cspan address=\"10.1002/jso.27284\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDaltroy LH, Cats-Baril WL, Katz JN, Fossel AH, Liang MH. The North American spine society lumbar spine outcome assessment Instrument: reliability and validity tests. Spine (Phila Pa 1976). 1996;21:741\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/00007632-199603150-00017\u003c/span\u003e\u003cspan address=\"10.1097/00007632-199603150-00017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eTable 1 Patient follow- up after minimally invasive bilateral fixed angle locking system\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 1, 71years, gastric cancer stage IV (UICC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 2, 47 years, breast cancer stage IV (UICC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003ePatient 3, 59 years, Non-Hodgkin lymphoma stage IVb (Ann- Arbor)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre- Treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePelvic Pain on NRS (0-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eDistance of walking in meter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eTime of Walking at once in minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePain medication on WHO Analgesic Ladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003eIII daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003eIII daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003eIII daily\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eQuality of Life, SF 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePCS-12 (Physical Score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e23.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e31.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e24.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eMCS-12 (Mental Score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e17.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e34.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e34.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eIntraoperative Complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost- Treatment Status at Hospital Discharge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePelvic Pain on NRS (0-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eDistance of walking in meter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eTime of Walking in minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePain medication on WHO Analgesic Ladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003eIII at demand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003eIII daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePatient satisfaction (NASS Score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eQuality of Life, SF 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePCS-12 (Physical Score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e22.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e37,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eMCS-12 (Mental Score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e26,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eStatus of Ambulation as recommended\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003eFull weight bearing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003eFull weight bearing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eStatus of Ambulation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003eFull- weight bearing, walking aids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003eFull weight bearing, walking aids\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eStay in Hospital after surgery in days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e3- Months follow Up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePelvic Pain on NRS (0-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eDistance of walking in meter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eTime of Walking in minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePain medication on WHO Analgesic Ladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003eIII daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003eIII daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePatient satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eQuality of Life, SF 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePCS-12 (Physical Score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eMCS-12 (Mental Score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e30.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e12- Months follow Up\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePelvic Pain on NRS (0-10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eDistance of walking in meter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eTime of Walking in minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePain medication on WHO Analgesic Ladder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003eStage II daily\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePatient satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eQuality of Life, SF 12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003ePCS-12 (Physical Score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e27.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eMCS-12 (Mental Score)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e49.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.840336134453782%\" valign=\"top\"\u003e\n \u003cp\u003eDeceased\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.31512605042017%\" valign=\"top\"\u003e\n \u003cp\u003e111day post-surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.105042016806724%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.73949579831933%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eNASS patient satisfaction index (1- the treatment met my expectations, 2- I did not improve as much as I had hoped, but I would undergo the same treatment for the same outcome, 3- I did not improve as much as I had hoped, and I would not undergo the same treatment for the same outcome, 4- I am the same or worse than before treatment)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pathologic pelvic fracture, sacral fracture, minimal invasive pelvic surgery","lastPublishedDoi":"10.21203/rs.3.rs-4680007/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4680007/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eMetastatic bone disease (MBD) and its complications have a significant impact on patients' quality of life. Pathological fractures are a particular problem as they affect patient mobility and pose a high risk of non-union. The pelvis is frequently affected by MBD and its fixation is challenging. We present a case series of three pathological sacral fractures treated with a new minimally invasive bilateral fixed angle locking system.\u003c/p\u003e\n\u003cp\u003eCase presentation\u003c/p\u003e\n\u003cp\u003eCase 1 and 2 suffered a pathological transforaminal sacral fracture without adequate trauma in stage 4 carcinomas (gastric cancer and breast cancer). Both were initially treated with non-surgical treatment, which had only a limited effect and led to imminent immobility. Both were operated on with fluoroscopic navigation and underwent transsacral SACRONAIL® stabilisation according to CT morphology (S1 + S2 and S1 respectively). Immediately after the operation, pain decreased and mobilisation improved.\u003c/p\u003e\n\u003cp\u003eCase 3 had a pathological transalar sacral fracture during the 2nd cycle of chemotherapy due to non-Hodgkin's lymphoma. He soon became immobile and could only move in a wheelchair. The operation was performed with CT navigation due to the very small corridors and an implant was inserted in S1 and S2. The patient reported immediate pain relief and his ability to walk improved over the following months. Despite continued chemotherapy, no wound complications occurred.\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eThe cases show the advantages of the minimally invasive bilateral fixed angle locking system SACRONAIL® in the treatment of patients with pathological sacral fractures. It allows immediate full weight bearing and the risk of secondary surgical complications is low. All cases showed an improvement in pain scores and mobility.\u003c/p\u003e","manuscriptTitle":"Use of a newly developed minimally invasive bilateral fixed angle locking system in the treatment of pathological pelvic fractures: A case series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-29 21:21:27","doi":"10.21203/rs.3.rs-4680007/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-09T15:23:58+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"52771719811785208759440030956108230353","date":"2024-09-01T18:59:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-01T10:55:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149067275494028558894150943954781469812","date":"2024-09-01T05:45:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97903401793532055930850691248587522102","date":"2024-08-14T09:29:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-14T01:28:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332960698300024046065324915345766981148","date":"2024-08-10T11:01:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"226294348894914054228767414500452504042","date":"2024-08-08T00:49:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-21T11:04:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-11T17:20:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-04T23:04:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Surgical Oncology","date":"2024-07-03T11:19:40+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-surgical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjso","sideBox":"Learn more about [World Journal of Surgical Oncology](http://wjso.biomedcentral.com)","snPcode":"12957","submissionUrl":"https://submission.nature.com/new-submission/12957/3","title":"World Journal of Surgical Oncology","twitterHandle":"@OncoBioMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"536ef67c-024e-4933-8579-e07d56863541","owner":[],"postedDate":"July 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-14T15:58:42+00:00","versionOfRecord":{"articleIdentity":"rs-4680007","link":"https://doi.org/10.1186/s12957-024-03551-x","journal":{"identity":"world-journal-of-surgical-oncology","isVorOnly":false,"title":"World Journal of Surgical Oncology"},"publishedOn":"2024-10-08 15:56:56","publishedOnDateReadable":"October 8th, 2024"},"versionCreatedAt":"2024-07-29 21:21:27","video":"","vorDoi":"10.1186/s12957-024-03551-x","vorDoiUrl":"https://doi.org/10.1186/s12957-024-03551-x","workflowStages":[]},"version":"v1","identity":"rs-4680007","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4680007","identity":"rs-4680007","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}