Sacral dysmorphism and its influence on hardware choice in sacral fractures: A scoping review

Purpose In the setting of sacral fractures, percutaneous screw fixation is a reliable, safe, and minimally invasive method for managing most stable and unstable fractures. However, significant variations in sacral anatomy due to sacral dysmorphism (SDM) could prevent safe implementation. This scoping review aimed to highlight such a detrimental yet under-reported variable in managing sacral fractures. Methods A scoping review was conducted following the Arksey and O’Malley framework for scoping studies. A comprehensive literature search of four electronic databases was conducted to identify relevant peer-reviewed studies. Data were extracted from eligible articles to summarize, collate, and create a narrative account of the findings. Results Twenty-one articles were included in our review (18 level III, two level II, and one level I). Studies were categorized into three main groups based on the investigated outcomes: prevalence and determinants of SDM, effect of SDM on the surgical corridor, and efficacy of different intra-operative imaging modalities. The prevalence of SDM ranged from 10 to 85%. The presence of SDM decreased the available surgical corridor at S1, with a compensated increase at S2 and S3. Mixed results regarding accuracy and revision rate were identified between different intra-operative imaging techniques. Conclusion SDM represents consistent yet atypical “safe zone,” sizes, and angles that require careful analysis and technique alterations when placing upper and second sacral segment screws. Considering their limited availability, high cost, and mixed results, navigated imaging systems represent a promising technique that requires more rigorous examination of its efficacy before widespread adoption.