Screw-in-screw fixation of fragility sacrum fractures provides high stability without loosening-biomechanical evaluation of a new concept

J Orthop Res. 2021 Apr;39(4):761-770. doi: 10.1002/jor.24895. Epub 2020 Nov 5.


Surgical treatment of fragility sacrum fractures with percutaneous sacroiliac (SI) screw fixation is associated with high failure rates. Turn-out is detected in up to 20% of the patients. The aim of this study was to evaluate a new screw-in-screw implant prototype for fragility sacrum fracture fixation. Twenty-seven artificial hemipelvises were assigned to three groups (n = 9) for instrumentation of an SI screw, the new screw-in-screw implant prototype, ora transsacral screw. Before implantation, a vertical osteotomy was set in zone 1 after Denis. All specimens were biomechanically tested to failure in upright position. Validated setup and test protocol were used for complex axial and torsional loading applied through the S1 vertebral body to promote turn-out of the implants. Interfragmentary movements were captured via optical motion tracking. Screw motions were evaluated by means of triggered anteroposterior X-rays. Interfragmentary movements and implant motions were significantly higher for SI screw fixation compared to both transsacral and screw-in-screw fixations. In addition, transsacral screw and screw-in-screw fixations revealed similar construct stability. Moreover, screw-in-screw fixation successfully prevented turn-out of the implant that remained during testing at 0° rotation for all specimens. From biomechanical perspective, fragility sacrum fracture fixation with the new screw-in-screw implant prototype provides higher stability than an SI screw, being able to successfully prevent turn-out. Moreover, it combines the higher stability of transsacral screw fixation with the less risky operational procedure of SI screw fixation and can be considered as their alternative treatment option.

Keywords: SI screw; backing out; biomechanical testing; cutthrough; fragility fracture; locking screw; pelvis; sacroiliac screw; screw loosening; screw tilt; screw-in-screw; transsacral fixation; transsacral screw; unscrewing.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Biomechanical Phenomena
  • Bone Screws*
  • Fracture Fixation, Internal / instrumentation*
  • Fracture Fixation, Internal / methods
  • Fractures, Bone / surgery
  • Humans
  • Osteotomy / instrumentation
  • Osteotomy / methods
  • Pelvis / surgery
  • Radiography
  • Sacrum / surgery*
  • Spinal Fractures / surgery
  • Stress, Mechanical
  • X-Rays