Lumbopelvic fixation for high-energy sacral fractures and spinopelvic dissociation: A systematic review and meta-analysis of complications, unplanned revision and implant removal

Why clinicians should know about it

• Picked for Spine Surgery (paper of the day, 6 November 2026): Sacral fracture fixation outcomes, revisions, and complications

Abstract

INTRODUCTION: Secondary procedures after lumbopelvic fixation (LPF) include planned implant removal, removal for symptoms and revision for complications. Their differing indications, together with limited comparative evidence, complicate counselling and surgical planning. METHODS: PubMed, Embase, Scopus and Cochrane CENTRAL were searched to May 2026 (PROSPERO CRD420251036375) for comparative and single-arm studies (≥10 LPF patients). High-energy injuries and fragility fractures were considered separately. Random-effects models summarised complications, unplanned revision, implant removal and within-study comparisons of surgical approaches and fixation strategies. RESULTS: Twenty-five studies were included (22 high-energy, 3 fragility). Across 19 high-energy LPF cohorts (564 patients), pooled surgical-site infection was 9.3% (95% CI 6.1-14.1), implant loosening or failure was 5.3%, nonunion occurred in 4 of 389 patients (1.0%) and loss of reduction in 2 of 355. Pooled unplanned revision was 11.9% (95% CI 8.7-16.0; prediction interval 5.3-24.3), most often for infection or wound complications. Implant removal was 79.0% in routine-removal series and 17.3% in selective-removal series. Four studies compared minimally invasive and open LPF. Pooling three studies showed less blood loss with minimally invasive LPF (mean difference -271 mL, 95% CI -367 to -175) and shorter operative time (-51 min, -97 to -5); the operative-time association did not persist with Hartung-Knapp adjustment. Infection (OR 0.41, 95% CI 0.09-1.83) and revision (OR 0.35, 95% CI 0.09-1.43) estimates were inconclusive. Four cohorts comparing LPF with posterior pelvic-ring fixation alone reported higher odds of revision after LPF (OR 3.96, 95% CI 1.63-9.60), with substantial potential for confounding by indication. Certainty was very low. CONCLUSIONS: Nonunion and loss of reduction were infrequent after LPF, while unplanned revision most often involved infection or wound complications. Implant removal varied with institutional policy and warrants separate counselling. Minimally invasive LPF was associated with less blood loss, but comparative evidence remains insufficient to establish lower complication rates, equivalent mechanical outcomes or superiority of either fixation strategy.

Abstract as published, via PubMed.