Abstract
BACKGROUND: Vertically displaced sacral fractures are complex injuries commonly resulting from high-energy trauma and often complicated by neurological deficits, pelvic instability, and leg length discrepancy. When managed conservatively or under emergent conditions, they are prone to malunion. Surgical correction in these cases is technically demanding due to the intricate sacral anatomy and proximity of neurovascular structures. CASE DESCRIPTION: A 26-year-old female war victim had a malunited, vertically displaced left sacral ala fracture. Initial treatment with an anterior external fixator failed to address the vertical displacement. Four months after the injury, the patient presented with severe pelvic pain, inability to walk, and a 6-cm leg length discrepancy. Neurological examination revealed decreased dorsiflexion strength and sensory deficits on the left foot. A 3-stage, single-setting surgical correction was performed: anterior pelvic osteotomy using the Stoppa approach; posterior sacral osteotomy and reduction via a posterior midline approach; and triangular osteosynthesis involving lumbo-pelvic distraction and transverse fixation. The anterior osteotomy site was subsequently stabilized with a reconstruction plate. Intraoperative neuromonitoring was utilized throughout the procedure. OUTCOMES: The surgery reduced the pelvic asymmetry and reduced the leg length discrepancy from 6 cm to approximately 1 cm. Postoperatively, the patient maintained her preoperative motor status, with dorsiflexion strength of 3/5 initially, improving to 4/5 within 3 weeks. Sensory deficits remained stable without further deterioration. She was mobilized with nonweight-bearing ambulation immediately postoperatively, progressing to full weight bearing by the third postoperative week. One month after surgery, she developed a superficial wound infection that resolved with outpatient wound care and oral antibiotics. At the 6-month follow-up, the patient was walking independently without assistive devices. Radiographs confirmed stable fixation and maintenance of reduction with satisfactory signs of bone healing. No neurological deterioration or implant-related complications were observed. Clinical and radiographic assessments supported a successful outcome. CONCLUSION: This case illustrates the feasibility and efficacy of a comprehensive, single-session surgical approach for treating a vertically displaced sacral fracture malunion. Triangular osteosynthesis combined with sacral osteotomy provides biomechanical stability and enables early mobilization. Multistage intraoperative positioning and careful dissection are critical for successful outcomes. CLINICAL RELEVANCE: Malunited vertically displaced sacral fractures are uncommon but highly disabling, often associated with pelvic asymmetry, leg length discrepancy, and neurological deficits. Surgical correction is challenging because of complex sacral anatomy and proximity to critical neurovascular structures. The successful restoration of alignment, early mobilization, and functional improvement in this case highlight the feasibility of this approach. This report offers practical technical guidance of a single-session, staged anterior-posterior osteotomy and triangular osteosynthesis for surgeons managing similarly complex sacral malunion deformities.