Operative management of traumatic sacral fractures and in-hospital mortality: a national analysis

PURPOSE: Sacral fractures cause substantial morbidity and mortality, yet prior studies have focused on fixation strategy and functional outcomes rather than survival. In the largest cohort to date, we evaluated factors associated with lower in-hospital mortality following operative management among adults with sacral fractures. METHODS: We performed a retrospective cohort study using the National Trauma Data Bank (2017-2022). Adults with sacral fractures were identified by ICD-10-CM codes. We balanced baseline differences using overlap weighting, stabilized inverse probability weighting, and 1:1 propensity score matching, confirmed by multivariable logistic regression, with prespecified subgroup and sensitivity analyses. RESULTS: Among 105,649 adults with sacral fractures, median age was 57 years, 54.3% were female, and in-hospital mortality was 5.4%. Overall, 22.7% underwent operative management. Crude mortality was lower in operative than nonoperative patients (2.9% vs. 6.2%, p<0.001). After overlap weighting, surgery remained associated with lower mortality (OR 0.37), with consistent findings across matched (OR 0.33), stabilized weighting (OR 0.39), and multivariable analyses (aOR 0.23; all p<0.001). The association persisted across nine sensitivity analyses (aOR range 0.19-0.25). Benefit was present across all fracture zones, with the greatest effect in Zone III (aOR 0.14 vs. Zone I aOR 0.28, Zone II aOR 0.20). Older adults also benefited (aOR 0.32). Operative use increased modestly from 21.2% to 23.0% over the study period. CONCLUSIONS: Operative management was associated with lower in-hospital mortality in the largest sacral fracture cohort studied to date. Fewer than one in four patients underwent surgery, supporting reassessment of operative thresholds, particularly for higher-zone injuries, through prospective validation.