Efficacy Analysis of Anterior versus Posterior Surgical Approaches for Denis Zone III Sacral Fractures: A Retrospective Comparative Study

Background Sacral fractures represent 30–40% of pelvic ring injuries, with Denis Zone III fractures posing the greatest challenge due to their involvement of the central sacral canal and foramina, often resulting in neurological deficits, pelvic instability, and complications such as rectal, bladder, and sexual dysfunction. Surgical management is standard, but the choice between anterior and posterior approaches remains debated, particularly regarding hemorrhage control, neural decompression, and recovery. Methods This retrospective cohort study reviewed 42 patients with Denis Zone III sacral fractures treated from December 2015 to June 2025. Group A (n = 19) underwent anterior sacral approach, including 15 cases with digital subtraction angiography (DSA)-guided temporary abdominal aortic balloon occlusion (AABO) for high-bleeding-risk fractures. Group B (n = 23) underwent traditional posterior open reduction and internal fixation. Outcomes assessed included operative time, intraoperative blood loss, hospital stay, radiographic reduction quality (Matta criteria), neurological recovery, Majeed functional scores, Visual Analog Scale (VAS) pain scores, and complications. Statistical analysis used independent t-tests (P < 0.05 significance threshold). Results All procedures were completed successfully. Group A had longer operative times (159.7 ± 30.3 min vs. 100.8 ± 22.2 min; t = 7.26, P < 0.05) but lower blood loss (423 ± 90 mL vs. 780 ± 145 mL; t = 9.34, P < 0.05) and shorter hospital stays (14.0 ± 4.5 days vs. 17.2 ± 5.4 days; t = 2.09, P < 0.05). Wound healing was primary in all Group A cases, versus 13.0% infection rate (3/23) in Group B. Radiographic reduction was comparable (excellent/good: 94.7% Group A vs. 91.3% Group B; P > 0.05). VAS and Majeed scores improved significantly postoperatively in both groups (VAS at discharge: t = 20.3, P < 0.05; Majeed at 6 months: t = 15.4, P < 0.05), with no intergroup differences. Mean follow-up was 9.7 months (Group A) and 9.1 months (Group B). Conclusions Although more time-intensive, the anterior approach with selective AABO reduces intraoperative blood loss and wound complications while providing equivalent functional and neurological outcomes to the posterior approach. This supports its use in high-risk Denis Zone III fractures, advocating for patient-specific surgical selection.